APNOEA RETRAINING AND BREATHING

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1 SNORING,, SLEEPS APNOEA AND BREATHING RETRAINING Sleep disorders are a modern epidemic, but medical interventions aren t always successful or well tolerated. The good news is that there are simple techniques which can be used to restore correct breathing and improve sleep within only a few days. by Tess Graham 2014 BreatheAbility International Post Office Box 4393 Manuka, ACT 2603, Australia Telephone: +61 (0) admin@breatheability.com At age 48, Bill sometimes wondered if he was going to die early, or at least have to give up work. His 20-year-plus snoring problem had deteriorated into sleep apnoea where his dreadful snoring was now interrupted by worrying silences (where he had stopped breathing), then gasping and choking episodes as he resumed breathing. Sometimes Bill woke himself up with particularly loud snoring or the jerking of his body as he fought for his breathing to resume. His days were punctuated by nausea, diarrhoea and debilitating fatigue. Fainting was the final straw, and Bill went to see his doctor. An overnight "sleep study" showed that Bill had obstructive sleep apnoea, a condition where breathing stops intermittently throughout the night due to obstruction in the upper airway. He was advised to have laser surgery to remove a portion of his soft palate. The other option put to Bill was to use a CPAP (continuous positive airway pressure) machine an air pump attached to a face mask. However, Bill was not guaranteed that surgery was a permanent solution nor that it would solve his particular problem, and he learned that some spouses of CPAP wearers find the appliance very intrusive. Difficult decisions, but something had to be done. Snoring and sleep apnoea are hazardous to health and need to be taken seriously. I'll talk more about Bill a little later. Snoring and Sleep Apnoea Explained Snoring is the noise created by turbulence and vibration of the tissues lining the throat as air passes through to the lungs. Snoring is far more than just a bad noise: it increases the risk of high blood pressure, heart attack and erectile dysfunction, and can put stress on a relationship. There is a high incidence of chronic snoring among men who suffer strokes. Furthermore, worsening snoring is a risk factor for developing the much more serious condition of sleep apnoea (or apnea). Sleep apnoea is where breathing stops for intervals of 10 seconds or more, repetitively throughout the night, causing a significant drop in the amount of oxygen in the blood. With obstructive sleep apnoea, the walls of the throat may "collapse" inwards or part of the soft palate or the tongue may be drawn back into the throat, obstructing air flow. As well as causing devastating daytime sleepiness, untreated sleep apnoea puts you at greater risk for high blood pressure, angina, irregular heart rhythms, heart attack, depression, obesity, diabetes and cancer. In children, it is associated with retarded growth as well as learning and behavioural problems. The burden of sleep-breathing disorders rests heavily not only on the sufferer but also their bed partner, their employer and the health system. The bed partner is not getting a good night's sleep and maybe the neighbours aren't, either. Road users are at risk. People with sleep apnoea are said to be two to seven APRIL MAY NEXUS 33

2 times more likely to have a road accident. 1 They also have an increased incidence of workplace accidents. The direct and flow-on costs to business and the health care system are enormous. Sleep disorders cost the Australian economy more than $10 million each year 2, and the number of people being diagnosed each year continues to grow. These costs are skyrocketing as the incidence of snoring and sleep apnoea increases. SOME STATISTICS It s estimated that around 40 per cent of the adult population snores at least occasionally, with the figure rising to around 60 per cent in the over 40s. While the incidence of snoring is greater in men and the middle-aged, more than 30 per cent of middle-aged women are said to snore habitually. A study of primary school children in Perth, Western Australia, found that 15.2 per cent were habitual snorers. 3 In 2010, an estimated 4.7 per cent of the Australian population over 20 years of age had obstructive sleep apnoea (OSA) though this may be underestimated as OSA is considered to be significantly underdiagnosed. 4 The US National Sleep Foundation estimates that more than 18 million American adults have sleep apnoea and that a minimum prevalence of 2 to 3 per cent exists in children. 5 Medical Treatments and Appliances It will come as no surprise that with these statistics there is a thriving industry in diagnostic "sleep clinics" and in manufacturing and selling products to treat the problems. New sleep clinics are popping up in suburban areas, and nearby are shops with sleep apnoea supplies including a large array of machines and masks from which to choose. These places did not even exist 30 years ago. Oral appliances (dental splints) are supplied by dental surgeries, and all manner of products, devices and accessories are sold in pharmacies and on the Internet, all promising relief. This is relief, not cure, as it is acknowledged that in most cases the underlying problem persists and lifetime treatment is required. When we look at the medically approved treatments for snoring and sleep apnoea, we see that for the most part they have been designed to create larger or more rigid (more open) breathing passages to allow freer air flow to the lungs. Treatments offered include: Medication to reduce nasal inflammation and congestion. Surgical procedures such as removing tonsils and adenoids, trimming "excess tissue" from the soft palate, opening or "reboring" nasal passages, reducing the size of the tongue or anchoring it in a more forward position, and remodelling or repositioning the jaw. Oral appliances such as mandibular advancement splints and tongue retainers which are worn during sleep to hold the jaw and tongue more forward to help brace open the airway at the back of the throat. CPAP, an apparatus used during sleep and consisting of an air-pump machine, tubing and face or nose mask which delivers positive air pressure to brace the airway open and prevent obstructive sleep apnoea. CPAP is the "gold standard" treatment for sleep apnoea. However, as a gold-standard treatment it has a significant shortcoming. While it works extremely well to reduce or eliminate apnoea episodes and improve sleep quality, studies show that only 30 to 60 per cent of people for whom CPAP is the recommended option complied with the treatment. 6 Not surprisingly, many people find CPAP unacceptable or intolerable. This can be because of claustrophobia, or because they've started a new relationship, or because of difficulty in finding a comfortable mask or machine despite the wide variety available. The use of CPAP on a nightly basis for the rest of your life can be a daunting prospect, and many reject it. The success rate of the surgical options varies with the different procedures, but estimates suggest that it is generally not more than 50 per cent, especially in the long term. The oral appliances can be very helpful for snorers and people with less severe apnoea, but they also are not always successful or tolerable and are not recommended in cases of severe sleep apnoea. CPAP full face mask When CPAP or an oral appliance suits the patient and is worn all night, the night-time symptoms of snoring and sleep apnoea can be eliminated or greatly reduced and energy levels are much better during the day. It can be a remarkable turnaround in health and well-being for many people. However, these appliances only work if they are worn every night for most of the night. There is no carry-over improvement in the underlying snoring or apnoea problem. What s Going On In Our Bedrooms? Lying there at night, trying to ignore the noise of a snoring bed partner, have you ever wondered why people snore? If you've had the altogether scary experience of lying next to a loved one who stops breathing and then 34 NEXUS APRIL MAY 2014

3 jerks their body and makes choking sounds while struggling to get a breath in, have you ever wondered why their breathing stops or when they will start breathing again? The traditional medical viewpoint sees snoring and sleep apnoea connected with the breathing passages being or becoming too narrow to allow easy, quiet and continuous breathing during sleep. Contributing factors are seen to include nasal congestion, a deviated nasal septum, enlarged tonsils and adenoids, excess fat around the neck, a small or retracted jaw, a narrow upper palate or an overly large tongue. However, this "explanation", while indeed including factors which contribute to airway narrowing or obstruction, fails to explain how snoring and apnoea can occur in people with none of these factors being present or can be absent despite several of them being present. Also, it does not explain why sleep apnoea often develops in people many years after they have developed their "risky" adult facial features and body type. Consider this: unless you have had facial injuries, you likely have had much the same-shaped nose and upper palate and the same-sized jaw and tongue all your adult life. If you are 45 now and chronically snore and have sleep apnoea, but did not at age 30, it is unlikely that your tongue has grown significantly larger, your septum has become more deviated or your jaw has narrowed. Something has changed substantially, but what is it? Could there possibly be another way of looking at this problem which reveals a more fundamental solution? What s Been Missed? The first thing you need to know is that snoring and sleep apnoea do not occur in people with a normal breathing pattern. People who snore and have sleep apnoea do not breathe correctly; there are no exceptions. While snoring and sleep apnoea can certainly be made worse by anatomical factors and things like drinking too much alcohol or having a cold, a fundamental contributing factor in both is a high inspiratory airflow rate: high-volume, high-speed breathing that is, inhaling an excessive amount of air and inhaling it rapidly. Most often, snorers are unaware of their heavy air usage. In the daytime, they can be so used to it that they don't notice their mouth-breathing, somewhat heavier breathing, upper-chest breathing or their intermittent The first thing you need to know is that snoring and sleep apnoea do not occur in people with a normal breathing pattern. People who snore and have sleep apnoea do not breathe correctly; there are no exceptions. deep breaths, sighs or yawns. These are all indicators of an overbreathing pattern. When you're lying down and asleep, however, overbreathing and its effects may be very noticeable to an observer. Anyone who has slept next to a heavy snorer will identify with this high "drive to breathe". One woman described her partner's snoring this way: "He breathes two breaths for my one. When he breathes in, it's like he's sucking the paint off the walls; when he breathes out, I feel I have to hold on to the edge of the bed so he doesn't blow me out." When you breathe in too quickly and/or too heavily, the soft tissues lining your airway can become dehydrated, swollen and congested, narrowing your airway. During sleep, when your throat muscles are more relaxed, these tissues can vibrate and create the snoring noise. Obstructive sleep apnoea is like sucking too hard on a straw. Breathe in quickly or heavily enough and you may suck the walls of your throat closer together, or suck your tongue or uvula backwards, and limit or completely obstruct the flow of air to your lungs for a period of time. These effects are related to laws of physics: the Venturi and Bernoulli effects. Research has shown that men with sleep apnoea breathe an average of 15 litres of air each minute. 7 This is three times as much as a healthy breather does. Now a hearty snore and a suction force sufficient to obstruct your throat are not likely to happen when you breathe normally which is to breathe in and out, silently, slowly, gently, about 10 times a minute, 500 millilitres per breath, a total of around five litres of air each minute. This breathing is called physiologically normal breathing. 8 As well as its mechanical effects on the airway (turbulence, vibration, suction), described above, highvolume breathing creates imbalance in the levels of carbon dioxide and oxygen in the blood, affecting blood chemistry. If the level of carbon dioxide drops sharply, the signal from the brain to the diaphragm may fail and breathing may cease temporarily. This is called central sleep apnoea. When imbalance in carbon dioxide is maintained over a critical period of time, the carbon dioxide "set point" of the breathing receptors in the brain which drive your breathing become altered from the optimum. From then on, you can end up unconsciously breathing at a rate that is detrimental to body function and chemical APRIL MAY NEXUS 35

4 FAULTY-BREATHING QUIZ [ ] Do you snore? [ ] Do you ever wake up gasping or choking and coughing? [ ] Is your breathing audible day or night? [ ] Is your breathing heavy or laboured? [ ] Are you breathless at any time? [ ] Do you often feel spacey or dizzy? [ ] Do you mouth-breathe? [ ] Do you breathe with your upper chest? [ ] Do you breathe more than 14 times a minute? [ ] Is your breathing irregular or erratic? [ ] Do you breath-hold in the day or night? [ ] Do you have panic attacks? [ ] Do you have a persistent or irritable cough? [ ] Is your nose often stuffy or congested? [ ] Do you feel like you can t get enough air when you nose-breathe? [ ] Do you sigh, yawn or clear your throat often? If you have answered YES to one or more of these, then you likely have a disordered breathing pattern and may benefit from breathing retraining. processes and results in reduced oxygenation of cells, tissues and organs throughout the body (the Bohr effect). Breathing is a critically important body function. It is the first thing we do in life, and the last. Many people are getting it wrong over 20,000 times a day. It is very likely that a person's breathing pattern has changed significantly over the period of time in which they developed a heavy snoring and apnoea problem. However, someone with snoring and sleep apnoea is unlikely to know this, and checking a person's baseline breathing pattern is not part of standard medical diagnosis. Nor do the commonly used treatments for snoring and sleep apnoea seek to address the fundamental disturbance in breathing pattern the abnormal way of breathing. People are often steered towards surgical, pharmaceutical or appliance-based interventions without considering what they can do themselves to improve their breathing habits. (This is not unlike obese patients with poor eating habits having gastric band surgery without first being advised to try to improve their diet.) Overbreathing: Overlooked! Snoring and sleep apnoea are fundamentally problems with the way you breathe day and night. Overbreathing is a prime contributory factor in snoring and sleep apnoea and thankfully it's one that you can do something about. One of the most comprehensive discussions on overbreathing or hyperventilation is the aptly titled paper by Dr Gregory Magarian et al.: "Hyperventilation syndrome: A diagnosis begging for recognition" (1983). 9 He commented that while acute hyperventilation (as in a "panic attack") is fairly easy to see, the chronic form often goes unrecognised. Medical scientist and physician Professor Konstantin Buteyko coined the term hidden hyperventilation because of the often subtle presentation of its chronic form. His exhaustive research spanning several decades from the 1950s showed chronic hyperventilation to be very prevalent in the general population. 10 Chest physician Dr Claude Lum published extensively on the hyperventilation syndrome. In his article "Hyperventilation: the tip and the iceberg" (1975) 11 he had this to say. "The many organs involved are often reflected in the number of specialists to whom the patient gets referred, and my colleagues have variously dubbed this the 'multiple doctor' or the 'fat folder syndrome'. Indeed the thickness of the case file is often an important diagnostic clue." The consequences of overbreathing day after day are far reaching. The body struggles and tires as it tries to maintain equilibrium. Unfortunately, diagnosis of this extremely common disorder does not appear to have improved at all since Magarian, Buteyko and Lum published their findings. Yet the incidence of overbreathing is even greater now. More and more people are breathing too rapidly or are snoring or mouth-breathing and these include large numbers of children. Rarely are parents and teachers aware of the consequences of this. Parents may have to cope with constant mucus conditions and tired children, teachers with behavioural and learning issues, dentists with tooth decay, orthodontists with the narrow upper palates and crowded and crooked teeth which are consequences of mouth-breathing. Breathing Retraining It was a stroke of good luck for Bill (whom we met at the beginning of this article) that, while faced with the difficult choice between throat surgery and CPAP, he heard about a breathing retraining course. The concept made sense to him after all, for over two decades there obviously had been something wrong with the way he 36 NEXUS APRIL MAY 2014

5 was breathing! From the second day of the breathing course, he noticed an improvement in his sleep. By the end of that week, his concentration and stamina were better and, according to his wife, he was no longer snoring. Some months later, he had a repeat sleep study done and there was no evidence of sleep apnoea. By taking responsibility for the way he breathed, Bill had in effect "fixed" himself. Breathing training/retraining is the specific discipline in which the primary goal is to normalise each aspect of the breathing pattern (rate, rhythm, volume, use of the nose, use of the diaphragm) for all situations (awake, asleep, at rest, during eating, speech and exercise). 12 The process involves identifying incorrect breathing habits, undoing them and replacing them with the correct ones. Step by step, you replace faulty breathing with silent, efficient, gentle diaphragm-breathing. It works because while breathing is automatic, you can also consciously vary it. Think of your brain as having a manual override and reset button. You practise breathing correctly during the day to retrain (i.e., reprogram or reset) the brain's "drive to breathe" centre to operate at the correct level at rest, when exercising and while sleeping. When it is reset, quieter, softer, more regular breathing is maintained day and night. Assessing The Breathing Pattern There are some simple checks and observations that can be made to alert to the presence of overbreathing and other dysfunctions. Breathing educators assess their clients by observing the rate, rhythm, volume, mode and mechanics of breathing, and through questionnaires. They also use breath-hold tests or capnometry. (Capnometry monitors the partial pressure of carbon dioxide in expired air.) People with asthma, anxiety or sleep apnoea often tick off more than 20 different symptoms of overbreathing as they fill in the form on their first visit to a breathing educator. They can often be observed overbreathing while they complete the questionnaire! Janelle, aged 42, came for breathing retraining because of her heavy snoring and sleep apnoea. She also had restless legs, dizziness, chest pains, palpitations, anxiety, lots of mucus and debilitating fatigue. As she put it, she had already "been through the mill", having undergone a sleep study, an operation on her nose and an exercise stress test with her cardiologist. She was prescribed various medications. She had tried but could not adjust to sleeping with a CPAP machine; she felt claustrophobic. Janelle's breathing was not fast but was audible, very The benefits are immediate, and most people comment that they have had their best sleep in decades within just a few days of starting the process. heavy and from the upper chest. She sighed frequently. On her pre-training questionnaire she marked off 54 different symptoms of overbreathing, ranking many of them moderate to severe. Janelle was amazed to find out that providing information about what was happening in the day and how she breathed when awake was just as important to the breathing educator as her night-time symptoms. For Janelle, eight days into breathing retraining she was sleeping well. Her husband said that she no longer snored. Her chest pain and palpitations had ceased. She was calm and had more energy. The Training Process A typical breathing training program involves an initial consultation with a breathing educator, then a structured program of five to eight 90-minute sessions (60-minute sessions for children). Clients should practise the exercises and techniques on a daily basis, formally and informally, until their breathing pattern is normal and stable or until they reach the best point they are capable of within the confines of their condition. They can then taper down the exercises to maintain the improvements. It really is that simple. The benefits are immediate, and most people comment that they have had their best sleep in decades within just a few days of starting the process. Clients are advised that changes in prescribed medication and treatments must be undertaken only in consultation with their doctor. A follow-up sleep study is recommended for clients with sleep-breathing disorders. Scientific Evidence Breathing retraining is a science-based process, and peer-reviewed studies show its effectiveness in normalising breathing patterns The most researched and best-known form of breathing retraining is the Buteyko Method of Breathing Reconditioning, developed by and named after Ukrainian doctor Konstantin Buteyko. While breathing retraining has been acknowledged as an effective and safe adjunct therapy for asthma by the US government's Agency for Healthcare Research and Quality and by the British Thoracic Society, unfortunately it is not as widely known as a management option for sleep-breathing disorders. However, there is a large body of anecdotal evidence supporting its effectiveness. In 2010, the Buteyko Institute of Breathing & Health conducted a retrospective survey among its members. Practitioners who participated had collectively taught over 11,000 APRIL MAY NEXUS 37

6 clients with sleep apnoea. A majority of practitioners (73 per cent) estimated that over 95 per cent of clients had improved their sleep after completing a course in breathing retraining. 18 The simplest things in life are often the best: changing the way you breathe has to beat having a machine do it for you. Five Tips for Better Breathing, Health and Sleep 1. Be aware of your breathing. Know that physiologically normal breathing is nasal, silent, slow, soft, smooth breathing. 2. Breathe through your nose whenever it is comfortable to do so. 3. Breathe more gently. If your nose is blocked or you are uncomfortable breathing through it, then try to breathe more gently through your mouth. 4. Sit more upright. When you slouch, you are more likely to breathe faster and with the upper chest, which is tiring and makes you feel stressed. 5. See a breathing educator for additional help. What Makes You Breathe Incorrectly? Breathing is influenced by many factors, including stress, training in breathing, habit, posture and diet. For those who have sleep apnoea, it is most likely that they breathe more heavily and/or more quickly now than they used to do. They may have developed a habit of mouth-breathing without noticing it, an irritable dry cough, habitual sighing or throat clearing, or breathing more quickly and with the upper chest because of a slumped seated posture or persistent anxiety. Getting Help For Your Breathing The number of breathing educators worldwide is comparatively small, but is growing due to the consistently profound results achieved with breathing retraining. In Australia, there are breathing educators in most capital cities and in some regional centres. Snoring and sleep apnoea can have devastating health and social consequences. They need to be adequately addressed by one means or another. Breathing retraining is a safe, natural and commonsense approach to what is, after all, a breathing problem. It should be part of a mainstream approach. At the very least, breathing retraining should be offered as an option to people with sleep-breathing disorders who have found surgical or appliance-based approaches unsuccessful or unacceptable. It is hoped that awareness of poor breathing habits and of the benefits of breathing retraining will continue to grow in the community and will lead to implementation of prevention strategies within our primary health care system. Breathing retraining offers a wonderful opportunity to empower yourself to improve your health and quality of life. It is never too late to change. An 80-year-old actually volunteered herself for a television news story because she wanted to let other people know that "you can teach an old dog new tricks". There is nothing more fundamental to health than getting your breathing right. About the Author: Tess Graham is a physiotherapist and breathing educator. She has extensive clinical and research experience in breathing retraining and has worked exclusively in this field for over 20 years. Two of her three children had asthma, which was continuing to worsen despite being managed by conventional medical treatments. The turnaround for them came when they took part in a breathing retraining course. This was also the turning point of Tess s career. She undertook considerable research into breathing, including training in the Buteyko Breathing Method. In 1993 in Canberra, she established Australia s first dedicated breathing clinic. Tess has now taught breathing retraining programs to over 5,500 people and lectured throughout Australia and overseas. She is the author of Relief from Snoring and Sleep Apnoea: A step-by-step guide to restful sleep and better health through changing the way you breathe (Viking/Penguin, 2012; reviewed in NEXUS 21/02). Tess Graham is director of BreatheAbility International. She can be contacted by telephone at +61 (0) , by at admin@breatheability.com or via the BreatheAbility website, Endnotes 1. Austroads Ltd, "Assessing Fitness to Drive", March 2012 (4th edition), p. 105, accessed 19 March Deloitte Access Economics, "Re-awakening Australia: The economic cost of sleep disorders in Australia, 2010", commissioned by the Sleep Health Foundation, published October 2011, 3. Zhang, G., Spickett, J., Rumchev, K., Lee, A.H., Stick, S., "Snoring in primary school children and domestic environment: A Perth school based study", Respir. Res Nov 4; 5(1):19, published online 4 November 2004, doi: / , 4. Deloitte, ibid. Continued on page NEXUS APRIL MAY 2014

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