In “Morbis Popularibis,” Hippocrates observed that nasal polyps were associated with restless sleep.¹ The relationship between nasal obstruction, mouth breathing, snoring and sleep apnea  is well documented ^2-4, and for decades the Buteyko Method has been successfully implemented to help control these conditions.  Simply by unblocking the nose, switching to nasal breathing and reducing breathing volume, snoring and sleep apnea can be significantly reduced.

Breathing too intensely, often through the mouth can result in many of the sleep-disordered breathing symptoms below. How many do you experience?

• Snoring
• Sleep apnea
• Disrupted sleep
• Night time asthma symptoms (3-5am)
• Needing to use the bathroom during the night
• Fatigue first thing in the morning
• Dry mouth
• Symptoms upon waking, such as wheezing, coughing, breathlessness or a blocked nose

Snoring and sleep apnea can be extremely disruptive to sleep for both sleeper and their sleeping partners. Snoring occurs due to a large volume of air passing through a narrow space, causing turbulence in the soft palate, nose or back of the throat. There are two factors in play here: the first is that the individual is breathing too noisily and heavily during sleep; the second is that their upper airways may be narrow due to nasal congestion or structural issues. Sleep apnea is a severe form of sleep-disordered breathing which involves the sleeper involuntary stopping their breath during sleep. After a period of time spent holding the breath, the sleeper partially awakens to resume breathing with large gasps.

If you want to sleep better and wake up feeling energised and refreshed, breathe through your nose, breathe light by applying the Buteyko Method and learn Myofunctional therapy to strengthen the upper airways. Light and calm breathing reduces both snoring and obstructive sleep apnea as well as activating the body’s relaxation mode, leading to deeper and better quality sleep.

Breathing quietly and gently through the nose reduces the risk of obstructive sleep apnea, a condition which involves stopping of the breath during sleep caused by collapse of the upper airways.  People with narrow airways, often caused by mouth breathing during childhood are more prone to obstructive sleep apnea.

To understand how the breath is held during sleep, imagine a collapsible paper straw. If you were to place one end of the straw in your mouth and inhale air forcefully through it, it would cause the inner walls of the straw to collapse in on themselves. If you continued to draw air in through the straw, the collapse would become more severe. In engineering terms this is called the Bernoulli Principle: as fluid (or in this case, air) flows, negative pressure develops at the periphery of the flow. As the flow velocity increases, so does the negative pressure.

Collapse of the upper airway occurs if the negative upper airway pressure generated as the breath is drawn into the lungs is greater than the dilating force of the upper airway muscles.⁶ The individual breathes out, and just as they are about to breathe in, the negative pressure created by trying to take air into the lungs causes the walls of the upper airways to collapse. As the breath hold continues, the breathing centre in the brain sends messages to the diaphragm to resume breathing. As the diaphragm contracts to draw air into the lungs, increased negative pressure enforces the breath hold. After a time, the oxygen de-saturation of the blood decreases enough to partially wake the brain and resume breathing. Finally, the sleeper finally takes in a breath with a loud gasp, followed by a series of heavy and intense breaths. This in turn causes another collapse of the airways and the cycle is repeated throughout the night.

During an episode of apnea, the sleeper may not even be conscious of holding their breath, or the racket created as they resume breathing. It is usually their sleeping partner who lies awake listening to what is going on, sometimes too fearful to go to sleep. Just like snoring, there are two factors we need to consider: the first is the width of the upper airways and the second is breathing volume.

Most procedures for improving obstructive sleep apnea involve attempting to open the airways – either by bringing the lower jaw forward with surgery or using a continuous positive airway pressure (CPAP) machine to splint open the airway at night. While these interventions are successful in their own right, to further reduce sleep apnea, it is also necessary to consider breathing volume. Any engineer considering the diameter of a tube will also need to consider the flow – after all, one is entirely dependent on the other.

Mouth breathing during sleep leads to a larger breathing volume as too much air is drawn into the lungs. Not only does the negative pressure on the upper airways increase, but over-breathing also causes the airways to cool and dry out, leading to inflammation and further narrowing of the airways. Anyone who has ever had a little too much to drink of an evening will know how it feels to wake the following morning with your throat raw and inflamed. The same thing happens to your airways when you breathe through your mouth at night, inflaming and narrowing the airways. The body expends energy to condition incoming air within the upper airways condition before it is drawn to the lungs. Taking too much air in through the mouth overwhelms the upper airways, leading to inflammation. This combination of larger breathing volume and narrower airways is a recipe of obstructive sleep apnea. Buteyko Breathing specifically changes breathing volume towards normal, thereby reducing turbulence and negative pressure in the upper airway.

Several research studies have showed how breathing through the nose offers a distinct advantage during sleep, resulting in fewer incidences of obstructive sleep apnea than when a patient breathes through the mouth at night. (apnea-hypopnoea index 43+/-6) than nasally (1.5+/-0.5).⁷ In fact, the wearing of a chin strap to prevent mouth breathing demonstrated the same or better results in improving severe obstructive sleep apnea than the use of a CPAP machine in one paper.⁸ This is an extraordinary result, especially since a many people are unable to wear a CPAP due to the inconvenience and side effects of wearing a mask over the face during sleep.

In an interesting study which aimed to determine the effect of a blocked nose during sleep, subjects slept with their nostrils blocked on one night and open on another. Blocking of the nose caused participants to wake up more often, reduced the quality of their sleep and caused a significant increase in sleep disorders.⁹  In another study to determine the effect of breathing through the nose during sleep by wearing a porous paper tape across the lips, researchers found that the number of sleep disturbances significantly reduced.¹⁰

Having a stuffy nose adversely affects sleep both in children and adults. After a night spent breathing heavily through the mouth, a child will wake up exhausted, causing poor concentration and frustration at school. If this continues over a period of time, a psychological evaluation and possible diagnosis of ADD or ADHD may follow. When I speak to any parent who has a child labelled with ADD, my first piece of advice is to check their sleep habits. Are they breathing through their mouth? Are they twisting and turning during the night, waking up with the bed clothes tangled in the morning? Do they snore or hold their breath during sleep? Is their breathing audible during sleep? Answering yes to any of these questions suggests that the child is suffering the detrimental effects of mouth breathing. Nasal breathing is of the utmost importance if you wish to improve your child’s quality of sleep. Any adult will understand the knock-on effect of crankiness and frustration when they have a poor night’s sleep – so how can a child face the day with boundless energy if their sleep is not right?

It is very easy for a child or adult to decongest their nose by applying the simple breath hold exercise from the Buteyko Method. Click HERE to view video on how to unblock the nose.

The good news is that sleep experts are becoming increasingly concerned about the impact of open mouth breathing during sleep, especially for children. Among these researchers is Dr Christian Guilleminault, a leading figure in the field of sleep medicine. In the early 1970s, while working at the Stanford University Sleep Disorders Clinic, Dr Guilleminault monitored the blood pressure of sleeping patients and discovered that when patients held their breath during sleep, their blood pressure dramatically increased. Since then, Dr Guilleminault has made many further discoveries in the field of sleep medicine. Among these, which I am delighted to include, is his recognition that: “the case against mouth breathing is growing, and given its negative consequences, we feel that restoration of the nasal breathing route as early as possible is critical.” This particular paper, which was published in 2015, goes on to say that “restoration of nasal breathing during wake and sleep may be the only valid ‘complete’ correction of pediatric sleep disordered breathing.” ¹¹

Gravity also plays a role in both snoring and sleep apnea. When you lie on your back, there is no restriction to breathing and breathing volume grows larger, leading to a greater severity in snoring. Sleeping on your back also encourages the mouth to open, and as the lower jaw hinges downwards it impedes on the upper airway, reducing airway diameter. A variety of studies have made it clear that anyone with obstructive sleep apnea who sleeps on their back will experience a higher number of apneas per night, and will also hold their breath for longer. During a study of 574 patients with sleep apnea, researchers found that patients had at least twice as many instances of apneas/hypopnea when sleeping on their back as compared to sleeping on their side. The paper concluded that “body position during sleep has a profound effect on the frequency and severity of breathing abnormalities in obstructive sleep apnea patients.”¹² A similar assessment of 2,077 obstructive sleep apnea patients over a period of ten years found that 53.8% experienced at least twice as many breathing abnormalities while sleeping on their backs compared with sleeping on their side. The paper concluded that “avoiding the supine posture during sleep may significantly improve the sleep quality and daytime alertness of many positional patients.”¹³

Re-educate your breathing for a great night’s sleep with our Buteyko self instructional DVD set for Snoring and Sleep Apnea

References:

1. L. Hippocrates, De Morbus Popularibus, Frien, Sheep, London, UK, 1717.
2. Kim EJ, Choi JH, Kim KW, Kim TH, Lee SH, Lee HM, Shin C, Lee KY, Lee SH.
   The impacts of open-mouth breathing on upper airway space in obstructive sleep apnea: 3-D MDCT analysis.Eur Arch Otorhinolaryngol. 2010 Oct 19.
3. Kreivi HR, Virkkula P, Lehto J, Brander P.Frequency of upper airway symptoms before and during continuous positive airway pressure treatment in patients with obstructive sleep apnea syndrome. Respiration. 2010;80(6):488-94.
4. Ohki M, Usui N, Kanazawa H, Hara I, Kawano K. Relationship between oral breathing and nasal obstruction in patients with obstructive sleep apnea.Acta Otolaryngol Suppl. 1996;523:228-30.
5. Snoring and Obstructive Sleep Apnea. David N.F. Fairbanks and Samuel A. Mickelson.
6. W. T. McNicholas. The nose and OSA: variable nasal obstruction may be more important in pathophysiology than fixed obstruction. European Respiratory Journal 2008 32: 3-8;
7. Fitzpatrick MF¹, McLean H, Urton AM, Tan A, O’Donnell D, Driver HS. Effect of nasal or oral breathing route on upper airway resistance during sleep. Eur Respir J. 2003 Nov;22(5):827-32.
8. Vorona R et. Al. Treatment of Severe Obstructive Sleep Apnea Syndrome with a Chinstrap. Clin Sleep Med. Dec 15, 2007; 3(7): 729–730.
9. Olsen KD, Kern EB, Westbrook PR. Sleep and breathing disturbance secondary to nasal obstruction. Otolaryngol Head Neck Surg. 1981 Sep-Oct;89(5):804-10.
10. Huang TW, Young TH Novel porous oral patches for patients with mild obstructive sleep apnea and mouth breathing: a pilot study. Otolaryngol Head Neck Surg. 2015 Feb;152(2):369-73.
11. Seo-Young Lee* , Christian Guilleminault, Hsiao-Yean Chiu,**, Shannon S. Sullivan. Mouth breathing, “nasal dis-use” and pediatric sleep-disordered-breathing. Sleep and Breathing (2015) Stanford University Sleep Medicine Division, Stanford Outpatient Medical Center, Redwood City CA
12. Oksenberg A, Silverberg DS, Arons E, Radwan H. Positional vs nonpositional obstructive sleep apnea patients: anthropomorphic, nocturnal polysomnographic, and multiple sleep latency test data. Chest. 1997 Sep;112(3):629-39.
13. Oksenberg A, Arons E, Greenberg-Dotan S, Nasser K, Radwan H. [The significance of body posture on breathing abnormalities during sleep: data analysis of 2077 obstructive sleep apnea patients]. [Article in Hebrew] Harefuah. 2009 May;148(5):304-9, 351, 350.
14. Am J Gastroenterol. 1999 Aug;94(8):2069-73. Influence of spontaneous sleep positions on nighttime recumbent reflux in patients with gastroesophageal reflux disease. Khoury RM¹, Camacho-Lobato L, Katz PO, Mohiuddin MA, Castell DO.
15. http://www.cnn.com/2010/TECH/05/13/sleep.gadgets.ipad/
16. http://www.health.harvard.edu/newsletters/Harvard_Health_Letter/2012/May/blue-light-has-a-dark-side