1. Glenn White BSc MSc MBIBH BIBH Practitioner/trainer www.buteykobreathing.co.nz SNORING – SLEEP APNOEA - ASTHMA - CROOKED TEETH... WHAT’S THE LINK?

2. www.buteykobreathing.co.nz BREATHING AWARENESS 1.Count the number of breaths you take in one minute 2.Place one hand on upper chest, one hand on belly - take 2 breaths in and out through the nose and note relative hand movements - repeat breathing through open mouth

3. Breathing ParameterNormal characteristics Route Nose: rest, physical exercise, sleep Location (dominant) Diaphragm Respiration rate 8-12 breaths per minute Minute volume 4-6 litres per minute Tidal volume 500 ml per breath Feel of breathing Easy, comfortable, satisfying Rhythm Regular, smooth Sound Inaudible; at rest, sleep Heart rate 60-80 beats per minute After Graham, T 2012, Relief from snoring and sleep apnoea FUNCTIONAL BREATHING

4. Breathing ParameterCharacteristics Route mouth breathing or heavy nose breathing Location (dominant) Thoracic dominant Respiration rate > 14 breaths per minute Minute volume > 9 litres per minute * Appearance of breathing obvious upper chest or abdominal movement Feel of breathing Heavy, windy full breaths Rhythm Irregular: sighs, yawns, coughs, sniffs Sound Audible; at rest, sleep (snoring) After Graham, T 2012, Relief from snoring and sleep apnoea DYSFUNCTIONAL BREATHING

5. DAYTIME SYMPTOMS OF DYSFUNCTIONAL BREATHING Blocked or runny nose Open-mouth breathing Heavy laboured breathing Wheezing, asthma, chest tightness Sighing or frequent deep breaths Frequent yawning Irritable cough Throat clearing Short of breath on exertion Upper chest breathing pattern Anxiety/ panic attacks Dry mouth Difficulty swallowing Gastric reflux

6. Breathing Disordered Sleep www.buteykobreathing.co.nz NIGHT-TIME SYMPTOMS OF DYSFUNCTIONAL BREATHING difficulty getting off to sleep restless sleep, frequent waking waking up-tired

7. www.buteykobreathing.co.nz SYMPTOMS OF BREATHING DISORDERED SLEEP Snoring sleep apnoea insomnia vivid dreams-nightmares night-time cramps frequent urination, bed wetting night thirst, dry mouth on waking groggy on waking asthma, night-time coughing night-time anxiety/panic attacks restless sleep restless leg syndrome increased nasal congestion teeth grinding sleep-walking, sleep-talking morning headache blocked nose on waking morning thirst high morning pulse messy bed on waking

8. MORNING BREATH

9. One of the lung’s primary functions is to maintain optimum levels of O 2 and CO 2 in airways and blood THE LUNGS AND CARBON DIOXIDE (CO 2 ) Mouth breathing and over-breathing result in CO 2 loss resulting in CO 2 deficit (hypocapnia)

10. An optimal level of CO 2 is essential in airways and blood for oxygen delivery to brain and body tissues CO 2 is a broncho/ vaso dilator 1 Optimal PaCO 2 is essential for the release of oxygen from blood to body tissues (The Bohr Effect) The Importance of CO 2 1 DAVIS FREED Am.J.Respir.Crit. Care Med.2001, 785-789

11. MRI SCAN red - yellow = highest oxygen dark blue = least oxygen The right hand image shows a 40% reduction in brain oxygen after one minute of big volume breathing. This explains the sensation of dizziness that often accompanies a panic attack. (source Litchfield 1999) OVER-BREATHING AND CO 2 LOSS REDUCES BRAIN OXYGEN

12. www.buteykobreathing.co.nz Dysfunctional breathing = hyperventilation Hyperventilation = breathing more than the medical norm Normal resting minute volume for a 70-kg human 4-6 litres/min for older physiological textbooks 6-9 litres/min for some modern textbooks > 9 litres/min is defined as hyperventilation

13. HUMAN BREATHING VOLUMES HAVE DOUBLED IN FIFTY YEARS 6 4.9 5.3 4.6 7.8 6.9 12 11

14. Hyperventilation (over-breathing) - a mechanism that is often overlooked in asthma. Hyperventilation whether spontaneous or exercise induced, is known to cause asthma 2, 3, 4 Average MV measured for asthmatics in Brisbane Buteyko trial - 15 litres per minute (normal 10 litres) 1 1 Bowler S, Green A, Mitchell C, Medical Journal of Australia 1998; 169: 575-578 2 Demeter & Cordasco The American Journal of Medicine, (1986), vol 81 pp 989. 3 Clarke PS, Gibson, JR Aust Fam Physician. 1980 4 Sterling, GM., Clin Sci, (1968), vol 34, pp 277-285 5 van den Elshout, FJJ et al., Thorax, (1991), vol 46, pp 28-32 Loss of CO 2 through hyperventilation can trigger bronchoconstriction in asthmatics 4, 5

15. HYPERVENTLATION - HYPOCAPNIA AND ASTHMA Hypocapnia is the rule in asthma until respiratory failure sets in 3 Hyperventilation and hypocapnia (CO 2 deficit) are common in asthma 1, 2, 3 1 Tobin, MJ et al. Chest, 1983; 84:287-294. 2 Hormbrey, J. et al., European Respiratory Journal, 1988;1: 846-852. 3 Clarke, PS., Australian Family Physician. 1980; Vol 9, October

16. www.buteykobreathing.co.nz Hypocapnia can trigger mast cell de-granulation and histamine release Kontos et al. American Jnl of physiology 1972 Coakley et al. Jnl of Leukocyte Biology 2002:71 Strider et al., Allergy 2010 airways – asthma, hay fever skin – eczema gut – food allergies, irritable bowel (IBS) Perera, J. The hazards of heavy breathing. New Scientist, Dec 1988 HYPERVENTLATION - HYPOCAPNIA - INFLAMATION

17. Average tidal volumes of 950ml and average minute volumes of 15 litres per minute during the day were recorded in males diagnosed with sleep apnoea 1 1 Radwan et al., Eur Resp J 1995 2 Naughton M, Benard D, Rutherford R, Am J Respir Crit Care Med 1994; 3 Chan C, Woolcock A, Sullivan C. Am Rev Respir Dis 1989 Asthma improves with breathing control, through application of Continuous Positive Airways Pressure 3 CPAP reduces hyperventilation while applied 2 HYPERVENTLATION – SLEEP APNOEA - ASTHMA

18. carbon dioxide deficit – hypocapnia dehydrated and inflamed airways increased mucus production disruption in breathing regulation smooth muscle constriction - bronchial, cardiovascular, gastrointestinal, urinary reduced oxygenation - broncho-spasm, vaso-constriction, Verigo-Bohr Effect pH disturbance bigger breathing volume = more inhaled irritants histamine production CONSEQUENCES OF OVER-BREATHING: www.buteykobreathing.co.nz

19. OVER- BREATHING CHECKLIST habitual mouth breathing audible breathing nasal congestion/ mucus upper chest breathing pattern poor posture, shoulders high, forward, slouching frequent sighing or yawning large inhalations through mouth when speaking rapid breathing rate > 15 breaths/minute paradoxical (reverse) breathing irregular breathing pattern, breath-holding cold hands and feet dry skin: face, lips, hands and feet

20. www.buteykobreathing.co.nz STRESS MAKES US BREATHE MORE If the stress is prolonged over-breathing becomes habitual stress in workplace, school, home, bereavement, financial illness, infection lack of exercise, athletes over-training over-eating, skipping meals, too much refined carbs, low protein some medications; e.g. bronchodilator medications caffeine, nicotine, alcohol, recreational drugs promotion of deep breathing techniques computer games, excessive use of personal technologies IN SUMMARY LIFE

21. MOUTH BREATHING AND TONGUE POSITION Nasal breathing with tongue in the roof of the mouth helps iiiensure wide dental arches and straight teeth The tongue is one of the strongest muscles in the body, capable of exerting 500 grams of pressure. It only takes 1.7 grams of pressure to move a tooth. Mouth breathers carry the tongue in the floor of the mouth potentially leading to narrow dental arches, crowded teeth, receding chin, smaller jaw and risk of sleep apnoea Normal wide arches Narrow arches No room for tongue here

22. Lateral airway views of a Mouth breather Nasal breather Note low tongue postureNote correct tongue posture

23. nose breather mouth breather CT SCANS

24. Mandibular advancement showing opening of airway

25. MOUTH BREATHER Uncorrected open-mouth breathing is likely to result in: crooked teeth narrow dental arches receding chin protruding nose narrow airway and high risk of developing obstructive sleep apnoea by the age of thirty

26. Anterior open bite, narrow upper arch

28. Bolton standard Mouth breathing at an early age can effect dental arch development. Narrow jaws can lead to crooked teeth and a distorted facial profile. If the underlying mouth breathing habit is not corrected features become more exaggerated with age.

29. www.buteykobreathing.co.nz DENTAL DISORDERS LINKED TO OPEN MOUTH BREATHING dental decay malocclusion narrowing of dental arch dental crowding, crooked teeth cross-bite anterior open bite gum disease, bad breath inflammation of adenoids and tonsils TMJ dysfunction

30. SNORING AND SLEEP APNOEA EXPLAINED - it’s your breathing breathing stimulated snoring over-breathing blood pH normalising O 2 release to cells inflame/narrow airways vibration noise suction effect CO 2 increase CO 2 deficit (hypocapnia) central sleep apnoea CO 2 < apnoeic threshold cellular hypoxia obstructive sleep apnoea

31. MRI scan red - yellow = highest oxygen dark blue = least oxygen This may might help explain the link between sleep apnoea and a higher incidence of cancer 1 and Alzheimer’s 2 SNORING - SLEEP APNOEA AND BRAIN HYPOXIA 1 Dr. F. Javier Nieto 2 Osorio et al 2013

32. www.buteykobreathing.co.nz BUTEYKO BREATHING RETRAINING Asthma Chronic nasal congestion Allergic rhinitis Sleep apnoea, chronic snorers Panic attack Dental disorders resulting from open-mouth breathing Who are our clients:

33. www.buteykobreathing.co.nz BUTEYKO BREATHING RETRAINING Rate Rhythm volume Mechanics - correct use of breathing muscles Use of the nose - inhale/exhale To normalise each aspect of the breathing pattern: Tess Graham – Relief from Snoring and Sleep Apnoea p 80 - For all situations: awake, asleep, at rest, when eating, speech and physical exercise

34. www.buteykobreathing.co.nz THE NOSE YOUR PORTABLE AIR CONDITIONER warms filters humidifies disinfects (germicidal action of NO in paranasal sinuses 1 nasal breathing increases arterial CO 2 by 20% and O 2 by 8% 2 2 Swift et al Lancet 1988 1 Lundberg Anat Rec 2008

35. www.buteykobreathing.co.nz NOSE UN-BLOCKING EXERCISE 1. Breathe in and out normally through nose 2. Hold on the out breathe for as long as is comfortable 3. Then gradually resume very gentle breathing It may help to pinch the nose and nod your head a few times In stubborn cases or when the blockage is due to a cold, the exercise may need to be repeated several times

36. www.buteykobreathing.co.nz DIAPHRAGM BREATHING EXERCISE sit with upright posture on a stable firm chair move to the front edge of the chair, upper legs parallel with the floor, knees directly over the ankles practise breathing gently into the belly Breathe slowly, rhythmically and gently making each breath as small as you can Do this for 3-5 minutes a few times a day to help tone the diaphragm and reduce upper chest breathing Small movements

37. REDUCING BREATHING VOLUME Hold the index finger under your nose to feel how much air goes in and out. When you are breathing normally you will feel warm air across your finger on the out-breath and cool air on the in-breath. Try slowing your breathing down until you can hardly feel any air across your finger. If you have a healthy breathing pattern you should be able to maintain this sensation of no air on your finger for five minutes or more. An exercise to help habituate to reduced breathing volume

38. FEATHER BREATHING Soft invisible breathing as practised by the Samurai

39. TWO TO FIVE BREATHING EXERCISE You can use this breathing exercise to de-stress, help overcome an anxiety/panic attack, relieve breathlessness, chest tightness or asthma and to help you sleep. This exercise can be done sitting, standing or lying down. Try to breathe gently through your nose and breathe from the belly.

40. www.buteykobreathing.co.nz Breathe well by day and you will breathe well by night BREATHE WELL – SLEEP WELL Nose breathing by day and you are more likely to nose breathe during sleep; try to sleep with mouth closed Do some nose clearing and breathing exercises prior to sleep Sleep with upper body slightly elevated Avoid sleeping on back, left is best Avoid stimulating foods, drinks and activities at least 90- minutes before sleep Turn screens off at least 60 minutes before sleeping Sleep in a dark, well ventilated room, do not get over-heated

41. Foods containing refined white flour, sugar: refined breakfast cereals, pasta, noodles, cakes, cookies Drinks with added sugar: soft drinks, fruit juice... Milk and milk products, goats milk, soy milk, protein shakes Soft cheeses, cottage cheese, ice cream, yoghurt Chocolate Caffeine, alcohol Food additives; MSG, sulphites, sodium benzoate, nitrites, aspartame Foods that adversely affect breathing and may trigger asthma, nasal congestion, snoring, poor sleep or headache Note: over-eating leads to over-breathing

42. BREATHING AND SPEAKING Breathing tips for talking: Try to talk less Talk more slowly Breathe in through your nose at the start of each sentence Do not take a big breath in before speaking Breathe more gently and quietly when talking Speak in shorter sentences

43. www.buteykobreathing.co.nz Instruct to nasal breathe if possible Slow breathing rate and try to reduce breathing volume Try to breathe diaphragmatically Reduce or eliminate consumption of dairy products Reduce or eliminate refined carbohydrates especially foods and drinks with added sugar Sleep on the left side with head elevated BREATHING GUIDELINES FOR ASTHMA RELIEF Guidelines for reducing minute volume and normalisation of the breathing pattern

44. www.buteykobreathing.co.nz ASTHMA AND SPORT Instruct to breathe through the nose, whenever possible to help maintain the bronco dilating effects of CO 2 in airways Adjust intensity to allow comfortable nasal breathing Drop shoulders and breathe from diaphragm Slow the rate and reduce breathing during breaks in play and after physical exertion to boost cellular O 2 and reduce lactic acid We instruct not to pre-dose with reliever medication but to carry at all times and use if needed. 1 1 Any changes to prescription medication, where appropriate, are undertaken by the clients’ prescribing doctor.

45. SUMMARY POINTS 1 of 2 Over-breathing and low tongue posture can result in underdeveloped jaw, narrowed nasal passages and upper airways this can lead to respiratory disorders such as chronic nasal congestion, glue ear and adenoid enlargement It can contribute to asthma and a higher risk of developing sleep apnoea in adult life

46. SUMMARY POINTS 2 of 2 Asthmatics over-breathe. People who snore are over-breathing. Sleep apnoea is a compensatory mechanism in response to hypocapnia resulting from over-breathing (snoring) Recognition of over-breathing, and awareness of the harm caused by it can be immediately beneficial. Correct breathing has profound benefits to general and specific health.

47. SIX THINGS YOU CAN DO: 1. Instruct on the importance of nasal breathing for ADL 2. To maintain nasal breathing at rest, during physical exertion, sleep 3. Correct tongue posture; with tongue in roof of the mouth 4. To supress yawns and the urge to sigh, gasp, cough, snort, sniff 5. Instruct on nasal clearance using the nose un-blocking exercise 6. Instruct on diaphragmatic breathing

48. www.buteykobreathing.co.nz BUTEYKO BREATHING CLINIC PROGRAM * Four initial, consecutive 90-minute breathing retraining sessions Two follow up sessions within six weeks Telephone support and additional sessions if required for six weeks Breathing exercises practised for six weeks Life-long awareness of the concepts is recommended course fee $605 Ages four and up Referral not essential * Buteyko clinic practitioners teach the Buteyko Institute Method of breathing retraining.

49. THE TEAM- BIBH PRACTITIONERS Glenn White Practioner trainer Auckland Tricia Enriquez-Gault Auckland Olga Horne Auckland Susan Allen Wanaka Viv Smith Queenstown Arisa Shioda DS Japan Eddie Johnson Auckland Pia Schroeter Auckland Melody Sloggett Auckland Dina Ceniza Auckland Our practitioners teach to Buteyko Institute of Breathing and Health (BIBH) standards. The BIBH is ISO 9001:2008 Certified Ines Steward Auckland OUR TRAINEES