Glenn White BSc MSc MBIBH BIBH Practitioner/trainer buteykobreathing

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

2. BREATHING AWARENESS Count the number of breaths you take in one minute 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 www.buteykobreathing.co.nz

3. FUNCTIONAL BREATHING After Graham, T 2012, Relief from snoring and sleep apnoea

4. DYSFUNCTIONAL BREATHING After Graham, T 2012, Relief from snoring and sleep apnoea

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

7. 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 www.buteykobreathing.co.nz

8. MORNING BREATH

9. THE LUNGS AND CARBON DIOXIDE (CO2) One of the lung’s primary functions is to maintain optimum levels of O2and CO2 in airways and blood Mouth breathing and over-breathing result in CO2 loss resulting in CO2deficit (hypocapnia)

10. The Importance of CO2 • An optimal level of CO2is essential in airways and blood for oxygen delivery to brain and body tissues • CO2is a broncho/ vaso dilator 1 • Optimal PaCO2is essential for the release of oxygen from blood to body tissues (The Bohr Effect) 1DAVIS FREED Am.J.Respir.Crit. Care Med.2001, 785-789

11. OVER-BREATHING AND CO2 LOSS REDUCES BRAIN OXYGEN 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)

12. 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 www.buteykobreathing.co.nz

13. Human breathing volumes have doubled in fifty years 12 12 12 11 7.8 6.9 6 5.3 4.9 4.6

14. Average MV measured for asthmatics in Brisbane Buteyko trial - 15 litres per minute (normal 10 litres) 1 Hyperventilation whether spontaneous or exercise induced, is known to cause asthma 2, 3, 4 Hyperventilation (over-breathing) - a mechanism that is often overlooked in asthma. Loss of CO2through hyperventilation can trigger bronchoconstriction in asthmatics 4, 5 • 1 Bowler S, Green A, Mitchell C, Medical Journal of Australia 1998; 169: 575-5782Demeter & Cordasco The American Journal of Medicine, (1986), vol 81 pp 989.3Clarke PS, Gibson, JR AustFam Physician. 1980 4Sterling, GM., ClinSci, (1968), vol 34, pp 277-2855van den Elshout, FJJ et al., Thorax, (1991), vol 46, pp 28-32

15. Hyperventilation andhypocapnia (CO2 deficit)are common in asthma 1, 2, 3 Hypocapniais the rule in asthma until respiratory failure sets in 3 HYPERVENTLATION - HYPOCAPNIA AND ASTHMA • 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. Hypocapnia can trigger mast cell de-granulation and histamine release • airways – asthma, hay fever • skin – eczema • gut – food allergies, irritable bowel (IBS) HYPERVENTLATION - HYPOCAPNIA - INFLAMATION Perera, J. The hazards of heavy breathing. New Scientist, Dec 1988 Kontos et al. American Jnl of physiology 1972 Coakley et al. Jnl of Leukocyte Biology 2002:71 Strider et al., Allergy 2010 www.buteykobreathing.co.nz

17. HYPERVENTLATION – SLEEP APNOEA - ASTHMA 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 CPAP reduces hyperventilation while applied2 • Asthma improves with breathing control, through application of Continuous Positive Airways Pressure 3 • 1Radwan et al., EurResp J 19952 NaughtonM, Benard D, Rutherford R, Am J RespirCrit Care Med 1994; 3 Chan C, Woolcock A, Sullivan C. Am Rev Respir Dis 1989

18. CONSEQUENCES OF OVER-BREATHING: • 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 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 www.buteykobreathing.co.nz

20. 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 www.buteykobreathing.co.nz

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 Narrow arches No room for tongue here Normal wide arches

22. Lateral airway views of a Mouth breather Nasal breather Note low tongue posture Note 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. 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 www.buteykobreathing.co.nz

30. SNORING AND SLEEP APNOEA EXPLAINED- it’s your breathing breathing stimulated snoring over-breathing inflame/narrow airways vibration noise CO2 deficit (hypocapnia) blood pH normalisingO2 release to cells CO2 < apnoeic thresholdcellular hypoxia suction effect obstructivesleep apnoea centralsleep apnoea CO2 increase

31. SNORING - SLEEP APNOEA AND BRAIN HYPOXIA 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 1 Dr. F. Javier Nieto 2 Osorio et al 2013

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

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

34. THE NOSE YOUR PORTABLE AIR CONDITIONER • warms • filters • humidifies • disinfects (germicidal action of NO in paranasal sinuses 1 • nasal breathing increases arterial CO2 by 20% and O2 by 8% 2 1 Lundberg Anat Rec 2008 2 Swift et al Lancet 1988 www.buteykobreathing.co.nz

35. NOSE UN-BLOCKING EXERCISE • Breathe in and out normally through nose • Hold on the out breathe for as long as is comfortable • 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 www.buteykobreathing.co.nz

36. 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 www.buteykobreathing.co.nz

37. REDUCING BREATHING VOLUME An exercise to help habituate to reduced 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.

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. BREATHE WELL – SLEEP WELL Breathe well by day and you will breathe well by night • 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 www.buteykobreathing.co.nz

41. Foods that adversely affect breathing and may trigger asthma, nasal congestion, snoring, poor sleep or headache • 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 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. BREATHING GUIDELINES FOR ASTHMA RELIEF Guidelines for reducing minute volume and normalisation of the breathing pattern • 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 www.buteykobreathing.co.nz

44. ASTHMA AND SPORT • Instruct to breathe through the nose, whenever possible to help maintain the bronco dilating effects of CO2 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 O2and 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. www.buteykobreathing.co.nz

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

46. 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. www.buteykobreathing.co.nz

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