SNORING, SLEEP APNOEA AND BREATHING R

SNORING, SLEEP APNOEA
AND BREATHING RETRAINING

Sleep disorders are A t age 48, Bill sometimes wondered if he was going to die early, or at
a modern epidemic, least have to give up work. His 20-year-plus snoring problem had
deteriorated into sleep apnoea—where his dreadful snoring was
but medical now interrupted by worrying silences (where he had stopped
interventions aren’t breathing), then gasping and choking episodes as he resumed breathing.
always successful or
Sometimes Bill woke himself up with particularly loud snoring or the jerking
well tolerated. of his body as he fought for his breathing to resume. His days were
The good news is 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 there are that Bill had obstructive sleep apnoea, a condition where breathing stops
simple techniques intermittently throughout the night due to obstruction in the upper airway.
which can be used
to restore correct 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
breathing and pressure) machine—an air pump attached to a face mask. However, Bill was
improve sleep within 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
only a few days. 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
by Tess Graham © 2014 taken seriously. I'll talk more about Bill a little later.

BreatheAbility International Snoring and Sleep Apnoea Explained
Post Office Box 4393 Snoring is the noise created by turbulence and vibration of the tissues

Manuka, ACT 2603, Australia lining the throat as air passes through to the lungs. Snoring is far more than
Telephone: +61 (0)2 8188 1343 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
Email: [email protected] incidence of chronic snoring among men who suffer strokes. Furthermore,
http://BreatheAbility.com 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 2014 www.nexusmagazine.com NEXUS • 33

times more likely to have a road accident.1 They also to hold the jaw and tongue more forward to help brace
have an increased incidence of workplace accidents. open the airway at the back of the throat.

The direct and flow-on costs to business and the • CPAP, an apparatus used during sleep and consisting
health care system are enormous. Sleep disorders cost of an air-pump machine, tubing and face or nose mask
the Australian economy more than $10 million each which delivers positive air pressure to brace the airway
year2, and the number of people being diagnosed each open and prevent obstructive sleep apnoea.
year continues to grow. These costs are skyrocketing as
the incidence of snoring and sleep apnoea increases. CPAP is the "gold standard" treatment for sleep
apnoea. However, as a gold-standard treatment it has a
SOME STATISTICS significant shortcoming. While it works extremely well to
• It’s estimated that around 40 per cent of the adult reduce or eliminate apnoea episodes and improve sleep
population snores at least occasionally, with the figure quality, studies show that only 30 to 60 per cent of
rising to around 60 per cent in the over 40s. people for whom CPAP is the recommended option
• While the incidence of snoring is greater in men and complied with the treatment.6
the middle-aged, more than 30 per cent of middle-aged
women are said to snore habitually. Not surprisingly, many people find CPAP unacceptable
• A study of primary school children in Perth, Western or intolerable. This can be because of claustrophobia, or
Australia, found that 15.2 per cent were habitual because they've started a new relationship, or because of
snorers.3 difficulty in finding a comfortable mask or machine
• In 2010, an estimated 4.7 per cent of the Australian despite the wide variety available. The use of CPAP on a
population over 20 years of age had obstructive sleep nightly basis for the rest of your life can be a daunting
apnoea (OSA) though this may be underestimated as prospect, and many reject it.
OSA is considered to be significantly underdiagnosed.4
• The US National Sleep Foundation estimates that more The success rate of the surgical options varies with the
than 18 million American adults have sleep apnoea and different procedures, but estimates suggest that it is
that a minimum prevalence of 2 to 3 per cent exists in generally not more than 50 per cent, especially in the
children.5 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.

Medical Treatments and Appliances CPAP full face mask
It will come as no surprise that with these statistics
When CPAP or an oral appliance suits the patient and
there is a thriving industry in diagnostic "sleep clinics" is worn all night, the night-time symptoms of snoring
and in manufacturing and selling products to treat the and sleep apnoea can be eliminated or greatly reduced
problems. New sleep clinics are popping up in suburban and energy levels are much better during the day. It can
areas, and nearby are shops with sleep apnoea supplies be a remarkable turnaround in health and well-being for
including a large array of machines and masks from many people. However, these appliances only work if
which to choose. These places did not even exist 30 they are worn every night for most of the night. There is
years ago. no carry-over improvement in the underlying snoring or
apnoea problem.
Oral appliances (dental splints) are supplied by dental
surgeries, and all manner of products, devices and What’s Going On In Our Bedrooms?
accessories are sold in pharmacies and on the Internet, Lying there at night, trying to ignore the noise of a
all promising relief. This is relief, not cure, as it is
acknowledged that in most cases the underlying snoring bed partner, have you ever wondered why people
problem persists and lifetime treatment is required. snore? If you've had the altogether scary experience of
lying next to a loved one who stops breathing and then
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

34 • NEXUS www.nexusmagazine.com APRIL – MAY 2014

jerks their body and makes choking sounds while deep breaths, sighs or yawns. These are all indicators of

struggling to get a breath in, have you ever wondered an overbreathing pattern. When you're lying down and

why their breathing stops or when they will start asleep, however, overbreathing and its effects may be

breathing again? very noticeable to an observer.

The traditional medical viewpoint sees snoring and Anyone who has slept next to a heavy snorer will

sleep apnoea connected with the breathing passages identify with this high "drive to breathe". One woman

being or becoming too narrow to allow easy, quiet and described her partner's snoring this way: "He breathes

continuous breathing during sleep. Contributing factors two breaths for my one. When he breathes in, it's like

are seen to include nasal congestion, a deviated nasal he's sucking the paint off the walls; when he breathes

septum, enlarged tonsils and adenoids, excess fat out, I feel I have to hold on to the edge of the bed so he

around the neck, a small or retracted jaw, a narrow upper doesn't blow me out."

palate or an overly large tongue. However, this When you breathe in too quickly and/or too heavily, the

"explanation", while indeed including factors which soft tissues lining your airway can become dehydrated,

contribute to airway narrowing or obstruction, fails to swollen and congested, narrowing your airway. During

explain how snoring and apnoea can occur in people sleep, when your throat muscles are more relaxed, these

with none of these factors being tissues can vibrate and create the

present or can be absent despite snoring noise.

several of them being present. Also, it Obstructive sleep apnoea is like sucking

does not explain why sleep apnoea The first thing you too hard on a straw. Breathe in quickly
often develops in people many years or heavily enough and you may suck

after they have developed their "risky" need to know is the walls of your throat closer

adult facial features and body type. that snoring and together, or suck your tongue or uvula
Consider this: unless you have had backwards, and limit or completely

facial injuries, you likely have had sleep apnoea do obstruct the flow of air to your lungs
much the same-shaped nose and not occur in for a period of time. These effects are
upper palate and the same-sized jaw related to laws of physics: the Venturi

and tongue all your adult life. If you people with a and Bernoulli effects.
are 45 now and chronically snore and normal breathing Research has shown that men with
have sleep apnoea, but did not at age
sleep apnoea breathe an average of 15

30, it is unlikely that your tongue pattern. People litres of air each minute.7 This is
has grown significantly larger, who snore and three times as much as a healthy
your septum has become more breather does.

deviated or your jaw has have sleep apnoea Now a hearty snore and a
narrowed. do not breathe suction force sufficient to
obstruct your throat are not likely
Something has changed

substantially, but what is it? correctly; there to happen when you breathe
Could there possibly be another are no exceptions. normally—which is to breathe in
way of looking at this problem and out, silently, slowly, gently,

which reveals a more fundamental about 10 times a minute, 500

solution? millilitres per breath, a total of

around five litres of air each

What’s Been Missed? minute. This breathing is called

The first thing you need to know physiologically normal breathing.8

is that snoring and sleep apnoea do not occur in people As well as its mechanical effects on the airway

with a normal breathing pattern. People who snore and (turbulence, vibration, suction), described above, high-

have sleep apnoea do not breathe correctly; there are no volume breathing creates imbalance in the levels of

exceptions. carbon dioxide and oxygen in the blood, affecting blood

While snoring and sleep apnoea can certainly be made chemistry. If the level of carbon dioxide drops sharply,

worse by anatomical factors and things like drinking too the signal from the brain to the diaphragm may fail and

much alcohol or having a cold, a fundamental breathing may cease temporarily. This is called central

contributing factor in both is a high inspiratory airflow rate: sleep apnoea.

high-volume, high-speed breathing—that is, inhaling an When imbalance in carbon dioxide is maintained over

excessive amount of air and inhaling it rapidly. a critical period of time, the carbon dioxide "set point" of

Most often, snorers are unaware of their heavy air the breathing receptors in the brain which drive your

usage. In the daytime, they can be so used to it that they breathing become altered from the optimum. From then

don't notice their mouth-breathing, somewhat heavier on, you can end up unconsciously breathing at a rate

breathing, upper-chest breathing or their intermittent that is detrimental to body function and chemical

APRIL – MAY 2014 www.nexusmagazine.com NEXUS • 35

FAULTY-BREATHING QUIZ do something about.
One of the most comprehensive

[ ] Do you snore? discussions on overbreathing or

[ ] Do you ever wake up gasping or choking and coughing? hyperventilation is the aptly titled paper
by Dr Gregory Magarian et al.:

[ ] Is your breathing audible day or night? "Hyperventilation syndrome: A

[ ] Is your breathing heavy or laboured? diagnosis begging for recognition"
(1983).9 He commented that while

[ ] Are you breathless at any time? acute hyperventilation (as in a "panic

[ ] Do you often feel “spacey” or dizzy? attack") is fairly easy to see, the
chronic form often goes

[ ] Do you mouth-breathe? unrecognised.

[ ] Do you breathe with your upper chest? Medical scientist and physician
Professor Konstantin Buteyko coined

[ ] Do you breathe more than 14 times a minute? the term hidden hyperventilation

[ ] Is your breathing irregular or erratic? because of the often subtle
presentation of its chronic form. His

[ ] Do you breath-hold in the day or night? exhaustive research spanning several

[ ] Do you have panic attacks? decades from the 1950s showed
[ ] Do you have a persistent or irritable cough? chronic hyperventilation to be very
prevalent in the general population.10

[ ] Is your nose often stuffy or congested? Chest physician Dr Claude Lum
[ ] Do you feel like you can’t get enough air when you nose-breathe? published extensively on the
hyperventilation syndrome. In his

[ ] Do you sigh, yawn or clear your throat often? article "Hyperventilation: the tip and
the iceberg" (1975)11 he had this to

If you have answered YES to one or more of these, then you likely have a say. "The many organs involved are
disordered breathing pattern and may benefit from breathing retraining. often reflected in the number of
specialists to whom the patient gets

processes and results in reduced oxygenation of cells, referred, and my colleagues have variously dubbed this

tissues and organs throughout the body (the Bohr the 'multiple doctor' or the 'fat folder syndrome'. Indeed

effect). the thickness of the case file is often an important

Breathing is a critically important body function. It is diagnostic clue."

the first thing we do in life, and the last. Many people The consequences of overbreathing day after day are

are getting it wrong over 20,000 times a day. far reaching. The body struggles and tires as it tries to

It is very likely that a person's breathing pattern has maintain equilibrium.

changed significantly over the period of time in which Unfortunately, diagnosis of this extremely common

they developed a heavy snoring and apnoea problem. disorder does not appear to have improved at all since

However, someone with snoring and sleep apnoea is Magarian, Buteyko and Lum published their findings.

unlikely to know this, and checking a person's baseline Yet the incidence of overbreathing is even greater now.

breathing pattern is not part of standard medical More and more people are breathing too rapidly or are

diagnosis. Nor do the commonly used treatments for snoring or mouth-breathing—and these include large

snoring and sleep apnoea seek to address the numbers of children. Rarely are parents and teachers

fundamental disturbance in breathing pattern—the aware of the consequences of this. Parents may have to

abnormal way of breathing. People are often steered cope with constant mucus conditions and tired children,

towards surgical, pharmaceutical or appliance-based teachers with behavioural and learning issues, dentists

interventions without considering what they can do with tooth decay, orthodontists with the narrow upper

themselves to improve their breathing habits. (This is palates and crowded and crooked teeth which are

not unlike obese patients with poor eating habits having consequences of mouth-breathing.

gastric band surgery without first being advised to try to

improve their diet.) Breathing Retraining

It was a stroke of good luck for Bill (whom we met at

Overbreathing: Overlooked! the beginning of this article) that, while faced with the

Snoring and sleep apnoea are fundamentally problems difficult choice between throat surgery and CPAP, he

with the way you breathe—day and night. heard about a breathing retraining course. The concept

Overbreathing is a prime contributory factor in snoring made sense to him—after all, for over two decades there

and sleep apnoea—and thankfully it's one that you can obviously had been something wrong with the way he

36 • NEXUS www.nexusmagazine.com APRIL – MAY 2014

was breathing! From the second day of the breathing heavy and from the upper chest. She sighed frequently.

course, he noticed an improvement in his sleep. By the On her pre-training questionnaire she marked off 54

end of that week, his concentration and stamina were different symptoms of overbreathing, ranking many of

better and, according to his wife, he was no longer them moderate to severe. Janelle was amazed to find out

snoring. Some months later, he had a repeat sleep study that providing information about what was happening in

done—and there was no evidence of sleep apnoea. By the day and how she breathed when awake was just as

taking responsibility for the way he breathed, Bill had in important to the breathing educator as her night-time

effect "fixed" himself. symptoms. For Janelle, eight days into breathing

Breathing training/retraining is the specific discipline retraining she was sleeping well. Her husband said that

in which the primary goal is to normalise each aspect of she no longer snored. Her chest pain and palpitations

the breathing pattern (rate, rhythm, volume, use of the had ceased. She was calm and had more energy.

nose, use of the diaphragm) for all situations (awake,

asleep, at rest, during eating, speech and exercise).12 The Training Process

The process involves identifying incorrect breathing A typical breathing training program involves an initial

habits, undoing them and replacing them with the consultation with a breathing educator, then a structured

correct ones. Step by step, you replace faulty breathing program of five to eight 90-minute sessions (60-minute

with silent, efficient, gentle diaphragm-breathing. It sessions for children).

works because while breathing is automatic, you can Clients should practise the exercises and techniques

also consciously vary it. on a daily basis, formally and

Think of your brain as having a informally, until their breathing

manual override and reset The benefits are immediate, pattern is normal and stable or
button. You practise breathing until they reach the best point

correctly during the day to and most people comment they are capable of within the
retrain (i.e., reprogram or reset) confines of their condition.
the brain's "drive to breathe" that they have had their They can then taper down the

centre to operate at the correct best sleep in decades exercises to maintain the
level at rest, when exercising within just a few days of improvements.
and while sleeping. When it is
It really is that simple. The

reset, quieter, softer, more starting the process. benefits are immediate, and
regular breathing is maintained most people comment that they

day and night. have had their best sleep in

decades within just a few days

Assessing The Breathing Pattern of starting the process.

There are some simple checks and observations that Clients are advised that changes in prescribed

can be made to alert to the presence of overbreathing medication and treatments must be undertaken only in

and other dysfunctions. consultation with their doctor. A follow-up sleep study is

Breathing educators assess their clients by observing recommended for clients with sleep-breathing disorders.

the rate, rhythm, volume, mode and mechanics of

breathing, and through questionnaires. They also use Scientific Evidence

breath-hold tests or capnometry. (Capnometry monitors Breathing retraining is a science-based process, and

the partial pressure of carbon dioxide in expired air.) peer-reviewed studies show its effectiveness in

People with asthma, anxiety or sleep apnoea often tick normalising breathing patterns.13–17

off more than 20 different symptoms of overbreathing as The most researched and best-known form of

they fill in the form on their first visit to a breathing breathing retraining is the Buteyko Method of Breathing

educator. They can often be observed overbreathing Reconditioning, developed by and named after Ukrainian

while they complete the questionnaire! doctor Konstantin Buteyko.

Janelle, aged 42, came for breathing retraining because While breathing retraining has been acknowledged as

of her heavy snoring and sleep apnoea. She also had an effective and safe adjunct therapy for asthma by the

restless legs, dizziness, chest pains, palpitations, anxiety, US government's Agency for Healthcare Research and

lots of mucus and debilitating fatigue. As she put it, she Quality and by the British Thoracic Society,

had already "been through the mill", having undergone a unfortunately it is not as widely known as a management
sleep study, an operation on her nose and an exercise option for sleep-breathing disorders.
stress test with her cardiologist. She was prescribed
various medications. She had tried but could not adjust However, there is a large body of anecdotal evidence
to sleeping with a CPAP machine; she felt supporting its effectiveness. In 2010, the Buteyko
claustrophobic. Institute of Breathing & Health conducted a
retrospective survey among its members. Practitioners
Janelle's breathing was not fast but was audible, very who participated had collectively taught over 11,000

APRIL – MAY 2014 www.nexusmagazine.com NEXUS • 37

clients with sleep apnoea. A majority of practitioners (73 It should be part of a mainstream approach. At the
per cent) estimated that over 95 per cent of clients had very least, breathing retraining should be offered as an
improved their sleep after completing a course in option to people with sleep-breathing disorders who
breathing retraining.18 have found surgical or appliance-based approaches
unsuccessful or unacceptable.
The simplest things in life are often the best: changing
the way you breathe has to beat having a machine do it It is hoped that awareness of poor breathing habits
for you. and of the benefits of breathing retraining will continue
to grow in the community and will lead to
Five Tips for Better Breathing, implementation of prevention strategies within our
Health and Sleep primary health care system.

1. Be aware of your breathing. Know that Breathing retraining offers a wonderful opportunity to
physiologically normal breathing is nasal, empower yourself to improve your health and quality of
life. It is never too late to change. An 80-year-old
silent, slow, soft, smooth breathing. actually volunteered herself for a television news story
because she wanted to let other people know that "you
2. Breathe through your nose whenever it can teach an old dog new tricks".
is comfortable to do so.
There is nothing more fundamental to health than getting your
3. Breathe more gently. If your nose is
blocked or you are uncomfortable breathing right. ∞

breathing through it, then try to breathe About the Author:
more gently through your mouth. Tess Graham is a physiotherapist and breathing educator.
She has extensive clinical and research experience in
4. Sit more upright. When you slouch, breathing retraining and has worked exclusively in this field
you are more likely to breathe faster and for over 20 years. Two of her three children had asthma,
with the upper chest, which is tiring and which was continuing to worsen despite being managed by
conventional medical treatments. The turnaround for
makes you feel stressed. them came when they took part in a breathing retraining
course. This was also the turning point of Tess’s career.
5. See a breathing educator She undertook considerable research into breathing,
for additional help. including training in the Buteyko Breathing Method. In
1993 in Canberra, she established Australia’s first dedicated
What Makes You Breathe Incorrectly? breathing clinic. Tess has now taught breathing retraining
Breathing is influenced by many factors, including programs to over 5,500 people and lectured throughout
Australia and overseas. She is the author of Relief from
stress, training in breathing, habit, posture and diet. Snoring and Sleep Apnoea: A step-by-step guide to restful
For those who have sleep apnoea, it is most likely that sleep and better health through changing the way you
breathe (Viking/Penguin, 2012; reviewed in NEXUS 21/02).
they breathe more heavily and/or more quickly now than
they used to do. They may have developed a habit of Tess Graham is director of BreatheAbility International.
mouth-breathing without noticing it, an irritable dry She can be contacted by telephone at +61 (0)2 8188 1343,
cough, habitual sighing or throat clearing, or breathing by email at [email protected] or via the
more quickly and with the upper chest because of a BreatheAbility website, http://BreatheAbility.com.
slumped seated posture or persistent anxiety.
Endnotes
Getting Help For Your Breathing 1. Austroads Ltd, "Assessing Fitness to Drive", March
The number of breathing educators worldwide is 2012 (4th edition), p. 105, http://tinyurl.com/m3rqnv8,
accessed 19 March 2012
comparatively small, but is growing due to the 2. Deloitte Access Economics, "Re-awakening Australia:
consistently profound results achieved with breathing The economic cost of sleep disorders in Australia, 2010",
retraining. In Australia, there are breathing educators in commissioned by the Sleep Health Foundation,
most capital cities and in some regional centres. published October 2011, http://tinyurl.com/l9pzwob
3. Zhang, G., Spickett, J., Rumchev, K., Lee, A.H., Stick, S.,
Snoring and sleep apnoea can have devastating health "Snoring in primary school children and domestic
and social consequences. They need to be adequately environment: A Perth school based study", Respir. Res.
addressed by one means or another. Breathing 2004 Nov 4; 5(1):19, published online 4 November 2004,
retraining is a safe, natural and commonsense approach doi: 10.1186/1465-9921-5-19, http://tinyurl.com/ko4kkmu
to what is, after all, a breathing problem. 4. Deloitte, ibid.

Continued on page 83

38 • NEXUS www.nexusmagazine.com APRIL – MAY 2014