A 2019
study states that OSA is twice as common in people with epilepsy than in
the gene ral population, and as in other OSA cases, its incidence increases
with age.74 According to this review , subjective self-reporting of daytime
sleepiness is particularly unhe lpful as a diagnostic tool for OSA in
epileptics, becau se a diverse range of comorbidities can cause tiredness in
epilepsy . The prevalence of sleep disorders in epileptic children is under -
recognized.71 Children with epilepsy often experience changes in the way
they sleep—how  quickly they fall asleep, their total sleep time, sleep
architecture, and spontaneous arousals—and they are more likely to suffer
from broken sleep and daytime drowsiness.71
Many things can cause sleep disruption in children with epilepsy ,
including the epilepsy itself and antiepileptic medications. These childrenpresent with conditions includin g SDB, OSA, and limb movements during
sleep. The poor quality of sleep that results has a negative impact on seizure
control that may logically be related to hyperventilation cause d by mouth
breathing during sleep. Sleep deprivation can trigger seizures, and frequent
seizures cause broken sleep, creating a vicious cycle. Even when seizures
occur during wakefulness, they can have a negative impact on sleep.71
Antiepileptic drugs can cause marked weight gain in children. Aside from a
general feeling of tiredness and poor health, this increases the likelihood of
SDB as excess fat on the abdomen and tongue restricts the movement of the
diaphragm and narrows the airways.75
According to a 2019 paper , several small retrospective studies have
found that positive airway press ure treatments such as CPAP can produce a
significant reduction in seizures for people who have comorb id epilepsy
and OSA74. A 2018 article in Epilepsy Foundation  reported that patients
treated with positive airway pressure had a 63% chance of a reduction in
seizures of up to 50%.70 This was comp ared with a 14% chance for those
who were untreated. Apnea, hypercapnia (too much  blood CO2), and oxygen desaturation
(when blood oxygen levels drop below normal) can all occur  during and
immediately after a seizure, especially with generalized tonic-clonic
seizures.74 The respiratory disturbances that occur during apnea suggest
activation of the central autonomic network, an intricate system of
structures in the brain that performs a key role in the working of the
autonomic nervous system.76 This may contribute to sudden unexpected
death in epilepsy (SUDEP), the leading cause of epilepsy-related death in
patients with drug-resistant epilepsy . People who die from SUDEP
generally have a history of nocturnal seizures and centrally mediated post-
seizure cardiorespiratory dysfunction.77 They often die during sleep, and
while sleeping prone (face down), but it is unknown whether OSA
contributes to sudden death.76
A 2018 study explored the relati onship between SUDEP and SDB in 30
participants and reported that cardiorespiratory dysfunction was more
common in patients at high risk of SUDEP , while SDB was found in 88% of
sleep-study results.77While epilepsy and SDB often coexist, one of the difficulties faced by
medical practitio ners when identifying abnormal events that are related to
sleep disorders rather than epilepsy is the fact that signs of nocturnal
seizures can overlap with symptoms of SDB.77 A 2014 paper describes the
case of a three-year -old child who demonstrated EEG activity during
seizure that could also be associated with a particular form of OSA. The
child’ s seizures were charac terized by increased respir atory rate,
paradoxical breathing, and oxygen desaturation.78 In this case,
cardiorespiratory sleep study results initially led to a misdiagnosis of severe
OSA. Excessive daytime sleepiness and sleep disorders are know n to be
common in adults with epilepsy , and one 2006 study found that children
with epilepsy also reported worse daytime sleepiness than a control group. In this study , researchers concluded that further research using screening
questionnaires and formal sleep studies is needed to accurately assess the
prevalence of sleep disorders in children with epilepsy .79
A 2008 study evaluated abnormal results in 40 epileptic children who
had each been referred for a sleep study because of various problems with
sleep.71 Snoring  was observed in 83% of patients, and SDB inclu ding
obstructive hyperventilation, sleep apnea, and upper -airway  resistance
syndrome was found in 42.5% of the children. Children who had poor
seizure control also experienced  poor quality sleep, a higher arousal index,
and a higher percentage of REM sleep states compared to those who were
either seizure-free or had good seizure-control. Those children who had both epilepsy and OSA generally had a much
greater body mass index and longer sleep latency—the amount of time it
takes to get to sleep. Significantly , they also demonstrated more severe
oxygen desatura tion than children who had sleep apnea uncomplicated by
epilepsy .71 A considerable number of the children with epilepsy who were
referred for polysomnography presented with SDB, including OSA. This
study concluded that treatment of OSA by removing the tonsils and
adenoids may lead to an improvement in sleep disturbances, which might in
turn result in better seizure control and quality of life. The researchers
suggested that physicians should routinely screen for snoring and other
signs of OSA when examining children with epilepsy .71 How ever, there isan argument that as with SDB  in nonepileptic children, developing the
airways and training in full-ti me nasal breathing should be considered
before resorting to sur gery. Research into the link between SDB and epilepsy is still very limited. It
is unclear whether epilepsy causes OSA or whether OSA exists  comorbidly
alongside epilepsy . But the evidence linking seizure frequency and duration
to chronic hyperventilation, coupled with the research confirming that
mouth breathing  during sleep is a common in both OSA and chronic
hyperventilation, would indicate that improving or eradicating SDB may
help with seizure control. THE V AGUS NER VE CONNECTION T O EPILEPSY
Electronic stimulation of the vagus nerve using implanted devices has been
used in the treatment of epilepsy and depression for several decades.80
More recently , noninvasive devices have been developed. As we discovered
in Chapter Four , vagal stimulation can also be achieved naturally by
practicing a breathing rate of six breaths per minute. The vagus nerve  innervates a wide range of organs, but its function can
be most  easily assessed in relation to the rhythm of the heart. Heart rate
variability (HRV) is indicative of vagal tone. As we know , low vagal tone
correlates with lower parasympa thetic activity and is linked to a wide range
of mental and physical conditions and early mortality .80
People with epilepsy , particular ly those whose seizure control is poor,
have lower vagal tone, leading researchers in a 2017 study to theorize that
natural stimulation of the vagus nerve might improve seizure control.80
Interestingly , the most common self-reported seizure trigger for people with
epilepsy is stress, a fact that points to an autonomic imbalance.81 The paper
discusses three natural methods for increasing HRV and parasympathetic
tone—stress reduction, nutrition, and exercise—but does not mention the
relationship between slow diaph ragmatic breathing and vagal tone. None of
the three suggestions mentioned  in the study were found to reduce seizures. But the researchers do report that patients have been known to experience
increased vagal tone and a subsequent reduction in seizures by listening to
music by Mozart.80 Equally , as already discussed, slow breathing has beenfound to reduce the onset and duration of seizures. This may have some
relation to activation of the parasympathetic nervous system as well as
counteracting the biochemical effects of hyperventilation. The study
concludes that much more work is needed to examine the impact of the
various methods for optimizing HR V on seizure occurrence. Vagus nerve stimulation is widely used to treat patients over the age of
12 years who have refractory epilepsy .82 A retrospective  study published in
2007 examined the data to find out whether the procedure had any adverse
implications for younger children. Scientists reviewed statistics for 26
children, aged between 3 and 17 years, who had been treated with vagus
nerve stimulation implants between 1998 and 2004. The children
predominantly suffered with symptomatic-generalized epilepsy . Seventy-
seven percent presented with moderate to severe intellectual disability , and
65 had more than 30 seizures every month. The duration of treatment in the
studied children ranged from one month to eight years. After treatment,  frequency of seizures reduced more than 50% in 54%
of the children. Two became seizure-free, 23% experienced seizure
reduction of less than 50%, and four developed the ability to end seizures
using the implan t. OSA was found in four of the children after placement of
the implant.82 The study concluded that vagus nerve stimulation is an
effective treatment for childre n with refractory epilepsy but that an
overnight sleep study should be used to identify patients with preexisting
OSA before the device is implanted.82
A small study of adults also made the connection between vagus nerve
stimulation and SDB in epileptic patients.83 The 2020 paper followed three
cases representative of SDB brought on by vagal activity in refractory
epilepsy . Of the three participa nts, two had sleep apnea and the third a
condition called stridor , which presents as a high-pitched wheezing. This
paper drew the same conclusion, as the 2007 study involving children, that
given the high incidence of OSA in people with refractory epilep sy, patients
should be screened for SDB before being treated with a vagus nerve
stimulation implant. However , researchers also suggest that SDB is a rare
complication of vagus nerve stimulation and, where sleep apnea occurs, it
must be investigated alongside data regarding the firing of the nerve
stimulator .A more recent study looked at the outcome of vagus nerve stimulation
treatment in terms of HRV and electrocardiogram (ECG) readings in
patients with drug-resistant epilepsy .84 Participants were 32 patients who
had received vagus nerve stimulation implants at the same hospital, and 32
healthy age- and gender -matched controls. Researchers found that those
people who failed to respond to vagus nerve stimulation—defined as having
less than a 50% seizure reduction one year after treatment—had
significantly lower preoperative vagal tone than those who responded well
to the treatment. In simple terms, patients whose parasympathetic tone was
worse received less benefit from the treatment. This would indic ate that it is
possible to predict the level of seizure reduction after treatment .84 It would
also suggest that patients who are able to improve their vagal tone,
something it is possible to do using breathing exercises, would gain more
benefit from the vagus nerve stimulation implant in terms of relief from
epilepsy symptoms. A 2018 study evaluated the effects of vagus nerve stimulation on HRV
in 20 epilepti c children.85 Researchers also investigated whether
antiepileptic drugs had any negative impact on HRV. Prior to treatment with
vagus nerve stimulation, all of the children showed increased heart rates,
less variability in heart rate, and more extreme frequency readings (whether
low or high) than children in a control group. “Remarkable” improvement
was seen after six months of treatment, but this did not continue
incrementally , and no further changes were seen after 12 months. HRV was
still markedly lower than in healthy children. Base levels of HRV were also
found to be further reduced in patients who had lived with epilepsy for
longer and those in whom epileptic focus was localized—where partial
seizures arise from one part of the brain, such as the temporal lobe. When a child has epilepsy , the autonomic nervous system is heavily
balanced toward the sympathetic branch. Although vagus nerve stimulation
seems to offer substantial benefits in the short term, increasing vagal tone
and redressing the balance with the parasympathetic nervous system, HRV
remained lower than in healthy children, even after long-term treatment. The researchers concluded that, while factors including epilepsy duration,
age, epileptic focus, medicatio n, and seizure frequency may all lead toreduced HRV, epilepsy itself may contribute to impaired autonomic
regulation of the cardiovascular system.85
It is worth noting that a vagus nerve stimulation implant, while it
activates the parasympathetic branch of the ANS, does not address the
biochemical influence of CO2 or the effects of dysfunctional breathing. The
study does not record whether children were examined for signs of chronic
hyperventilation, which plays a key role in seizure onset, frequency , and
duration. Unlike the implant, the breathing exercises in this book can be
used to naturally stimulate the vagus nerve while simultaneously
rebalancing blood gases and addressing underlying breath ing pattern
disorders. EPILEPSY AND MIGRAINE: IS THERE A LINK? In the 1999 book Breathe Well, Be Well, Robert Fried explains that, in
general, medical practitioners are largely unaware of the role
hyperventilation plays in many common disorders.33 Fried lists cond itions,
including hypertension, migraine, chronic muscle fatigue, idiopathic
epilepsy , stress, headaches, panic attacks, and depression. Even though
medical educa tion teaches the physiological disturbances that
hyperventilation causes, there is still a long way to go before the connection
is fully understood or integrated into treatments. We know  that healthy or unhealthy breathing has a profound effect on
the heart and that it can increase or decrease the diameter of the blood
vessels depending on how much CO2 is in the blood.33 Blood vessels
constrict when levels of CO2 are low, and this contributes to idiopathic
seizures and migraine. It also plays a role in Raynaud’ s syndrome, a
condition in which spasms in the arteries cause reduced blood flow to the
fingers and toes. In this book, we have already examined menstrual migraine in women,
and its relationship to cyclical hormone-induced hyperventilation. But are
migraines and epilepsy also related? Fried acknowledges that it may be
unexpected to read about migrai nes and epilepsy in the same chapter of his
book but states that it is “still a matter of conjecture that migraine and
epilepsy are entirely different entities.” He makes the case that epilepsy isas much  an arterial blood vessel problem affected by breathing as migraine
is and that the distinction between the two conditions can be ascribed to
whether the af fected arteries are inside or outside of the skull.33
According to an article in Neur ology Advisor , “patien ts with migraine
are more likely to have epilepsy , and patients with epilepsy are more likely
to experience migraine.” The article states that patients with seizure
disorders are twice as likely to suffer with migraines, a fact that can often
lead to misdiagnosis.86 It is certainly the case that both migraine and
epilepsy can be relieved by breathing training and nutritional
management.33 Indeed, as far back as 1907, the neurological researcher Sir
William R. Gowers described similarities between migraine and seizure
disorders33 in his book The Border-land of Epilepsy . In particular , he
identified hyperventilation as a contributing factor .87
One 2019 study describes comorbidities that frequently occur alongside
vestibular migraine88—migraine in which disruptions to balance, such as
vertigo, are present. Many of the study participants reported feelings of
anxiety , depression, and insomnia following the onset of vestibular
symptoms. Changes in function  affecting the senses, pain perception, and
muscle strength  were diagnosed, and some of the patients experienced
phobic disorders, including claustrophobia and agoraphobia prior to
symptoms occurring. In 42.7% of participants, abnormal eye movements
were observed. This ocular disturbance is called nystagmus, and it causes
the eyes to make  uncontrolled, repetitive movements that can affect balance
and coordination  and impair vision. In the study , nystagmus was induced by
hyperventilation in 22.5% of the patients.88
Connecting the eyes with breathing is not without precedent. In his
1942 book The Art of Seeing , Aldous Huxley wrote, “There  is a regular
correlation betw een attentive looking and quite unnecess ary, indeed
positively harmful, interference with breathing.”89 He went on to explain
that any improvement in the quality of circulation is immediately reflected
in better vision. Huxley , who had problems with his eyesight for his whole
life, tells how he saved himself from blindness when doctors had failed to
help. He connects quality of sight with better circulation and correct
breathing. Since  the entire body  suffers when we fail to breathe correctly , it
makes sense that the eyes would also be affected.90 In fact, in extremecases, breathing-related visual loss can be caused by retinal hemorrhage, for
instance, in patients with asthma who experience a sudden rise in intra-
abdominal or intra-thoracic pressure due to exacerbations.91
Ultimately , Fried asks the primary question, “Why do some people get
seizures when others do not?” He maintains that epilepsy is not the result of
disease of the nervous system and that seizures are, like migraines, due to
arterial blood vessel spasms rather than a “massive dischar ge of neurons in
the brain.” He suggests that the electrical dischar ge seen in seizures is the
result of the seizure, not its cause.33 He confirms from his own resea rch that
hyperventilation precedes seizure and describes a method for biofeedback-
assisted breathi ng reeducation to reduce the frequency and severity of
seizures in patients who do not respond to anticonvulsant drugs.30
SEIZING CONTROL OF SEIZURES WITH BREA TH
RETRAINING
The many links between CO2 and epilepsy—the influence of CO2 on the
electrical activity in the brain, the abnormal fluctuation in CO2 levels that
precedes grand mal seizures, and the abnormal levels of blood CO2 in
patients with petit mal and grand mal seizures—indicate that the gas plays a
significant role in triggering epileptic seizures30. While research into the
potentially thera peutic effects of breathing exercises is limited, some papers
do explore slow diaphragmatic and nasal breathing. A 1990 study looked at the impact of diaphragm breathing training on
seizure frequency .30 Subjects were taught diaphragm breathing techniques
by an instructor who worked with each person, instructing him or her on the
correct moveme nts of the chest and abdomen. Where necessary , the tutor
used practical methods including  a book positioned on the abdomen to help
the subject achieve the correct movement. During the breath training,
participants were asked to practice a specific respiratory pattern that
resulted in an end-tidal CO2 reading of 5%. The breathing rate used to
produce this pattern was around 12 to 14 breaths per minute, approximately
the same as normal respiration.The study focused on two facto rs, chronic hyperventilation and seizure
activity . The researchers report ed that, in every case, patients presenting
with idiopathic epilepsy also demonstrated moderate or severe chronic
hyperventilation. The control group contained several participants who had
moderate to severe hyperventilation but did not experience seizures.30
The results of this study produced considerable evidence to support the
theory that end-tidal CO2 biofeedback is “essential in the therapeutic
correction of abnormal respiration.” Scientists reported that it was not
enough to adjust the rate of respiration.30 Both statements are consistent
with the exercises in this book. The BOL T score provides a simple way to
get biofeedback about CO2 sensitiv ity, while the exercises teach reduced
breathing volume as well as a slower respiratory rate. In previous pilot studies, the same researchers discovered that patients
only became aware of their need to breathe from the diaphragm  once they
could see the difference in end-tidal CO2 compa red with chest
breathing.92,93 The “knowledge of results” presented by end-tidal CO2
biofeedback is believed to play a vital role in the lasting benef its of breath
training. In a similar way, the BOL T score can be used as a measure of
progress when practicing breathing exercises. In the 1990 study, the breath training procedure caused significant
improvements to habitual breathing patterns.30 In particular , participants
showed notable reductions in respiratory rate, which researchers explained
was due to the moderating effect of diaphragmatic breathing. EEG readings
were also interesting, normaliz ing, as a result of the breath training, in
participants with epilepsy . It was believed that the changes in EEG could be
due to greater blood flow and metabolism in the brain. Improved cerebral
circulation would be an expected result of reducing respiratory alkalosis,
which negative ly affects oxygen delivery to the brain. Conversely , a
combination of low CO2 and the ensuing alkalosis would be likely to
further inhibit oxygenation of the brain. Abnormal EEG  readings in people with moderate to severe chronic
hyperventilation are consistent with the practice of using voluntary
hyperventilation to induce epileptic seizures in EEG examinations. Remember , EEG  readings record the electrical signals in the brain, so they
will pick up any spike and wave  dischar ges or misfiring messages. Atypicalreadings are also common in migraine and are associated with hypoxia
(lack of blood oxygen) and the narrowing of the blood vessels in the brain. In the 1990 study , respiration training to correct overbreathing led to a
significant reduction in seizure activity in patients resistant to
anticonvulsant medications.30 The number of participants was too small to
accurately concl ude which variables predicted the reduction in seizures, and
none of the patients was seizure-free after the seven-month trial, but those
who experienced grand mal seizures had none during the trainin g period. In
all partic ipants, the frequency and severity of seizures, as well as the type of
seizure, was considerably modified by the breath training. The researchers
suggest that the stress-reducing effects of diaphragm breathing were also a
key factor in reducing seizures. The study findings indicate that at least some forms of epilepsy go
hand-in-hand with a considerable imbalance of the autonomic nervous
system.30 Whatever causes chronic hyperventilation, the result is a
narrowing of the blood vessels  in the brain, leading to poor brain blood
flow and metabolism, and predisposing susceptible people to seizures. Disrupting the blood acid-base balance inhibits oxygen delivery to the brain
and interrupts the reflexive relationship between the heart and the lungs. Diaphragm breathing exercises to correct hyperventilation can reduce
seizures by raising the seizure threshold. One suggestion made in several  earlier studies is that the link between
overbreathing and seizure activity may actually be airflow stimulating the
nasal mucosa.94 Researc h has reported that when air is blown into the nasal
cavity , it triggers epileptic areas of the brain.95 Also, in some  types of
epilepsy , nasal hyperventilation has been found more likely  than oral
hyperventilation to induce epileptic EEG activity . On a day-to-day basis, we spon taneously alternate our breathing from
one nostril to the other . Certain yogic breathing practices explore this,
focusing the breath in one nostr il at a time, a technique that scientists call
unilateral nostril breathing. Interestingly , studies have found that unilateral
nostril breathin g has a greater impact on the same-side brain
hemisphere.94,95 Right nostril breathing produces abnormalities in the right
side of the brain, and left nostril breathing affects the left side of the brain. It is unclear what causes this phenomenon, but researchers suggest that areflex involving stimulation of the olfactory nerve by nasal airflow is
involved.94,96
These ideas are expanded in 2016 research. Based on the same  ancient
yoga breathing technique of single nostril breathing, new evidence suggests
that altering nasal airflow between the nostrils can influence brain
activity .97 Researchers observed that when nasal breathing was through
only one nostril, cognitive function improved. This method has also been
shown to trigger seizure activity in epileptic patients. The paper
hypothesizes that rather than vasoconstriction being solely responsible for
seizure onset, seizure activity may be related to the way the air stimulates
the nasal mucosa.97 Scientists have found that, in some types of epilepsy ,
nasal hyperventilation was more likely than oral hyperventilation to
stimulate epilep tic EEG activity in the brain and that this effect was
inhibited by applying local anesthetic to the nasal mucosa. Although the mechanism, extent, and significance of these findings
remain unclear , evidence from studies of epileptics and arousal during sleep
indicates that a nasal airflow stimulus has some sort of activating effect on
the brain. This underlines the importance of reduced nasal breathing
exercises, in which the amount of air breathed is lessened. It is possible to
switch to nasal breathing and still hyperventilate if other aspects of poor
breathing patterns are not addressed. In 1984, an article published in the journal Psychosomatic Medicine
described the use of breathing exercises to self-regulate CO2 and control
seizures.92 The study follo wed 18 participants between the ages of 10 and
42 years, 11 of whom were male and 7 female. All those who took part
suffered moder ate to severe chronic hyperventilation and idiopathic,
medication-resistant seizures. The subjects were given diaphragmatic
breathing training with end-tidal CO2 biofeed back. This was very effective,
producing a rapid correction of breathing patterns. The patients’ breathing
even became comparable to that of people in an asymptom atic control
group. Ten of the participants remained in the study for at least seven
months. Following the treatment, EEG power spectrum readings had
normalized in eight people, as had cardiorespiratory synchronicity . These
people experienced a significan t reduction in the frequency and severity of
their seizures.In 1993, doctors from the Boston Neurobehavioral Institute (Harvard
Medical School)  applied the same principle to the treatment of two children
with severe developmental problems. Parents, caretakers, and teachers were
taught to modify the children’ s breathing to eliminate hyperventilation in
order to prevent seizures. The technique was successful in both cases.98
It is widely recognized that poor health is associated with lower
parasympathetic tone.99 This is certainl y the case in people with epilepsy . Those people who have intractable—hard to control—seizures have lower
vagal tone than those whose epilepsy is controlled. A 2010 study links the
fact that slow breathing exercises are known to increase parasympathetic
tone in healthy people with the theory that slow breathing exercises in
people with epilepsy might cause a similar increase in parasympathetic tone
and reduce seizure frequency . Slow breathing improves conditions
including hypert ension, asthma,  anxiety , and post-traumatic stress disorder ,
and it affects cortical activi ty and seizure thresholds through the
chemoreceptors, baroreceptors, and pulmonary stretch receptors. The
researchers suggest that slow breathing might also reduce seizure activity
by lessening anxiety . Few epileptics are aware of the link between seizures and breath ing, but
various studies demonstrate that breath retraining can successfully reduce
the severity and frequency of epileptic seizures, just as hyperventilation can
be (and is) used to induce seizures for EEG studies. While many factors
contribute to epilepsy , and resea rch on the therapeutic application of breath
retraining is still limited, hyperventilation is known to play a significant
role as a seizure trigger . Therefore, breathing exercises to correct
hyperventilation and normalize the imbalance of blood CO2 are likely to
prove helpful for people with epilepsy . Epilepsy is not caused by poor
breathing, but it is certainly exacerbated by it. While there is not enough
research to conclusively demonstrate that breathing reeducation will be
effective for everyone who suffers with epileptic seizures, the benefits of
healthy breathin g patterns, for general well-being and for reducing the
feelings of anxiety and panic that can happen as the result of living with an
unpredictable condition, will doubtless help build a better qualit y of life. To
my understandin g, while not all forms of epilepsy are breathin g-related, it
simply doesn’ t make sense for children and adults affected by epilepsy thatchronic hyperventilation and breathing pattern disorders are not addressed
in treatment. NICKY’S ST ORY: OVERBREA THING AND OVERREACHING
I am including Nicky’ s story for several reasons. She shared her journey
and research because her own life has changed so much for the better . More
important, her story also illustra tes what happens when we try too hard, go
at a new idea all guns a-blazing, and try to apply perfecti onism to a
breathing practi ce. Overall, Nicky’ s experience is one of courage and
persistence, and it provides invaluable insight. Nicky wouldn’ t have described herself as anxious. After all, she never
had panic attack s. She liked to be in control of her life and was organized,
efficient, and had good attention to detail. She wasn’ t aware that anything
was wrong with her breathing, but she would frequently lose her train of
thought in conversation, and her focus was poor. Her heart often raced, and
she sometimes had palpitations,  which her doctor assured her was normal. But she was irritable, hypersensitive to noise, and had ongoing digestive
issues. She knew this was related to a low level of intermittent anxiety , but
she couldn’t pinpoint why, as her life was not particularly stressful. If she
drank coffee, it would often bring on feelings of anxiety , and alcohol, which
she drank only rarely , would cause disturbed sleep. She was exercising for
at least an hour most days, but this seemed to make her more  tired rather
than fit and energized. She recovered slowly and had sore, aching muscles
most of the time. Nicky did every thing at a hund red miles an hour, driven by a never -
ending to-do list. If something  went wrong, her reaction was emotional,
angry , or tearful. She had strong physiological reactions to many of her
thoughts, regularly had nightmares, and was beginning to have night
sweats. She noticed that her breathing was irregular and that she frequently
sighed and yawned. Sometimes she would find herself breathing gently ,
become frightened, and try to breathe more deeply to correct it. After all,
she had learnt in yoga that deep breathing is good for you. When she
couldn’ t sleep, she used deep breathing to relax.Nicky also had nocturnal epile psy, irregular grand mal seizures, only
ever between 1 and 5 a.m., and intermittent partial complex seizures during
the day. Before a grand mal seizure, she would experience extreme
hyperventilation. Her husband would try to wake her, hoping to stop the
ensuing seizure, but neither of them knew if this was actually helpful. After
a grand mal seizure, she would sleep for two days, and during the following
weeks, she would have hundred s of very intense partial compl ex seizures,
like aftershocks with diminishing frequency . Her concentration and memory
were badly af fected. She could get lost driving around her own small town. A brain scan found no physical cause for Nicky’ s seizures. She felt like
a zombi e due to the side effects of her medication, and she was told that she
was at risk of going into “status.” This is where seizure after seizure occurs
until the heart fails. Her neurologist said that her seizures had to be fully
controlled, and she was prescribed Lamotrigine. On it, she had no more
seizures, but she still had regular episodes of nighttime hyperventilation. Then in 2016, Nicky took part in a breathing course. She had decided to
attend the instructor training, alongside the group course, to try to fix her
husband’ s chron ic snoring. At the start of the course, her BOL T score was
just 8 seconds, and she breathed at 20 breaths per minute during rest. Her
breathing was irregular , audible , and 50% through the mouth. Her blood
CO2 levels were between 26 mmHg and 32 mmHg, while a reading of
between 35 mmHg and 40 mmHg is considered normal. As the week of training progressed, she experienced a high level of
stress. She was frustrated that none of her healthcare providers had
identified the link between her breathing dysfunction and many of her
health problems. She had, for example, suffered severe postnata l depression
with both of her children, after births that were out of control and full of
fear and pain. The course also triggered an incredibly strong cleansing
reaction and a mounting concern over her seizure threshold. The breathing course had opened Nicky’ s eyes to the fact that her
breathing was incredibly unhea lthy. But it also became appar ent that she
should have learned much more slowly how to breathe functionally . She
should not have been in a group course at all, given the extent of her
hyperventilation and epilepsy , combined with her perfectionist tendencies. Instead, her training should have begun with awareness, then suppressingsighs, then full time nasal breathing, and moved slowly on to posture and
diaphragm breathing. Only once her BOL T score was about 20 seconds
should she have begun practicing with air hunger . After the course, it took Nicky two distressing weeks to be able to
breathe without trying to control every breath. She had resolved to stop
breathing in the old way immediately but couldn’ t work out how to breathe
functionally . She tried to implem ent everything she had learned at once. As
a result, she found herself on the edge of a panic attack most of the time. She experienced the following problems:
• She started using her diaphragm properly and it ached constantly , making it
impossible to switch her focus away from her breathing. • She changed her posture overnight and again experienced pain. Sitting was
uncomfortable, and she preferred to stand. • She stopped sighing and tried to breathe through her nose at all times. She tried to
retrain her breathing while speaking and began to lose weight because she didn’t
like the ef fect eating had on her breathing. • She tried to do the breathing exercises as taught but the reduced breathing
destabilized her respiration. • She experimented with her breathing, counted her breaths, and tried all sorts of
things to no avail. By lying down and reducing her breathing she could get her
breathing rate down to four or five breaths per minute, which felt good. When she
stopped the practice, her breathing became rapid again. She wondered whether
going from one state to the other was dangerous. By now, she had become very concerned about her seizure threshold. Her husband had to go away for a night, and she was terrified to go to sleep
without him there to wake her if her breathing changed. During the day, she
was so focused trying to work out how to breathe that she could barely do
anything else. Her breathing instructor advised her to ease up, stop taking her pulse,
stop practicing breath holds and counting her breaths, and just breathe
softly and gently through the nose, one step at a time. She finally had a
breakthrough when, one morning, in desperation and with a panic attack
imminent, she began to read the chapter Nine Healthy Breathing Habits in
Five Days , from Tess Graham’ s book Relief from Snoring and Sleep
Apnea .100 The instruction s in the book enabled Nicky to finally let go of
control and start to breathe easily again.Four months later, the improvements in Nicky’ s health were
extraordinary . She lost six kilos as her metabolism stabilized, and she didn’ t
need to drink so much water . The hyperexcitability and asynchronous firing
of brain neurons that, at times, caused her to be overreactive, emotional,
fragile, hostile, irrational, anxious, and fast, which she thought were part of
her personality , vanished. Raising her CO2 levels led to a much calmer
outlook. Her memory and cognitive function improved. She taped her
mouth every night, and her sleep quality became so good that she needed
less sleep, no longer needing  to go to the toilet during the night or
experiencing nightmares. Exerc ise no longer left her feeling exhausted or
achy, and her capacity for exercise increased. However , her BOL T score was still only 16 seconds, and her lack of
progress was frustrating. She wanted to achieve the level of super health
that she knew was available with a BOL T score over 40. To teach, she also
needed to improve her BOL T score. She had the time, energy, motivation,
and commitment to do the work , but her breathing instructor ’s advice was
just to relax and not focus on her BOL T score. At this point, her breathwork consisted of daily yoga or a walk , during
which she reduced her breathing, and one or two meditation sessions where
she lay on her back and practiced reduced breathing. She was still unable to
do the reduced breathing exercis e as it was taught to her. Two or three times
a week, she had bad breathing days when her head and sinuses would feel
constricted, and she would be less able to focus. She developed tension in her neck and shoulders. Her instructor
suggested that she try the Himalayan rock salt drink (a quarter teaspoon of
rock salt in warm  water three times a day) and see what happened. This had
been suggested in the course, but she had overlooked it. She took the drink
twice that day and has been taking it ever since. The tensi on problem
resolved immediately , and it has not returned. In September 2016, without consulting her doctor or specialist, Nicky
started to come off Lamotrigine  at a rate of 25 mg every few weeks. This
process took five months. She felt safe reducing the dose as she considered
the recurrence of some complex  partial seizures to be a warning system that
would let her know the epilepsy was still there. She also felt that as long asher mouth was taped at night, she wasn’ t likely to hyperventilate enough to
bring on a grand mal seizure. From her research, she unders tood that her BOL T score should be
around 35 befor e epilepsy would be controlled, but she decided to go ahead
and reduce the drug anyway . Everything was fine until she got down to 25
mg per day (down from six pills per day to one), and then her nervous
system reacted. Her nervous excitation and feelings of irritability returned,
and she struggled to get any work done. Her capacity for exercise reduced
again. She lost confidence in the future and in her breathing practice, and
she was nervous  about having come off her medication with a BOL T score
of only 16. Nicky realized that with such a low BOL T score, her breathing was still
too unstable for her epilepsy to be under good control. She need ed to make
some progress, and it seemed that by practicing strong breath holds she
might achieve this, but her breathing coach had told her not to practice
breath holds at all. She had also been warned that the intense detoxification
caused by strong breath holds could induce exacerbations of disease, which
in her case meant grand mal seizures. She was confused and frustrated. However , she persisted in seeking help
and working to understand her breathing. She also consulted physical
therapists and began to release long-standing physical tensions and
imbalances. Fast-forward to 2019, and Nick y noticed that, despite all the changes
she had made, speaking still left her feeling exhausted. She experienced
tension in her abdomen when she spoke for long periods, and she found
herself cancelling social engage ments due to a sense that she didn’ t have
enough breath to go out and talk for the evening. She also had a phobia of
public speaking. Nicky’ s ambition was still to become a breathing educator , but she
wasn’ t sure how this would work. She consulted speech therapist Hadas
Golan, who identified the problem: Nicky was speaking for too long
without taking a breath, exhaling  too much air, bringing it below the resting
expiratory level , leading her to gasp and overinflate her lungs on the
inhalation. This habit creates a lot of tension in the secondary breathing
muscles and abdominals. While Nicky still hyperventilates when she talks,
she now uses practice of reduced breathing, after teaching, to recover .Nicky also began taking a selection of supplements. In the book Normal
Breathing ,101 author Doctor Artour Rakhimov identifies that levels of
calcium, magnesium, potassium, and sodium tend to run low in
overbreathers, and Nicky began adding these minerals to her diet. Now , Nicky’ s end-tidal CO2 reading is between 38 mmH g and 40
mmHg at rest. Her BOL T score is around 20 seconds. She has not had either
type of seizure since she took the first breathing retraining course. In fact,
she believes the breathing pract ice probably saved her life. She is planning
to train as an instructor in New Zealand and works to raise awareness of
breathwork. One of her goals is for breathing dysfunction to be screened for
in general practice, and she is taking steps to promote this. ADVICE T O FELLOW PERFECTIONISTS AND
OVERBREA THERS
1. Before training as a breathing instructor , it is important to do a course yourself to
ensure that your own breathing health is suf ficient. 2. A client can be quite sick while appearing to be normal and high functioning. A
detailed health questionnaire is an important part of any breathing assessment. 3. For anyone with a serious health condition, breathing retraining cannot be
undertaken in a five-day course. Ongoing, long-term support is likely to be
necessary . 4. People with epilepsy must learn very gently and slowly . Weekly sessions are
enough. 5. If you have anxiety or control tendencies, the work should be taken very slowly ,
especially if you also have a serious health condition. 6. Long breath holds must not be practiced by anyone with epilepsy . 7. Chronic hyperventilators may not be able to relax the breathing muscles. When
muscles are underoxygenated, they become “jumpy .” This may also af fect the
diaphragm. 8. The body compensates for anemia by increasing breathing. This is an appropriate
physiological response, and iron levels should be restored before attempting
breathing retraining. If you have a history of anemia, you should check your iron
levels regularly . 9. Overbreathers tend to run low in macronutrients. 10. If you have had a dysfunctional breathing pattern for a long time, there are likely to
be biomechanical issues. It may benefit you to seek help from a physical therapist. 11. Even though breathing is something we all do, it is easy to misunderstand
instructions. If there is anything that feels wrong or seems to cause physical or
mental stress, stop the practice, and seek specialist advice, especially if you have a
serious health condition. 12. Never come of f your medication without consulting your doctor .13. Never underestimate the power of this work and the changes in the mind and body
that can result from a few simple breathing exercises. OceanofPDF .comUCHAPTER SIXTEEN
JOIN THE BREATHING REVOLUTION
ntil recently, knowledge of the power and application of optimal
breathing has been limited to elite sports, advanced yoga
practitioners, research scientists, and other high-level professionals. In the last few years, we have witnessed the beginning of a breathing
revolution. Since I started my own journey with the breath, my aim has
been to bring these resources to as many people as possible. I believe the
exercises and understandings in this book can truly change lives for the
better . Just as it is human nature to leave things undone until they become
necessary , it has perhaps taken a global respiratory pandemic to underline
that we can’ t take anything, not even our breath, for granted. I am grateful this topic is now getting the attention it deserv es. The
negative effects of oral breathing  have been debated in dentistry since 1910,
especially the issue of whether mouth breathing affects craniofacial
development in children. All the while, millions of children and adults have
continued to suffer the health impacts of poor breathing while an industry
argues about whether the problem exists. I feel sorry for the dentists, orthodontists, and medical doctors who tried
to highlight the importance of nasal and functional breathing patterns, only
to be ridiculed by their peers. I know Professor John Mew and his son Dr.
Mike Mew from  the United Kingdom well. I have visited their clinic and
observed them working with patients. Both have done their best to highlight
the importance of nasal breathing and received bad press within the
industry . Doctors William Hang, Kevin Boyd, James Bronson, Tamara
Gray , Carlos O’Connor , and James Bartley , along with Joy Moeller , Licia
Paskay , Barbara Greene, Samantha Weaver Moeller , and Marc Moeller , toname but a few, have also worked tirelessly in their quest to help children
and adults. I have often wondered why an industry populated with highly intelligent
people armed with dental and medical degrees has failed to realize the
importance of nasal and functio nal breathing. Breathing retraining is safe,
simple, and economically viable. It applies to major fields of dentistry ,
respiration, sleep, mental, and physical health. This same question was raised during a recent panel discussion held by
the Academy of Applied Myofunctional Sciences (AAMS). The answers
presented by each of the panelists suggested a lack of cooperation between
dentistry and medicine, lack of scientific research, and similar arguments. These are all valid points. However , I wasn’ t so guarded in my comments. My belief is that the real reason  breathing does not receive attention from
the medical and dental industrie s is that its therapeutic applica tions do not
promise signific ant profit. One thing is certain: if there were a promise of
lucrative return—the kind of money generated by big pharma and sleep
medicine—there would be interest. For breathing to be properly integrated
into medicine, it seems necessary for there to be either the prom ise of profit
or the avoidance of the kind of loss that might be encountered when patients
raise a lawsuit on realizing they were not of fered the best treatment. I am not claiming that breathin g is a cure-all. It is not a magic bullet. My intention is not for peop le to replace traditional treatments with
breathing exerc ises expecting a miracle. However , there is a role for
functional breathing alongside medicine. I can’t help but think back to 1994 when I had an operation to fix my
nose so that I could breathe better through it. The surgeon performed a
successful procedure, but nobody told me I needed to stop my habitual
mouth breathing. I continued to experience sleep-disordered breathing for
four years until I discovered the importance of nasal breathing in 1998. Three decades later, my four-year-old daughter had surgery to remove
her tonsils and adenoids. After the operation, there was no follow-up or
advice to suggest we should help her learn to breathe through her nose. It is
never sufficient to treat the nasal obstruction. It is crucial for the long-term
outcome to change the behavior of breathing. This fact is regularly
overlooked.To realize the potential application of breathing exercises, it is necessary
to practice. You can read this whole book and understand the importance of
light, slow, and deep nasal breathing, but your efforts will be wasted unless
you apply the exercises to your health. To begin with, set aside some time each day to devote to breathing
practice. It will be the best investment in your health and well-b eing. Wake
up 20 minutes earlier in the morning, sit down on a chair or the floor , cross-
legged or in the lotus position, close your eyes, and draw your attention to
your breathing. Gently soften and slow down your breath for 15 minutes to
generate a tolerable air hunger . As you go about your day, take some attention out of your mind and
direct it to your breath. Slow down your breathing with latera l expansion
and contraction of the lower ribs. Go for a walk or head to the gym and
apply light, slow, and deep breathing while you exercise. Remember the
mantra LSD, Light, Slow , and Deep . This book contains breathing exercises for everyone. Some stress the
body , others relax it, up-regulating and down-regulating your nervous
system. Most important, when you think of functional breathing, remember it is
not limited to the studio, to your practice, or to your workout . Functional
breathing pattern s are relevant during rest, sleep, and physical exercise, for
life. On a day-to-day basis, it is likely that much of your attention is
directed outward . Modern life is full of distractions. Emails, text messages,
social media alerts, work, and family all fight for your attention—to the
point that you surrender your attention outward. It is increasingl y rare for us
to bring our attention inward. For me, this mindfulness of the breath has been life changi ng. The
ability to shift my attention from my mind to my breath, to create space
between though ts, has given me a new outlook and focused my abilities
beyond what I would have thought possible. Y ou can trust that time given to
breathing practice will never go to waste. Functional breathing is a game
changer for health and performance. As you begin your practice, be patient. Progress does not alway s travel
in a straight line. We all have ups and downs over the years, and you will
have some bump s along the road. Persevere and make a continu ed effort to
bring good breathing into your way of life, and you will reap the rewards.To assis t you, our mobile apps, which are available free of charge,
contain guided exercises and instruction. We have two apps available:
ButeykoClinic is for children, teenagers, and adults and focuses mainly on
health. OxygenAdvantage is designed to help adults with health and sports
performance. I close by wishing you the very best in your application of functional
breathing patterns. OceanofPDF .comTCHAPTER SEVENTEEN
IS NASAL BREATHING YOUR FIRST LINE OF
DEFENSE AGAINST CORONAVIRUS? hroughout this book we have examined the importance of nasal
breathing. In the case of respiratory infections, research indicates
that where facemasks fail, the nose may provide a natural filter for
dangerous patho gens. We know that the nose filters, warms and humidifies
air on its way into the body , where mouth breathing does not. But as we
discussed in Chapters Three  and Ten, it may also help protect you from a
high viral load and the severe form of COVID-19. Let’s look at the research
in more detail. COVID-19 is a new disease. Little direct research is currently available
about its development, although knowledge is growing every day. However ,
studies that have been published on similar illnesses may be significant. One key paper from 2005, shortly after the outbreak of SARS (severe acute
respiratory syndrome coronavirus) reported that nitric oxide inhibits the
replication cycle of the virus. Although the total number of deaths relating
to COVI D-19 has far exceeded those recorded during the 2002–2003 SARS
epidemic, the current mortality rate is still much lower than that of SARS,
which killed 9.6% of those infected.1
Many people have asked why coronavirus is considered to be so much
more serious than the annual outbreak of influenza. In simple terms,
COVID-19 behaves very differently from flu and is much less well
understood. It has a very high viral load, and where flu results in a crippled
immune system, this new virus attacks a very specific type of cell called a
type 2 pneumocyte.2,3Type 2 pneumoc ytes are responsible for the production and secretion of
a molecule called surfactant, which reduces the surface tension of fluid in
the lungs and contributes to the elastic properties of the alveoli. It facilitates
oxygen transport to the blood and prevents lung collapse and edema. Now
imagine this function is comprom ised and it is easy why coronavirus can be
deadly for even a young, health y person, and why it can cause damage to
organs including the heart. In laboratory tests using Vero E6 cells, the authors of the 2005 study
found that nitric oxide has an antiviral effect, specifically inhibiting the
replication of the virus during early stages of infection. Their research
showed that NO inhibits viral protein and RNA synthesis—essential stages
of viral reproduction in SARS.4
Nitric oxide (NO) is produced in the paranasal sinuses. This means that
by breathing through the nose, we harness various properties of NO
including its pathogen-killing power . NO is understood to be a vasodilator
—it plays a role in the dilation of the blood vessels in the lungs so that
oxygen can be properly absorb ed from the air. But according  to a 1999
paper by scientists Lundber g and Weitzber g5, another biological function of
nitric oxide is the ef fect it has on the growth of various pathogens, including
viruses. What this tells us is that nitric oxide in the nasal airways could
represent an important first line of defense against infection. The existence
of nitric  oxide in exhaled air was first discovered in 1991.5 Later studies
clearly demonstrated that almo st all of this NO originates in the upper
airways, with only minor input from the lower respiratory tract and lungs. Nitric oxide (NO) has also been proven to be important for its role in
surfactant production.6,7 It controls production of surfactants by the alveolar
cells and preserves surfactant function. A paper  published in 2009 by the scientists responsible for the research
into the SARS virus, states that: “NO is involved in local host defense in the
upper airways.”8 The research, which also used isolated laboratory cells,
suggests that while it is unclear whether NO acts directly on
microor ganisms or if it works in combination with other components to
produce its toxic impact, it may help keep the sinuses sterile. Interestingly ,
the study found that NO inhibits the replication of SARS in two distinct
ways.8Research from 1999 and 2000 found NO has “opposing effects” in viral
infections, inclu ding flu and pneumonia, and it inhibits the replication of a
variety of viruses. And research into the human rhinovirus (HRV), the
primary cause of the common cold, concluded that humans actually produce
more nitric oxide in response to HR V infection, theorizing that the gas plays
a key role in viral clearance. Without the regular inhalation and exhalation through the nostrils, nitric
oxide in the nasal airways goes unused. Therefore, the simp lest way to
naturally increase NO is by nostril breathing. However , as we discovered in
Chapter Three , evidenc e suggests that humming is effective in emptying the
paranasal sinuses of accumulated NO, leading to far greater production of
the gas.9
Much of the worry around coronavirus stems from uncertainty . However , what is certain is that large amounts of nitric oxide are constantly
being released in the airways during nasal breathing, and that this gas has
been found to have important antiviral functions that defend against the
replication of flu-like illnesses . The mechanism of COVID-19 is still
unknown, and it would be cavalier to state that nasal breathing will kill the
virus. However , it has been consistently proven that nasal breath ing leads to
better overall health, and it makes logical sense, given that the primary
defense to airborne viruses is in the nose and not the mouth, that breathing
through the nose can support the body’ s natural resistance to infection. HOW DOES THE VIRUS SPREAD? Just like other respiratory infecti ons, the virus travels from person to person
in drople ts of bodily fluid such as mucus or saliva. When an infected person
sneezes or coughs, the virus disperses into the air and onto surrounding
surfaces. Drople ts from coughs and sneezes can travel several feet and stay
suspended in the air for up to 10 minutes, increasing the likelihood of
infection for anyone who come s into direct contact with a sick person or
touches a contaminated surface. The biggest issue here is that because COVID-19 is a brand new virus
in humans, no one has any immunity to it, and this increases both the fear
factor and the potential for infection. However , Bruce Ayleward, assistantdirector general of the WHO explains that: “Panic and hysteria are not
appropriate.” “This is a disease that is in the cases and their close contacts,”
he says. “It’s not a hidden enem y lurking behind bushes. Get organized, get
educated, and get working.”10
PREVENTIVE MEASURES
Much of the advice around coronavirus focuses on hygiene practices such
as frequent and thorough handwashing, self-isolating and catching sneezes
in the crook of the elbow . The use of face masks has become synonymous
with outbreaks of this type, and masks are now an accepted defense against
spreading Covid-19. The Center for Disease Control (CDC) recommends
that people wear masks in public settings, at events and gatherings, and
anywhere they will be around other people. When you wear a mask, you
protect others as well as yourself, but masks are not without controversy . Toward the end of April 2020, social media users began sharing images
online, claiming that continuous  use of a mask forces the weare r to breathe
in excess carbon dioxide (CO 2) from exhaled air, causing hypercapnia. Hypercapnia is the buildup of CO2 in the bloodstream, and it’s common in
conditions such as COPD. It can lead to dizziness, fatigue, headaches,
breathlessness, drowsiness, and disorientation. More severe symptoms
include loss of consciousness, seizures, and coma. While it can be dangerous to breathe in high levels of CO2, the claim is
inaccurate. It’s true that medical  masks have been found to cause headaches
in healthcare workers who wear them for a long time, but there is no
evidence that these masks are dangerous. According to Reuters, a representative from the CDC explains: “The
CO2 will slowly build up in the mask over time. However , the level of CO2
likely to build up in the mask is mostly tolerable to people exposed to it. You might get a headache but you most likely [would] not suffer the
symptoms obser ved at much higher levels of CO2. The mask can become
uncomfortable for a variety of reasons, including a sensitivity to CO2 and
the person will be motivated to remove the mask. It is unlikely that wearing
a mask will cause hypercapnia.”SUMMAR Y:
• The mechanism of COVID-19 remains unknown and it is not confirmed whether
breathing through the nose can inhibit this virus. • However , it is logical to breathe only through the nose given that the primary defense
to airborne viruses is in the nose and not the mouth, that breathing through the nose
can support the body’ s natural resistance to infection. • Breathe through your nose, especially in public places—on public transport, while
exercising at the gym, and so on. • While in public places, slow down your breathing and deliberately reduce the volume
of air taken into your lungs. • Be aware of your breath-hold time during rest. During a head cold, lower respiratory
tract infection or respiratory symptoms, breath-hold time during rest is reduced. T o
test, exhale through nose, hold breath and time how long it takes for you to
experience first definite desire to breathe. If it is less than 10 seconds, respiration is
not optimal. • You will find a suggested exercise protocol for COVID-19 recovery in Chapter T wo. OceanofPDF .comRESOURCES
MyoT ape mouth tape for sleep can be ordered from MyoT ape.com
Nasal dilators can be purchased from NasalDilator .com
The SportsMask can be found at SportsMask.com
A list of Oxygen  Advantage® registered breathing instructors can be found
at OxygenAdvantage.com/instructors
Downloadable app for sports performance: OxygenAdvantage
Downloadable app with exercises for children and adults: ButeykoClinic
Free children’ s breathing exerci ses can be found on YouTube by searching
Patrick McKeown, childr en
HRV MONIT ORS SUGGESTED BY DR. JA Y WILES:
• Lief Therapeutics wearable ECG
• Oura Ring
• WHOOP Strap
• BioStrap
• HeartMath Inner Balance™ or emW ave2®
• Polar H10 Chest Strap with the Elite HR V app
To find a myofunctional therapy specialist in your area, visit AomtInfo.or g
BONUS CHAPTERS
Available at https://oxygenadvantage.com/thebr eathingcur e
CHAPTER EIGHTEEN: PHENOTYPES OF OBSTRUCTIVE SLEEP APNEA
CHAPTER NINETEEN: THE BREA TH AND THE SINGING VOICE
CHAPTER TWENTY : ADUL T BREA THING CLASSIFICA TION (ABC)
CHAPTER TWENTY -ONE: THE SUBTLE ART OF YOGA BREA THING
REFERENCES
Available at https://oxygenadvantage.com/thebr eathingcur e
OceanofPDF .comWA C K N O W L E D G M E N T S
hen I changed career paths to teach breathing in 2002, it certainl y
raised a few eyebrows. It caused angst with some family
members and drew a good hearty laugh from others. Roll on 18 years , and my work continues, thanks to the help and support
of many people. I’ve learned two things that could be considered guiding
principles. First,  follow your intuition. It might be the best thing you ever
do. Second, with passion and effort, we are likely to attract the right people
at the right time! This book wouldn’ t exist witho ut those “right people.” I’m grateful to
the initial “whoosh up” from the Irish media. Thanks to the Galway
Advertiser  and Mary O’Connor for the very first article on the Buteyk o
method for asthma. Written in April of 2002, it sourced my first three
clients. And to the journalists who tested the technique for their asthma and
wrote stories on it. Kevin Murphy from the Irish Independent  and Sylvia
Thompson from the Irish Times. Both took a dedicated intere st in the
Buteyko method, writing many articles over the years. This book would not have been  possible without the help of Johanna
McW eeney , a tremendous write r, editor , and researcher who was able to
convert medical jar gon into reader -friendly tones. Many thanks to Laird Hamilton for writing the foreword and to the team
at XPT ; Pj Nestler , Gabby Reece, and Jennifer Meredith. To the breathing instructors Yasin Seiwasser , Robin Rothenber g, Nick
Heath, Dr. Jonathan Herron, Lisa Seaman, Geor gi Rose Lawlor , Dr. Jay
Wiles, Kathleen Dixon, Alessandro Romagnoli, Leonardo Pelagotti, Dr.
Paul Sly, Tim Anderson, and Magnus Appelber g. Thank you for sharingyour experience with the breath. Soprano Claire Wild, thank you for
checking the singing appendix. To James Nestor , whose book Breath repres ents the greatest
contribution to breathing in 20 years. It is one of the best books on
breathing I have read. The real-life examples in this book add the human touch. Some of the
stories you will read are from clients I have worked with. Others are from
readers who have written to me. Regardless, the personal element is very
important. Knowing that these exercises have helped people  makes the
work worthwhile. It provides me with the motivation to keep driving
forward. To Dr. Joseph Mercola for reaching out to his 2 million members on
Mercola.com, to inform them of the importance of nose breathing and
functional breathing patterns. To Joy, Marc, and Samantha Moeller for their
tireless dedication in advancing research into breathing and myofunctional
therapy . To the dentists and orthodontis ts Dr. John Mew and Mike Mew , Dr.
William Hang, Dr. Kevin Boyd , Dr. Marinela Banica, Dr. James Bronson,
Dr. Douglas Knight, Dr. Lynn and Dr. Ed Lipskis, Dr. Yue Weng Cheu, Dr.
Louisa Lee, Dr. Frank Seaman, Dr. James Metz, Dr. Derek Mahony , and Dr.
Tony O’ Connor . Thank you for highlighting an issue vital to the
development of our children. No doubt we often feel we are swimming
against the tide. The time is now ripe for calm waters. To Keith Pfeffer and Mary Glen n of Humanix Books for bringing The
Breathing Cur e to tens of thousands of people across the globe. The invited podcasts by Brian Rose, Dr. Rangan Chatterjee, Brian
Johnson, Ben Greenfield, XPT Performance, Dave Asprey , Darin Olien,
Ben Pakulski, Robin Rothenber g, and Pat Divily . Thank you. Currently , we are united with 290 Oxygen Advantage instructors and
400 Buteyko instructors from 50 countries. I never imagined the day where
we would have such a reach to bring functional breathing to so many
people. Thank you, Ana Mahe, for doing such a great job in managing Oxygen
Advantage and Buteyko Clinic  International. To our team—to my wife,
Sinead, and to Ana, Tina, Mlad en, Vesna, Lucas, Matias, Johanna, Daniel,
and Ronan—thanks so much.
_OceanofPDF.com_The_Breathing_Cure_-_Patrick_McKeown.txt
Summarize the following text section accurately and concisely. Maintain specific details and numerical information, and use anti-repetition mechanisms:

        A 2019
study states that OSA is twice as common in people with epilepsy than in
the gene ral population, and as in other OSA cases, its incidence increases
with age. 74 According to this review, subjective self-reporting of daytime
sleepiness is particularly unhe lpful as a diagnostic tool for OSA in
epileptics, becau se a diverse range of comorbidities can cause tiredness in
epilepsy. The prevalence of sleep disorders in epileptic children is under -
recognized. 71 Children with epilepsy often experience changes in the way
they sleep—how  quickly they fall asleep, their total sleep time, sleep
architecture, and spontaneous arousals—and they are more likely to suffer
from broken sleep and daytime drowsiness. 71
Many things can cause sleep disruption in children with epilepsy,
including the epilepsy itself and antiepileptic medications. These childrenpresent with conditions includin g SDB, OSA, and limb movements during
sleep. The poor quality of sleep that results has a negative impact on seizure
control that may logically be related to hyperventilation cause d by mouth
breathing during sleep. Sleep deprivation can trigger seizures, and frequent
seizures cause broken sleep, creating a vicious cycle. Even when seizures
occur during wakefulness, they can have a negative impact on sleep. 71
Antiepileptic drugs can cause marked weight gain in children. Aside from a
general feeling of tiredness and poor health, this increases the likelihood of
SDB as excess fat on the abdomen and tongue restricts the movement of the
diaphragm and narrows the airways. 75
According to a 2019 paper, several small retrospective studies have
found that positive airway press ure treatments such as CPAP can produce a
significant reduction in seizures for people who have comorb id epilepsy
and OSA74. A 2018 article in Epilepsy Foundation  reported that patients
treated with positive airway pressure had a 63% chance of a reduction in
seizures of up to 50%. 70 This was comp ared with a 14% chance for those
who were untreated. Apnea, hypercapnia (too much  blood CO2), and oxygen desaturation
(when blood oxygen levels drop below normal) can all occur  during and
immediately after a seizure, especially with generalized tonic-clonic
seizures. 74 The respiratory disturbances that occur during apnea suggest
activation of the central autonomic network, an intricate system of
structures in the brain that performs a key role in the working of the
autonomic nervous system. 76 This may contribute to sudden unexpected
death in epilepsy (SUDEP), the leading cause of epilepsy-related death in
patients with drug-resistant epilepsy. People who die from SUDEP
generally have a history of nocturnal seizures and centrally mediated post-
seizure cardiorespiratory dysfunction. 77 They often die during sleep, and
while sleeping prone (face down), but it is unknown whether OSA
contributes to sudden death. 76
A 2018 study explored the relati onship between SUDEP and SDB in 30
participants and reported that cardiorespiratory dysfunction was more
common in patients at high risk of SUDEP, while SDB was found in 88% of
sleep-study results. 77While epilepsy and SDB often coexist, one of the difficulties faced by
medical practitio ners when identifying abnormal events that are related to
sleep disorders rather than epilepsy is the fact that signs of nocturnal
seizures can overlap with symptoms of SDB. 77 A 2014 paper describes the
case of a three-year -old child who demonstrated EEG activity during
seizure that could also be associated with a particular form of OSA. The
child’ s seizures were charac terized by increased respir atory rate,
paradoxical breathing, and oxygen desaturation. 78 In this case,
cardiorespiratory sleep study results initially led to a misdiagnosis of severe
OSA. Excessive daytime sleepiness and sleep disorders are know n to be
common in adults with epilepsy, and one 2006 study found that children
with epilepsy also reported worse daytime sleepiness than a control group. In this study, researchers concluded that further research using screening
questionnaires and formal sleep studies is needed to accurately assess the
prevalence of sleep disorders in children with epilepsy. 79
A 2008 study evaluated abnormal results in 40 epileptic children who
had each been referred for a sleep study because of various problems with
sleep. 71 Snoring  was observed in 83% of patients, and SDB inclu ding
obstructive hyperventilation, sleep apnea, and upper -airway  resistance
syndrome was found in 42. 5% of the children. Children who had poor
seizure control also experienced  poor quality sleep, a higher arousal index,
and a higher percentage of REM sleep states compared to those who were
either seizure-free or had good seizure-control. Those children who had both epilepsy and OSA generally had a much
greater body mass index and longer sleep latency—the amount of time it
takes to get to sleep. Significantly, they also demonstrated more severe
oxygen desatura tion than children who had sleep apnea uncomplicated by
epilepsy. 71 A considerable number of the children with epilepsy who were
referred for polysomnography presented with SDB, including OSA. This
study concluded that treatment of OSA by removing the tonsils and
adenoids may lead to an improvement in sleep disturbances, which might in
turn result in better seizure control and quality of life. The researchers
suggested that physicians should routinely screen for snoring and other
signs of OSA when examining children with epilepsy. 71 How ever, there isan argument that as with SDB  in nonepileptic children, developing the
airways and training in full-ti me nasal breathing should be considered
before resorting to sur gery. Research into the link between SDB and epilepsy is still very limited. It
is unclear whether epilepsy causes OSA or whether OSA exists  comorbidly
alongside epilepsy. But the evidence linking seizure frequency and duration
to chronic hyperventilation, coupled with the research confirming that
mouth breathing  during sleep is a common in both OSA and chronic
hyperventilation, would indicate that improving or eradicating SDB may
help with seizure control. THE V AGUS NER VE CONNECTION T O EPILEPSY
Electronic stimulation of the vagus nerve using implanted devices has been
used in the treatment of epilepsy and depression for several decades. 80
More recently, noninvasive devices have been developed. As we discovered
in Chapter Four, vagal stimulation can also be achieved naturally by
practicing a breathing rate of six breaths per minute. The vagus nerve  innervates a wide range of organs, but its function can
be most  easily assessed in relation to the rhythm of the heart. Heart rate
variability (HRV) is indicative of vagal tone. As we know, low vagal tone
correlates with lower parasympa thetic activity and is linked to a wide range
of mental and physical conditions and early mortality. 80
People with epilepsy, particular ly those whose seizure control is poor,
have lower vagal tone, leading researchers in a 2017 study to theorize that
natural stimulation of the vagus nerve might improve seizure control. 80
Interestingly, the most common self-reported seizure trigger for people with
epilepsy is stress, a fact that points to an autonomic imbalance. 81 The paper
discusses three natural methods for increasing HRV and parasympathetic
tone—stress reduction, nutrition, and exercise—but does not mention the
relationship between slow diaph ragmatic breathing and vagal tone. None of
the three suggestions mentioned  in the study were found to reduce seizures. But the researchers do report that patients have been known to experience
increased vagal tone and a subsequent reduction in seizures by listening to
music by Mozart. 80 Equally, as already discussed, slow breathing has beenfound to reduce the onset and duration of seizures. This may have some
relation to activation of the parasympathetic nervous system as well as
counteracting the biochemical effects of hyperventilation. The study
concludes that much more work is needed to examine the impact of the
various methods for optimizing HR V on seizure occurrence. Vagus nerve stimulation is widely used to treat patients over the age of
12 years who have refractory epilepsy. 82 A retrospective  study published in
2007 examined the data to find out whether the procedure had any adverse
implications for younger children. Scientists reviewed statistics for 26
children, aged between 3 and 17 years, who had been treated with vagus
nerve stimulation implants between 1998 and 2004. The children
predominantly suffered with symptomatic-generalized epilepsy. Seventy-
seven percent presented with moderate to severe intellectual disability, and
65 had more than 30 seizures every month. The duration of treatment in the
studied children ranged from one month to eight years. After treatment,  frequency of seizures reduced more than 50% in 54%
of the children. Two became seizure-free, 23% experienced seizure
reduction of less than 50%, and four developed the ability to end seizures
using the implan t. OSA was found in four of the children after placement of
the implant. 82 The study concluded that vagus nerve stimulation is an
effective treatment for childre n with refractory epilepsy but that an
overnight sleep study should be used to identify patients with preexisting
OSA before the device is implanted. 82
A small study of adults also made the connection between vagus nerve
stimulation and SDB in epileptic patients. 83 The 2020 paper followed three
cases representative of SDB brought on by vagal activity in refractory
epilepsy. Of the three participa nts, two had sleep apnea and the third a
condition called stridor, which presents as a high-pitched wheezing. This
paper drew the same conclusion, as the 2007 study involving children, that
given the high incidence of OSA in people with refractory epilep sy, patients
should be screened for SDB before being treated with a vagus nerve
stimulation implant. However, researchers also suggest that SDB is a rare
complication of vagus nerve stimulation and, where sleep apnea occurs, it
must be investigated alongside data regarding the firing of the nerve
stimulator. A more recent study looked at the outcome of vagus nerve stimulation
treatment in terms of HRV and electrocardiogram (ECG) readings in
patients with drug-resistant epilepsy. 84 Participants were 32 patients who
had received vagus nerve stimulation implants at the same hospital, and 32
healthy age- and gender -matched controls. Researchers found that those
people who failed to respond to vagus nerve stimulation—defined as having
less than a 50% seizure reduction one year after treatment—had
significantly lower preoperative vagal tone than those who responded well
to the treatment. In simple terms, patients whose parasympathetic tone was
worse received less benefit from the treatment. This would indic ate that it is
possible to predict the level of seizure reduction after treatment. 84 It would
also suggest that patients who are able to improve their vagal tone,
something it is possible to do using breathing exercises, would gain more
benefit from the vagus nerve stimulation implant in terms of relief from
epilepsy symptoms. A 2018 study evaluated the effects of vagus nerve stimulation on HRV
in 20 epilepti c children. 85 Researchers also investigated whether
antiepileptic drugs had any negative impact on HRV. Prior to treatment with
vagus nerve stimulation, all of the children showed increased heart rates,
less variability in heart rate, and more extreme frequency readings (whether
low or high) than children in a control group. “Remarkable” improvement
was seen after six months of treatment, but this did not continue
incrementally, and no further changes were seen after 12 months. HRV was
still markedly lower than in healthy children. Base levels of HRV were also
found to be further reduced in patients who had lived with epilepsy for
longer and those in whom epileptic focus was localized—where partial
seizures arise from one part of the brain, such as the temporal lobe. When a child has epilepsy, the autonomic nervous system is heavily
balanced toward the sympathetic branch. Although vagus nerve stimulation
seems to offer substantial benefits in the short term, increasing vagal tone
and redressing the balance with the parasympathetic nervous system, HRV
remained lower than in healthy children, even after long-term treatment. The researchers concluded that, while factors including epilepsy duration,
age, epileptic focus, medicatio n, and seizure frequency may all lead toreduced HRV, epilepsy itself may contribute to impaired autonomic
regulation of the cardiovascular system. 85
It is worth noting that a vagus nerve stimulation implant, while it
activates the parasympathetic branch of the ANS, does not address the
biochemical influence of CO2 or the effects of dysfunctional breathing. The
study does not record whether children were examined for signs of chronic
hyperventilation, which plays a key role in seizure onset, frequency, and
duration. Unlike the implant, the breathing exercises in this book can be
used to naturally stimulate the vagus nerve while simultaneously
rebalancing blood gases and addressing underlying breath ing pattern
disorders. EPILEPSY AND MIGRAINE: IS THERE A LINK. In the 1999 book Breathe Well, Be Well, Robert Fried explains that, in
general, medical practitioners are largely unaware of the role
hyperventilation plays in many common disorders. 33 Fried lists cond itions,
including hypertension, migraine, chronic muscle fatigue, idiopathic
epilepsy, stress, headaches, panic attacks, and depression. Even though
medical educa tion teaches the physiological disturbances that
hyperventilation causes, there is still a long way to go before the connection
is fully understood or integrated into treatments. We know  that healthy or unhealthy breathing has a profound effect on
the heart and that it can increase or decrease the diameter of the blood
vessels depending on how much CO2 is in the blood. 33 Blood vessels
constrict when levels of CO2 are low, and this contributes to idiopathic
seizures and migraine. It also plays a role in Raynaud’ s syndrome, a
condition in which spasms in the arteries cause reduced blood flow to the
fingers and toes. In this book, we have already examined menstrual migraine in women,
and its relationship to cyclical hormone-induced hyperventilation. But are
migraines and epilepsy also related. Fried acknowledges that it may be
unexpected to read about migrai nes and epilepsy in the same chapter of his
book but states that it is “still a matter of conjecture that migraine and
epilepsy are entirely different entities. ” He makes the case that epilepsy isas much  an arterial blood vessel problem affected by breathing as migraine
is and that the distinction between the two conditions can be ascribed to
whether the af fected arteries are inside or outside of the skull. 33
According to an article in Neur ology Advisor, “patien ts with migraine
are more likely to have epilepsy, and patients with epilepsy are more likely
to experience migraine. ” The article states that patients with seizure
disorders are twice as likely to suffer with migraines, a fact that can often
lead to misdiagnosis. 86 It is certainly the case that both migraine and
epilepsy can be relieved by breathing training and nutritional
management. 33 Indeed, as far back as 1907, the neurological researcher Sir
William R. Gowers described similarities between migraine and seizure
disorders33 in his book The Border-land of Epilepsy. In particular, he
identified hyperventilation as a contributing factor. 87
One 2019 study describes comorbidities that frequently occur alongside
vestibular migraine88—migraine in which disruptions to balance, such as
vertigo, are present. Many of the study participants reported feelings of
anxiety, depression, and insomnia following the onset of vestibular
symptoms. Changes in function  affecting the senses, pain perception, and
muscle strength  were diagnosed, and some of the patients experienced
phobic disorders, including claustrophobia and agoraphobia prior to
symptoms occurring. In 42. 7% of participants, abnormal eye movements
were observed. This ocular disturbance is called nystagmus, and it causes
the eyes to make  uncontrolled, repetitive movements that can affect balance
and coordination  and impair vision. In the study, nystagmus was induced by
hyperventilation in 22. 5% of the patients. 88
Connecting the eyes with breathing is not without precedent. In his
1942 book The Art of Seeing, Aldous Huxley wrote, “There  is a regular
correlation betw een attentive looking and quite unnecess ary, indeed
positively harmful, interference with breathing. ”89 He went on to explain
that any improvement in the quality of circulation is immediately reflected
in better vision. Huxley, who had problems with his eyesight for his whole
life, tells how he saved himself from blindness when doctors had failed to
help. He connects quality of sight with better circulation and correct
breathing. Since  the entire body  suffers when we fail to breathe correctly, it
makes sense that the eyes would also be affected. 90 In fact, in extremecases, breathing-related visual loss can be caused by retinal hemorrhage, for
instance, in patients with asthma who experience a sudden rise in intra-
abdominal or intra-thoracic pressure due to exacerbations. 91
Ultimately, Fried asks the primary question, “Why do some people get
seizures when others do not. ” He maintains that epilepsy is not the result of
disease of the nervous system and that seizures are, like migraines, due to
arterial blood vessel spasms rather than a “massive dischar ge of neurons in
the brain. ” He suggests that the electrical dischar ge seen in seizures is the
result of the seizure, not its cause. 33 He confirms from his own resea rch that
hyperventilation precedes seizure and describes a method for biofeedback-
assisted breathi ng reeducation to reduce the frequency and severity of
seizures in patients who do not respond to anticonvulsant drugs. 30
SEIZING CONTROL OF SEIZURES WITH BREA TH
RETRAINING
The many links between CO2 and epilepsy—the influence of CO2 on the
electrical activity in the brain, the abnormal fluctuation in CO2 levels that
precedes grand mal seizures, and the abnormal levels of blood CO2 in
patients with petit mal and grand mal seizures—indicate that the gas plays a
significant role in triggering epileptic seizures30. While research into the
potentially thera peutic effects of breathing exercises is limited, some papers
do explore slow diaphragmatic and nasal breathing. A 1990 study looked at the impact of diaphragm breathing training on
seizure frequency. 30 Subjects were taught diaphragm breathing techniques
by an instructor who worked with each person, instructing him or her on the
correct moveme nts of the chest and abdomen. Where necessary, the tutor
used practical methods including  a book positioned on the abdomen to help
the subject achieve the correct movement. During the breath training,
participants were asked to practice a specific respiratory pattern that
resulted in an end-tidal CO2 reading of 5%. The breathing rate used to
produce this pattern was around 12 to 14 breaths per minute, approximately
the same as normal respiration. The study focused on two facto rs, chronic hyperventilation and seizure
activity. The researchers report ed that, in every case, patients presenting
with idiopathic epilepsy also demonstrated moderate or severe chronic
hyperventilation. The control group contained several participants who had
moderate to severe hyperventilation but did not experience seizures. 30
The results of this study produced considerable evidence to support the
theory that end-tidal CO2 biofeedback is “essential in the therapeutic
correction of abnormal respiration. ” Scientists reported that it was not
enough to adjust the rate of respiration. 30 Both statements are consistent
with the exercises in this book. The BOL T score provides a simple way to
get biofeedback about CO2 sensitiv ity, while the exercises teach reduced
breathing volume as well as a slower respiratory rate. In previous pilot studies, the same researchers discovered that patients
only became aware of their need to breathe from the diaphragm  once they
could see the difference in end-tidal CO2 compa red with chest
breathing. 92,93 The “knowledge of results” presented by end-tidal CO2
biofeedback is believed to play a vital role in the lasting benef its of breath
training. In a similar way, the BOL T score can be used as a measure of
progress when practicing breathing exercises. In the 1990 study, the breath training procedure caused significant
improvements to habitual breathing patterns. 30 In particular, participants
showed notable reductions in respiratory rate, which researchers explained
was due to the moderating effect of diaphragmatic breathing. EEG readings
were also interesting, normaliz ing, as a result of the breath training, in
participants with epilepsy. It was believed that the changes in EEG could be
due to greater blood flow and metabolism in the brain. Improved cerebral
circulation would be an expected result of reducing respiratory alkalosis,
which negative ly affects oxygen delivery to the brain. Conversely, a
combination of low CO2 and the ensuing alkalosis would be likely to
further inhibit oxygenation of the brain. Abnormal EEG  readings in people with moderate to severe chronic
hyperventilation are consistent with the practice of using voluntary
hyperventilation to induce epileptic seizures in EEG examinations. Remember, EEG  readings record the electrical signals in the brain, so they
will pick up any spike and wave  dischar ges or misfiring messages. Atypicalreadings are also common in migraine and are associated with hypoxia
(lack of blood oxygen) and the narrowing of the blood vessels in the brain. In the 1990 study, respiration training to correct overbreathing led to a
significant reduction in seizure activity in patients resistant to
anticonvulsant medications. 30 The number of participants was too small to
accurately concl ude which variables predicted the reduction in seizures, and
none of the patients was seizure-free after the seven-month trial, but those
who experienced grand mal seizures had none during the trainin g period. In
all partic ipants, the frequency and severity of seizures, as well as the type of
seizure, was considerably modified by the breath training. The researchers
suggest that the stress-reducing effects of diaphragm breathing were also a
key factor in reducing seizures. The study findings indicate that at least some forms of epilepsy go
hand-in-hand with a considerable imbalance of the autonomic nervous
system. 30 Whatever causes chronic hyperventilation, the result is a
narrowing of the blood vessels  in the brain, leading to poor brain blood
flow and metabolism, and predisposing susceptible people to seizures. Disrupting the blood acid-base balance inhibits oxygen delivery to the brain
and interrupts the reflexive relationship between the heart and the lungs. Diaphragm breathing exercises to correct hyperventilation can reduce
seizures by raising the seizure threshold. One suggestion made in several  earlier studies is that the link between
overbreathing and seizure activity may actually be airflow stimulating the
nasal mucosa. 94 Researc h has reported that when air is blown into the nasal
cavity, it triggers epileptic areas of the brain. 95 Also, in some  types of
epilepsy, nasal hyperventilation has been found more likely  than oral
hyperventilation to induce epileptic EEG activity. On a day-to-day basis, we spon taneously alternate our breathing from
one nostril to the other. Certain yogic breathing practices explore this,
focusing the breath in one nostr il at a time, a technique that scientists call
unilateral nostril breathing. Interestingly, studies have found that unilateral
nostril breathin g has a greater impact on the same-side brain
hemisphere. 94,95 Right nostril breathing produces abnormalities in the right
side of the brain, and left nostril breathing affects the left side of the brain. It is unclear what causes this phenomenon, but researchers suggest that areflex involving stimulation of the olfactory nerve by nasal airflow is
involved. 94,96
These ideas are expanded in 2016 research. Based on the same  ancient
yoga breathing technique of single nostril breathing, new evidence suggests
that altering nasal airflow between the nostrils can influence brain
activity. 97 Researchers observed that when nasal breathing was through
only one nostril, cognitive function improved. This method has also been
shown to trigger seizure activity in epileptic patients. The paper
hypothesizes that rather than vasoconstriction being solely responsible for
seizure onset, seizure activity may be related to the way the air stimulates
the nasal mucosa. 97 Scientists have found that, in some types of epilepsy,
nasal hyperventilation was more likely than oral hyperventilation to
stimulate epilep tic EEG activity in the brain and that this effect was
inhibited by applying local anesthetic to the nasal mucosa. Although the mechanism, extent, and significance of these findings
remain unclear, evidence from studies of epileptics and arousal during sleep
indicates that a nasal airflow stimulus has some sort of activating effect on
the brain. This underlines the importance of reduced nasal breathing
exercises, in which the amount of air breathed is lessened. It is possible to
switch to nasal breathing and still hyperventilate if other aspects of poor
breathing patterns are not addressed. In 1984, an article published in the journal Psychosomatic Medicine
described the use of breathing exercises to self-regulate CO2 and control
seizures. 92 The study follo wed 18 participants between the ages of 10 and
42 years, 11 of whom were male and 7 female. All those who took part
suffered moder ate to severe chronic hyperventilation and idiopathic,
medication-resistant seizures. The subjects were given diaphragmatic
breathing training with end-tidal CO2 biofeed back. This was very effective,
producing a rapid correction of breathing patterns. The patients’ breathing
even became comparable to that of people in an asymptom atic control
group. Ten of the participants remained in the study for at least seven
months. Following the treatment, EEG power spectrum readings had
normalized in eight people, as had cardiorespiratory synchronicity. These
people experienced a significan t reduction in the frequency and severity of
their seizures. In 1993, doctors from the Boston Neurobehavioral Institute (Harvard
Medical School)  applied the same principle to the treatment of two children
with severe developmental problems. Parents, caretakers, and teachers were
taught to modify the children’ s breathing to eliminate hyperventilation in
order to prevent seizures. The technique was successful in both cases. 98
It is widely recognized that poor health is associated with lower
parasympathetic tone. 99 This is certainl y the case in people with epilepsy. Those people who have intractable—hard to control—seizures have lower
vagal tone than those whose epilepsy is controlled. A 2010 study links the
fact that slow breathing exercises are known to increase parasympathetic
tone in healthy people with the theory that slow breathing exercises in
people with epilepsy might cause a similar increase in parasympathetic tone
and reduce seizure frequency. Slow breathing improves conditions
including hypert ension, asthma,  anxiety, and post-traumatic stress disorder,
and it affects cortical activi ty and seizure thresholds through the
chemoreceptors, baroreceptors, and pulmonary stretch receptors. The
researchers suggest that slow breathing might also reduce seizure activity
by lessening anxiety. Few epileptics are aware of the link between seizures and breath ing, but
various studies demonstrate that breath retraining can successfully reduce
the severity and frequency of epileptic seizures, just as hyperventilation can
be (and is) used to induce seizures for EEG studies. While many factors
contribute to epilepsy, and resea rch on the therapeutic application of breath
retraining is still limited, hyperventilation is known to play a significant
role as a seizure trigger. Therefore, breathing exercises to correct
hyperventilation and normalize the imbalance of blood CO2 are likely to
prove helpful for people with epilepsy. Epilepsy is not caused by poor
breathing, but it is certainly exacerbated by it. While there is not enough
research to conclusively demonstrate that breathing reeducation will be
effective for everyone who suffers with epileptic seizures, the benefits of
healthy breathin g patterns, for general well-being and for reducing the
feelings of anxiety and panic that can happen as the result of living with an
unpredictable condition, will doubtless help build a better qualit y of life. To
my understandin g, while not all forms of epilepsy are breathin g-related, it
simply doesn’ t make sense for children and adults affected by epilepsy thatchronic hyperventilation and breathing pattern disorders are not addressed
in treatment. NICKY’S ST ORY: OVERBREA THING AND OVERREACHING
I am including Nicky’ s story for several reasons. She shared her journey
and research because her own life has changed so much for the better. More
important, her story also illustra tes what happens when we try too hard, go
at a new idea all guns a-blazing, and try to apply perfecti onism to a
breathing practi ce. Overall, Nicky’ s experience is one of courage and
persistence, and it provides invaluable insight. Nicky wouldn’ t have described herself as anxious. After all, she never
had panic attack s. She liked to be in control of her life and was organized,
efficient, and had good attention to detail. She wasn’ t aware that anything
was wrong with her breathing, but she would frequently lose her train of
thought in conversation, and her focus was poor. Her heart often raced, and
she sometimes had palpitations,  which her doctor assured her was normal. But she was irritable, hypersensitive to noise, and had ongoing digestive
issues. She knew this was related to a low level of intermittent anxiety, but
she couldn’t pinpoint why, as her life was not particularly stressful. If she
drank coffee, it would often bring on feelings of anxiety, and alcohol, which
she drank only rarely, would cause disturbed sleep. She was exercising for
at least an hour most days, but this seemed to make her more  tired rather
than fit and energized. She recovered slowly and had sore, aching muscles
most of the time. Nicky did every thing at a hund red miles an hour, driven by a never -
ending to-do list. If something  went wrong, her reaction was emotional,
angry, or tearful. She had strong physiological reactions to many of her
thoughts, regularly had nightmares, and was beginning to have night
sweats. She noticed that her breathing was irregular and that she frequently
sighed and yawned. Sometimes she would find herself breathing gently,
become frightened, and try to breathe more deeply to correct it. After all,
she had learnt in yoga that deep breathing is good for you. When she
couldn’ t sleep, she used deep breathing to relax. Nicky also had nocturnal epile psy, irregular grand mal seizures, only
ever between 1 and 5 a. m. , and intermittent partial complex seizures during
the day. Before a grand mal seizure, she would experience extreme
hyperventilation. Her husband would try to wake her, hoping to stop the
ensuing seizure, but neither of them knew if this was actually helpful. After
a grand mal seizure, she would sleep for two days, and during the following
weeks, she would have hundred s of very intense partial compl ex seizures,
like aftershocks with diminishing frequency. Her concentration and memory
were badly af fected. She could get lost driving around her own small town. A brain scan found no physical cause for Nicky’ s seizures. She felt like
a zombi e due to the side effects of her medication, and she was told that she
was at risk of going into “status. ” This is where seizure after seizure occurs
until the heart fails. Her neurologist said that her seizures had to be fully
controlled, and she was prescribed Lamotrigine. On it, she had no more
seizures, but she still had regular episodes of nighttime hyperventilation. Then in 2016, Nicky took part in a breathing course. She had decided to
attend the instructor training, alongside the group course, to try to fix her
husband’ s chron ic snoring. At the start of the course, her BOL T score was
just 8 seconds, and she breathed at 20 breaths per minute during rest. Her
breathing was irregular, audible, and 50% through the mouth. Her blood
CO2 levels were between 26 mmHg and 32 mmHg, while a reading of
between 35 mmHg and 40 mmHg is considered normal. As the week of training progressed, she experienced a high level of
stress. She was frustrated that none of her healthcare providers had
identified the link between her breathing dysfunction and many of her
health problems. She had, for example, suffered severe postnata l depression
with both of her children, after births that were out of control and full of
fear and pain. The course also triggered an incredibly strong cleansing
reaction and a mounting concern over her seizure threshold. The breathing course had opened Nicky’ s eyes to the fact that her
breathing was incredibly unhea lthy. But it also became appar ent that she
should have learned much more slowly how to breathe functionally. She
should not have been in a group course at all, given the extent of her
hyperventilation and epilepsy, combined with her perfectionist tendencies. Instead, her training should have begun with awareness, then suppressingsighs, then full time nasal breathing, and moved slowly on to posture and
diaphragm breathing. Only once her BOL T score was about 20 seconds
should she have begun practicing with air hunger. After the course, it took Nicky two distressing weeks to be able to
breathe without trying to control every breath. She had resolved to stop
breathing in the old way immediately but couldn’ t work out how to breathe
functionally. She tried to implem ent everything she had learned at once. As
a result, she found herself on the edge of a panic attack most of the time. She experienced the following problems:
• She started using her diaphragm properly and it ached constantly, making it
impossible to switch her focus away from her breathing. • She changed her posture overnight and again experienced pain. Sitting was
uncomfortable, and she preferred to stand. • She stopped sighing and tried to breathe through her nose at all times. She tried to
retrain her breathing while speaking and began to lose weight because she didn’t
like the ef fect eating had on her breathing. • She tried to do the breathing exercises as taught but the reduced breathing
destabilized her respiration. • She experimented with her breathing, counted her breaths, and tried all sorts of
things to no avail. By lying down and reducing her breathing she could get her
breathing rate down to four or five breaths per minute, which felt good. When she
stopped the practice, her breathing became rapid again. She wondered whether
going from one state to the other was dangerous. By now, she had become very concerned about her seizure threshold. Her husband had to go away for a night, and she was terrified to go to sleep
without him there to wake her if her breathing changed. During the day, she
was so focused trying to work out how to breathe that she could barely do
anything else. Her breathing instructor advised her to ease up, stop taking her pulse,
stop practicing breath holds and counting her breaths, and just breathe
softly and gently through the nose, one step at a time. She finally had a
breakthrough when, one morning, in desperation and with a panic attack
imminent, she began to read the chapter Nine Healthy Breathing Habits in
Five Days, from Tess Graham’ s book Relief from Snoring and Sleep
Apnea. 100 The instruction s in the book enabled Nicky to finally let go of
control and start to breathe easily again. Four months later, the improvements in Nicky’ s health were
extraordinary. She lost six kilos as her metabolism stabilized, and she didn’ t
need to drink so much water. The hyperexcitability and asynchronous firing
of brain neurons that, at times, caused her to be overreactive, emotional,
fragile, hostile, irrational, anxious, and fast, which she thought were part of
her personality, vanished. Raising her CO2 levels led to a much calmer
outlook. Her memory and cognitive function improved. She taped her
mouth every night, and her sleep quality became so good that she needed
less sleep, no longer needing  to go to the toilet during the night or
experiencing nightmares. Exerc ise no longer left her feeling exhausted or
achy, and her capacity for exercise increased. However, her BOL T score was still only 16 seconds, and her lack of
progress was frustrating. She wanted to achieve the level of super health
that she knew was available with a BOL T score over 40. To teach, she also
needed to improve her BOL T score. She had the time, energy, motivation,
and commitment to do the work, but her breathing instructor ’s advice was
just to relax and not focus on her BOL T score. At this point, her breathwork consisted of daily yoga or a walk, during
which she reduced her breathing, and one or two meditation sessions where
she lay on her back and practiced reduced breathing. She was still unable to
do the reduced breathing exercis e as it was taught to her. Two or three times
a week, she had bad breathing days when her head and sinuses would feel
constricted, and she would be less able to focus. She developed tension in her neck and shoulders. Her instructor
suggested that she try the Himalayan rock salt drink (a quarter teaspoon of
rock salt in warm  water three times a day) and see what happened. This had
been suggested in the course, but she had overlooked it. She took the drink
twice that day and has been taking it ever since. The tensi on problem
resolved immediately, and it has not returned. In September 2016, without consulting her doctor or specialist, Nicky
started to come off Lamotrigine  at a rate of 25 mg every few weeks. This
process took five months. She felt safe reducing the dose as she considered
the recurrence of some complex  partial seizures to be a warning system that
would let her know the epilepsy was still there. She also felt that as long asher mouth was taped at night, she wasn’ t likely to hyperventilate enough to
bring on a grand mal seizure. From her research, she unders tood that her BOL T score should be
around 35 befor e epilepsy would be controlled, but she decided to go ahead
and reduce the drug anyway. Everything was fine until she got down to 25
mg per day (down from six pills per day to one), and then her nervous
system reacted. Her nervous excitation and feelings of irritability returned,
and she struggled to get any work done. Her capacity for exercise reduced
again. She lost confidence in the future and in her breathing practice, and
she was nervous  about having come off her medication with a BOL T score
of only 16. Nicky realized that with such a low BOL T score, her breathing was still
too unstable for her epilepsy to be under good control. She need ed to make
some progress, and it seemed that by practicing strong breath holds she
might achieve this, but her breathing coach had told her not to practice
breath holds at all. She had also been warned that the intense detoxification
caused by strong breath holds could induce exacerbations of disease, which
in her case meant grand mal seizures. She was confused and frustrated. However, she persisted in seeking help
and working to understand her breathing. She also consulted physical
therapists and began to release long-standing physical tensions and
imbalances. Fast-forward to 2019, and Nick y noticed that, despite all the changes
she had made, speaking still left her feeling exhausted. She experienced
tension in her abdomen when she spoke for long periods, and she found
herself cancelling social engage ments due to a sense that she didn’ t have
enough breath to go out and talk for the evening. She also had a phobia of
public speaking. Nicky’ s ambition was still to become a breathing educator, but she
wasn’ t sure how this would work. She consulted speech therapist Hadas
Golan, who identified the problem: Nicky was speaking for too long
without taking a breath, exhaling  too much air, bringing it below the resting
expiratory level, leading her to gasp and overinflate her lungs on the
inhalation. This habit creates a lot of tension in the secondary breathing
muscles and abdominals. While Nicky still hyperventilates when she talks,
she now uses practice of reduced breathing, after teaching, to recover. Nicky also began taking a selection of supplements. In the book Normal
Breathing,101 author Doctor Artour Rakhimov identifies that levels of
calcium, magnesium, potassium, and sodium tend to run low in
overbreathers, and Nicky began adding these minerals to her diet. Now, Nicky’ s end-tidal CO2 reading is between 38 mmH g and 40
mmHg at rest. Her BOL T score is around 20 seconds. She has not had either
type of seizure since she took the first breathing retraining course. In fact,
she believes the breathing pract ice probably saved her life. She is planning
to train as an instructor in New Zealand and works to raise awareness of
breathwork. One of her goals is for breathing dysfunction to be screened for
in general practice, and she is taking steps to promote this. ADVICE T O FELLOW PERFECTIONISTS AND
OVERBREA THERS
1. Before training as a breathing instructor, it is important to do a course yourself to
ensure that your own breathing health is suf ficient. 2. A client can be quite sick while appearing to be normal and high functioning. A
detailed health questionnaire is an important part of any breathing assessment. 3. For anyone with a serious health condition, breathing retraining cannot be
undertaken in a five-day course. Ongoing, long-term support is likely to be
necessary. 4. People with epilepsy must learn very gently and slowly. Weekly sessions are
enough. 5. If you have anxiety or control tendencies, the work should be taken very slowly,
especially if you also have a serious health condition. 6. Long breath holds must not be practiced by anyone with epilepsy. 7. Chronic hyperventilators may not be able to relax the breathing muscles. When
muscles are underoxygenated, they become “jumpy. ” This may also af fect the
diaphragm. 8. The body compensates for anemia by increasing breathing. This is an appropriate
physiological response, and iron levels should be restored before attempting
breathing retraining. If you have a history of anemia, you should check your iron
levels regularly. 9. Overbreathers tend to run low in macronutrients. 10. If you have had a dysfunctional breathing pattern for a long time, there are likely to
be biomechanical issues. It may benefit you to seek help from a physical therapist. 11. Even though breathing is something we all do, it is easy to misunderstand
instructions. If there is anything that feels wrong or seems to cause physical or
mental stress, stop the practice, and seek specialist advice, especially if you have a
serious health condition. 12. Never come of f your medication without consulting your doctor. 13. Never underestimate the power of this work and the changes in the mind and body
that can result from a few simple breathing exercises. OceanofPDF. comUCHAPTER SIXTEEN
JOIN THE BREATHING REVOLUTION
ntil recently, knowledge of the power and application of optimal
breathing has been limited to elite sports, advanced yoga
practitioners, research scientists, and other high-level professionals. In the last few years, we have witnessed the beginning of a breathing
revolution. Since I started my own journey with the breath, my aim has
been to bring these resources to as many people as possible. I believe the
exercises and understandings in this book can truly change lives for the
better. Just as it is human nature to leave things undone until they become
necessary, it has perhaps taken a global respiratory pandemic to underline
that we can’ t take anything, not even our breath, for granted. I am grateful this topic is now getting the attention it deserv es. The
negative effects of oral breathing  have been debated in dentistry since 1910,
especially the issue of whether mouth breathing affects craniofacial
development in children. All the while, millions of children and adults have
continued to suffer the health impacts of poor breathing while an industry
argues about whether the problem exists. I feel sorry for the dentists, orthodontists, and medical doctors who tried
to highlight the importance of nasal and functional breathing patterns, only
to be ridiculed by their peers. I know Professor John Mew and his son Dr. Mike Mew from  the United Kingdom well. I have visited their clinic and
observed them working with patients. Both have done their best to highlight
the importance of nasal breathing and received bad press within the
industry. Doctors William Hang, Kevin Boyd, James Bronson, Tamara
Gray, Carlos O’Connor, and James Bartley, along with Joy Moeller, Licia
Paskay, Barbara Greene, Samantha Weaver Moeller, and Marc Moeller, toname but a few, have also worked tirelessly in their quest to help children
and adults. I have often wondered why an industry populated with highly intelligent
people armed with dental and medical degrees has failed to realize the
importance of nasal and functio nal breathing. Breathing retraining is safe,
simple, and economically viable. It applies to major fields of dentistry,
respiration, sleep, mental, and physical health. This same question was raised during a recent panel discussion held by
the Academy of Applied Myofunctional Sciences (AAMS). The answers
presented by each of the panelists suggested a lack of cooperation between
dentistry and medicine, lack of scientific research, and similar arguments. These are all valid points. However, I wasn’ t so guarded in my comments. My belief is that the real reason  breathing does not receive attention from
the medical and dental industrie s is that its therapeutic applica tions do not
promise signific ant profit. One thing is certain: if there were a promise of
lucrative return—the kind of money generated by big pharma and sleep
medicine—there would be interest. For breathing to be properly integrated
into medicine, it seems necessary for there to be either the prom ise of profit
or the avoidance of the kind of loss that might be encountered when patients
raise a lawsuit on realizing they were not of fered the best treatment. I am not claiming that breathin g is a cure-all. It is not a magic bullet. My intention is not for peop le to replace traditional treatments with
breathing exerc ises expecting a miracle. However, there is a role for
functional breathing alongside medicine. I can’t help but think back to 1994 when I had an operation to fix my
nose so that I could breathe better through it. The surgeon performed a
successful procedure, but nobody told me I needed to stop my habitual
mouth breathing. I continued to experience sleep-disordered breathing for
four years until I discovered the importance of nasal breathing in 1998. Three decades later, my four-year-old daughter had surgery to remove
her tonsils and adenoids. After the operation, there was no follow-up or
advice to suggest we should help her learn to breathe through her nose. It is
never sufficient to treat the nasal obstruction. It is crucial for the long-term
outcome to change the behavior of breathing. This fact is regularly
overlooked. To realize the potential application of breathing exercises, it is necessary
to practice. You can read this whole book and understand the importance of
light, slow, and deep nasal breathing, but your efforts will be wasted unless
you apply the exercises to your health. To begin with, set aside some time each day to devote to breathing
practice. It will be the best investment in your health and well-b eing. Wake
up 20 minutes earlier in the morning, sit down on a chair or the floor, cross-
legged or in the lotus position, close your eyes, and draw your attention to
your breathing. Gently soften and slow down your breath for 15 minutes to
generate a tolerable air hunger. As you go about your day, take some attention out of your mind and
direct it to your breath. Slow down your breathing with latera l expansion
and contraction of the lower ribs. Go for a walk or head to the gym and
apply light, slow, and deep breathing while you exercise. Remember the
mantra LSD, Light, Slow, and Deep. This book contains breathing exercises for everyone. Some stress the
body, others relax it, up-regulating and down-regulating your nervous
system. Most important, when you think of functional breathing, remember it is
not limited to the studio, to your practice, or to your workout. Functional
breathing pattern s are relevant during rest, sleep, and physical exercise, for
life. On a day-to-day basis, it is likely that much of your attention is
directed outward. Modern life is full of distractions. Emails, text messages,
social media alerts, work, and family all fight for your attention—to the
point that you surrender your attention outward. It is increasingl y rare for us
to bring our attention inward. For me, this mindfulness of the breath has been life changi ng. The
ability to shift my attention from my mind to my breath, to create space
between though ts, has given me a new outlook and focused my abilities
beyond what I would have thought possible. Y ou can trust that time given to
breathing practice will never go to waste. Functional breathing is a game
changer for health and performance. As you begin your practice, be patient. Progress does not alway s travel
in a straight line. We all have ups and downs over the years, and you will
have some bump s along the road. Persevere and make a continu ed effort to
bring good breathing into your way of life, and you will reap the rewards. To assis t you, our mobile apps, which are available free of charge,
contain guided exercises and instruction. We have two apps available:
ButeykoClinic is for children, teenagers, and adults and focuses mainly on
health. OxygenAdvantage is designed to help adults with health and sports
performance. I close by wishing you the very best in your application of functional
breathing patterns.
No, the study does not mention OSA prevalence in people with epilepsy.
According to a 2019 study, is OSA more common in people with epilepsy?
The study does not discuss the relationship between OSA and SUDEP.
What is the relationship between OSA and SUDEP?
The text does not provide the recommended breathing rate for the 1990 study.
What is the recommended breathing rate for the 1990 study on breathing exercises and seizure control?
The passage does not mention the recommended breathing rate for the 1990 study.
What is the recommended breathing rate for the 1990 study on breathing exercises and seizure control?
The text does not explicitly state whether OSA contributes to SUDEP.
Can OSA contribute to sudden unexpected death in epilepsy (SUDEP)?