People
who consistentl y get too little sleep are more likely to be obese11 and
physically inactive, to smoke, or to suffer with heart disease,12 depression,
diabetes, asthma, and other disorders.13 Sleep deprivati on is considered a
public health epidemic, with more than a third of American adults regularly
getting by on too little sleep.14 Due to a culture  where lightbulbs, computer
screens, and stressful schedules make it difficult to find a reason to switch
off, the study claims that between 35% and 50% of adults worldwide show
symptoms of insomnia.15 Many cases of insomnia are thought to be theresult of hyper -arousal, a disorder that is present during both day and
night.16
As well as the cost to health, there are practical concerns regarding this
chronic sleep deprivation. Around 109,000 road traffic collisions resulting
in injury and 6,400 fatal crashes occur every year in the United States
because of a drowsy driver .17 Sleep deprivation costs the US economy $411
billion annually due to poor productivity and sick leave.18 Approximately
4% of Americans take prescribed hypnotic sleep aids,19 drugs that, along
with a wealth of unpleasant and unhealthy side ef fects, can be habit-forming
and cause disturbed sleep patterns.20
The authors of the 2019 insomn ia study suggest that slow breath ing can
be used along with sleep hygiene techniques to reverse disturbed sleep, and
this may provide a more desirable and effective long-term solut ion than the
over prescription of hypnotic drugs. To explain the effects of slow breathing
on insomnia, the study investiga tes the origins of the disorder in the context
of “evolutionary  mismatch.” This is a term to describe diseases that result
from evolved characteristics that were beneficial to our ancestors but due to
the pace of change in the human environment and lifestyl e, are now
maladaptive1. It has been suggested that insomnia is one such disorder . The
study’ s authors propose that a significant proportion of insomnia cases may
be due to a chronically overacti ve sympathetic nervous system  (SNS) or a
depressed paras ympathetic nervous system (PNS). This autonomic hyper -
arousal can be counteracted with slow, diaphragmatic breathing practice. As
the slow-wave sleep state promotes parasympathetic tone,21 a regular cycle
of healthy sleep stabilizes the autonomic nervous system (ANS), bringing
the body back into a calmer state. Slow breathing also causes the body to produce melatonin.22 This is an
essential sleep-inducing hormone that has been proven to improve vagal
tone and inhibit the activation of the SNS.23 Melatonin levels are lower in
people with insomnia and even further depleted in chronic insomnia,
indicating that the longer the sleep disorder is present, the more severe it
becomes.24
This can create a vicious cycle of worsening insomnia in which stress
increases, perpetuating hyperarousal of the SNS. New research also
suggests that slow breathing may help orchestrate oscillatory brain activity ,providing a mechanism to alter brain waves. This has implicat ions for the
potential modulation of brain activity to promote sleep.1
The researchers behind this extensive study conclude that slow
breathing to regulate the ANS  may be a more effective way to combat
insomnia than the prevailing “standard care” pharmaceutical interventions. There is still limited research into the use of slow, deep breathin g, although
significant evidence points to its efficacy in treating insomnia. The paper ’s
authors express the hope that their work will inspire more investigation into
the effectiveness of slow breathing in relieving hyperarousa l and thus
treating insomnia. There is a strong connection between insomnia and menta l health
disorders, includ ing depression. It is quite normal for people suffering from
depression to experience const ant fatigue. While there is no doubt that
depression contr ibutes to feelings of tiredness and exhaustion, the question
arises: Could it also be that poor quality sleep arising from  insomnia,
snoring, or sleep apnea may contribute to both depression and fatigue? In
answer to this, I cannot help but think of a young woman in her early
thirties who attended my clinic seeking relief from depression. She looked
totally washed out. When I asked her how she felt upon waking up, she told
me that she was exhausted most mornings. I asked whether her doctor , or
any doctor in the past, had ever referred her for a sleep study, and she
answered, “No.”  It seems obviou s to me that there may be many people in a
similar situation. The bottom line is, if you are feeling constantly tired, it is
likely that your sleep quality is poor . Research has shown that obstructive sleep apnea (OSA) can contribute
to the development of depression.25,26 Up to 67% of people with OSA also
experience insomnia, and depression scores are higher in individuals
presenting with both insomnia and OSA.25,26 This means that people with
sleep apnea may be at higher risk of depression because of the comorbid
insomnia symptoms. It makes sense, then, that some patients with a primary
diagnosis of depression should also be considered for a sleep study . The diagnostic criteria for insomnia disorder include daytime fatigue,
irritability , and difficulty concen trating. These are often the symptoms that
prompt patients to seek treatment for their mental health. They are also all
well-known consequences of both depression and OSA.25 When symptomsare similar across several conditions, a little more investigation is needed to
determine the root cause. There is a direct interplay between breathing, the emotions, and sleep:
• If your breathing patterns are poor , mood regulation, and sleep will be poor . • If sleep quality is inadequate, the emotions are unbalanced, you feel tired and
anxious, and breathing is dysfunctional. • If the emotions are high, you may have dif ficulty falling asleep or suf fer from
insomnia, and breathing will be fast, in the upper chest and ef fortful. Poor breathing is closely linked with stress and anxiety and increases
the risk of SDB . This is one reason why people with asthma are also more
likely to experience higher levels of anxiety and fatigue. Another factor that contributes to insomnia is fast breathing during
wakefulness.27 This means that, if you breathe  too fast, you are more likely
to be aroused from sleep. In a 2017 paper published in Science , researchers
identified a neural circuit within a brainstem region called the pre-Bötzinger
complex, a part of the brain that may be responsible for generating
respiratory rhyth m in mammals.28 They suggest that this neural circuit may
have evolved as a defense mech anism, “mobilizing the animal in the face of
rapid, irregular , or labored breat hing.” The researchers point to the fact that
fast, irregular breathing increase s alertness and can cause panic and anxiety
in humans27. Simila rly, increased activity  in the area of the brain
responsible for respiratory rhythms, hyperventilation, and sighing appears
to trigger arousal during sleep.27 This contrasts with the practic e of slow,
conscious, contr olled breathing, which is known to promote relaxation via
the PNS and is ef fective in treating stress disorders.27
This would seem to tie in with the theory that insomnia may be caused
by hyperarousal during wakefulness, and that an overactive sympathetic
nervous system may contribute to the problem. An earlier study from 1992
supports the theory that hyperventilation or “increasing ventilation”
prompts arousal from sleep, regardless of the stimulus that causes the
increase in breathing.29 Insomnia is a widespread problem not adequately
resolved by doctors and generall y addressed with medication. Knowing that
fast breathing and hyperventilation causes us to wake from sleep can be key
for people with insomnia and sleep apnea.Light, disturbed sleep leads to feelings of lethar gy, decreased
productivity , and heightened stress levels.30 In terms of physical well-being,
researchers have consistently reported a relationship between poor sleep
and high blood pressure, a connection that may be explained by the
physiological load that insuf ficient sleep adds to the nervous system31. Ultimately , poor sleep results in a reduced quality of life. The good news is
that disturbed or inadequate sleep is frequently connected to the way you
breathe at night, and that is something I can help you change. DOES COUNTING SHEEP HELP? Insomnia can manifest in two different ways: difficulty falling asleep and
waking suddenly after four or five hours’ sleep. If you struggle to get to sleep, practice Breathe Light  exercises during
the day. Exercise only with your mouth closed and improve your BOL T
score to over 20 seconds. Just before you intend to sleep, practice Breathe
Light  to create a tolerable feeling of air hunger for 15 minute s. Use
MyoT ape to ensure nasal breathing during sleep. If you wake after a few hours’ sleep, this may be due to heavy  snoring
or sleep apnea. If your airways narrow sufficiently during sleep to create an
increase of negative pressure and a buildup of carbon dioxi de, you are
likely to wake. The techniques in this book can be very helpful for snoring
and sleep apnea and for preventing this type of insomnia. Once you are awake, it can be very challenging to get back to sleep. The
mind is sufficiently alert to wander, but too groggy to get you out of bed. You can end up lying there for hours, worrying about how tired you will be
when you eventually have to get up in the morning. In both types of insomnia, the practice of “counting sheep” has
historically been  considered helpful. The idea is to count one imaginary
sheep after another as they jump across a fence in your mind’ s eye. There is
an early reference to this technique in the context of an anxiou s landowner
in an 1832 book Illustrations of Political Economy  by Harriet Martineau.32
The idea of counting sheep may be somewhat of an old wives’ tale, but
interestingly , scientists have demonstrated that it works. A team at Oxford
University explored the use of an imagery task in reducin g presleepcognitive activity and found that “imagery distraction” took up sufficient
brain power to prevent unwanted thoughts and worries. Researchers
examined 41 people with insomnia who were given either an imagery
distraction task, a general distraction task, or no instruction. The imagery
group were told to imagine a situation they found interesting , engaging,
pleasant, and relaxing.33 They were asked to spend two minutes picturing
this scene in as much detail as possible. It was found that this task helped
people fall asleep more quickly . If counting sheep works for you, great, but if you struggle with visual
imagery , cognitive tasks such as complex mental arithmetic problems also
improve sleep latency by preventing the brain from engaging with negative,
unwelcome thoughts.34 If neither of these methods work, it is also helpful to
bring your atten tion away from your mind and into your body . Unless the
mind is calm, sleep will continue to elude you. Try bringing your attention
to a small part of your body , such as your hand or foot, and hold your
attention there. If you find that easy, practice expanding your focus to
include a larger area of the body, say, perhaps, your feet and legs. Some
people find a body scan meditation helpful. When you bring your attention
into your body , it helps to bring space between your thoughts, quiet the
monkey mind, and allow you to fall asleep. Another way to calm the mind  is to focus on and gently slow your
breathing. It is normal for the mind to wander . When it does, quietly bring
your attention to your breath. This becomes easier with practice. As you go
about your day, make it a habit to bring attention to your breathi ng for short
periods. It is more important to do this regularly throughout the day, than it
is to be able to sustain the attention for a long time. SNORING AND OBSTRUCTIVE SLEEP APNEA
Snoring occurs when a large volume of air passes through a narrow space,
causing turbulence in the nose, mouth, or back of the throat. There are two
reasons this might happen: either the snorer is breathing too hard during
sleep, or the upper airway—the nose, mouth, and throat—is too narrow . Traditional snoring treatments, such as nasal dilators or surgical
procedures, are generally desig ned to increase space in the upper airway .These focus solely on the airway , ignoring the role of breathing. It is
common for children and adults  with asthma, anxiety , and faster breathing
habits to snore. Fast, hard breathing during the day translates into fast, hard
breathing during sleep. This is what creates the turbulence. To get clear about the link betw een breathing and snoring, it is helpful
to deliberately make the sound of a snore through your mouth. Open your
mouth, tighten your throat, and draw air fast into your mouth. You will feel
the turbulence at the back of your mouth where it meets your throat. Now ,
close your mouth. Try to snore  through your mouth when your mouth is
closed. It might sound obviou s, but this will prove to you that mouth
snoring stops completely when you breathe only through your nose. Next, make the sound of a snore through your nose. Nose snoring is also
created by fast breathing throug h a narrow space. At this point, it is worth
slowing down the speed of your breathing. Take a soft breath in through
your nose and allow a slow, relaxed breath out. As you continue to breathe
slowly through your nose, try to make the sound of a snore. You will find
that when you breathe slowly through your nose, you are much less likely
to snore . Snorin g is not solely due to narrow or collapsed airways. Fast,
hard breathing also contributes. To reduce nasal snoring, breathe only through your nose during  the day,
and practice Breathe Light  to improve your BOL T score to at least 20
seconds. For many people, this is enough to stop nasal snoring. If you have
a compromised nasal airway or small nose, your snoring may continue at a
lower intensity . If you wake up with a dry mouth in the morning, indicating that you
have been breathing through an open mouth, a support such as MyoT ape
can be very ef fective for maintaining lip closure during sleep. Snoring can also lead to sleep apnea, a more severe symptom of SBD,
where the sleeper involuntarily stops breathing during sleep. Obstructive
sleep apnea  (OSA) is becoming increasingl y widespread. Statistics suggest
that the conditio n affects up to 9% of women and 26% of men between 30
and 49 years old, and up to 27% of women and 43% of men aged between
50 and 7035. OSA is charac terized by breathing that stops during sleep. People with OSA tend to snore very loudly , and they experience frequent
episodes of shallow breathing (hypopnea ) and pauses in breathing (apnea )lasting 10 seconds or more.36 Aside from the apneas themselves, symptoms
that indicate OSA may include:
• Daytime tiredness
• Limited ability to concentrate
• Sudden awakening, sometimes with a racing heart or feeling of breathlessness
• Dry mouth on waking
• Night sweats and a frequent need to urinate
• Waking with a headache
• Impotence and erectile dysfunction in men36,37
When we inhale, air is drawn into the lungs, producing negative  suction
pressure in the upper airways. During the day, our upper airways are held
open by various dilator muscles , but when we sleep those muscles become
“lazy” and the airway is more vulnerable to collapse.38 Collapse occurs
when negative suction pressure exceeds the ability of the upper airway
dilator muscles to maintain an open airway . There are four possible places
where the airway may collapse during sleep:
• The soft palate can fall against the back of the throat
• The tongue can fall back into the airway
• The walls of the throat can collapse
• The epiglottis may close the airway39
To really visualize how breathin g stops during sleep, I find it helpful to
use the analogy of a paper straw . If you place one end of a straw into your
mouth and suck air forcefully  through it, the walls of the straw will
collapse. If you then continue trying to inhale through the straw once it has
collapsed, it will be impossible to do so. However , when you suck air into
the straw  more gently , the straw will maintain its shape and air will pass
through it. As soon as you increase the speed of airflow , the straw becomes
unable to withstand the increase in negative suction pressure. In essence, that is what happens during OSA. As the inhalation begins,
the nega tive suction pressure created by the effort to pull air into the lungs
causes the walls  of the upper airways to collapse. As the interruption in
breathing continues, the body no longer gets enough oxygen.36 The
respiratory center in the brain sends increasingly urgent messages to the
diaphragm, prom pting it to resume breathing. As the diaphragm contracts todraw air into the lungs, this further increase in negative pressure reinforces
the inability to breathe. Event ually , the oxygen saturation of the blood
becomes low enough to partially wake the brain, and the sleeper starts
breathing again with a loud gasp, followed by a series of heavy and intense
breaths. This can trigger another collapse of the airways, and so the cycle is
repeated throughout the night, often preventing the sufferer  from ever
entering deep sleep.36
Most people with OSA go undia gnosed and untreated.40–42 This may be
partly due to a lack of confidence in existing treatment options, but, in some
cases, patients avoid diagnos is out of concern for their lifestyle or
livelihood. I recently took a ride with a cab driver in California. During our
conversation, he told me that he suffers from OSA. He had visited the
hospital to under go a sleep study , but, when he arrived, it was made clear to
him that the licensing authoritie s would be notified if he tested positive. He
was essentially told that a diagnosis necessary for his overall well-being
might lose him his driver ’s license and therefore his job. Upon hearing this,
he naturally turned around and walked straight back out the door . Bearing in mind the percentage of road traffic accidents that are related
to driver  fatigue , sleep studies should not be a deterrent to drivers getting
help. The results of a 2020 study suggested that more than a quarter of
drivers hospitalized after motor vehicle crashes were at high risk for OSA.43
Researchers concluded that diagnosed or undiagnosed OSA is an
established hazard for drivers and represents a significant public health
concern. This is relevant to other professions too. There have, for example,
been numerous accounts of pilots falling asleep while flying. In 2013, the
British Airline Pilots’ Associat ion reported that more than half of pilots
have fallen aslee p when in charge of a plane, with 29% reporting that they
had woken up to find their copilot asleep as well.44
Other risk factor s are associated with OSA, not least being the danger of
sudden death. A 2015 study found that patients with OSA are more likely to
die during the night than people without the disorder . Scientists observed
112 adults over a period of 16 years. Sudden cardiac death (SCD), a
condition in which the patient suffers a fatal loss of heart function, was
recorded in 46% of OSA patien ts, compared with 21% of people without
OSA.45 OSA more than doubled the risk of SCD. The severity of sleepapnea was found  to relate directl y to the relative likelihood of SCD between
midnight and 6 a.m. When the results were evaluated in terms of sleep-
wake cycles, researchers found that 54% of OSA patients died while asleep,
compared with only 24% of non-OSA sufferers.45 In this study, the severity
and duration of apneas was linked with an increased incidence of high
blood pressure and abnormal heart rhythms45. While the factors leading to
increased risk of sudden cardiac death in sleep apnea are unclear , the
scientists concluded that,
apnea, hypoxemia, and hypercapnia act syner gistically to elicit
sympathetic activation, which is thought to be a major mechanism
underlying elevated risk of adverse cardiovascular consequences
and mortality . Vagal response s to apnea are also critical in triggering cardiac
arrhythmias.45
In a 2019 study  published in the American Journal of Respiratory and
Critical Care Medicine,  researc hers discovered an inverse relationship
between the duration of apneic events and overall risk of mortality in sleep
apnea.46 That study indicated that the people who are most at risk are not
those with severe sleep apnea or those who stop breathing for a minute or
more. Instead, they are the light sleepers who awake easily by slight
abnormalities in their breathing,  when CO2 levels rise or negative pressure
in the airways increases.46 The constant interruptions to sleep are quite
literally killing those people. That paper shows the importance of good
quality deep sleep with few if any awakenings. In the case of prolonged apneas , research from 2007 demonstrates that
the increased levels of CO2 may actually contribute to improved oxygen
uptake and delivery through mechanisms including vasodilation, actually
protecting the brain against injur y caused by lack of oxygen (hypoxia). This
paper concludes that the hypercapnia (high blood CO2), which occurs
during apneas, might be the body’ s way of adapting to severe, chronic,
intermittent sleep hypoxia.47
During snoring and sleep apnea, the sleeper may not even be conscious
of the noise created by their breathing. It is usually their sleep ing partnerwho lies awake,  sometimes too fearful or exasperated to sleep. After some
time, and often with a little persistence from their partner , the suf ferer might
attend a sleep clinic. Here, the doctor or nurse will normally begin the
consultation by requesting the completion of a questionnaire  called the
Epworth Sleepiness Scale . If the scale is positive, a referra l for a sleep study
is likely . While the Epworth Sleepiness Scale  is a validated questionnaire used by
many sleep centers, I have observed that it does not capture everyone
presenting with OSA. The probl em with a questionnaire such as this is that
some people are unaware of just how exhausted they are. Not everyone who
suffers from a sleep disorder experiences or recognizes symptoms of
tiredness—25% of patients with moderate obstructive sleep apnea have
neither subjective nor objective sleepiness.39 Also, up to 50% of people
with OSA are not obese. These people are falling between the cracks of
sleep medicine. The test for OSA is overnight polysomnography in a sleep center . Polysomnography involves monitoring both sleep and respiration, with the
primary measur e being the number of apneas and hypopneas per hour of
sleep. An apnea is categorized  as a total collapse of the upper airway ,
during which the patient completely ceases to breathe for 10 seconds or
more. A hypopn ea is a partial collapse of the upper airway that causes a
reduction in the amount of air taken into the lungs lasting for 10 seconds,
with a correspo nding decrease in blood oxygen of 3% or more, or EEG
arousal. The number of apneas and hypopneas during the sleep test are
added up and divided by the number of hours spent sleeping. The severity
of sleep apnea in adults is then defined by the following scale:
• Mild sleep apnea: 5 to 15 respiratory events per hour
• Moderate sleep apnea: 15 to 30 respiratory events per hour
• Severe sleep apnea: more than 30 respiratory events per hour
While the apnea hypopnea index  (AHI) is the measurement of choice
for most sleep clinics, it is not without its limitations and should, at best, be
considered a crude and imprecise measure of OSA.48 Apneas and
hypopneas have  fundamentally different effects on the individual, but the
index does not differentiate between the two. It could be argued that anapnea, which involves comple te collapse of the upper airway, is more
severe in its physiological impact than a hypopnea, which involves only
partial collapse.48 Furthermore, a hypopnea with a 4% drop in blood
oxygen saturatio n is less severe than one that causes an 8% to 10% drop,
but the index does not take this into account either . Apneas and hypopneas
can occur evenly throughout the night or cluster during one period of sleep. If the sufferer experiences several events in a short period of time, it might
still be possible to also manage 4 or 5 hours of decent quality sleep. This is
a very different experience than that of the individual who experiences
symptoms throughout the night, resulting in few, if any, hours of quality
sleep. Finally , the AHI correlates poorly with the key causes and
consequences of the disease.49,50
Traditional treatment of OSA normally focuses on the use of a CPAP
machine (continuous positive airway pressure)—a device that splints the
airway open at night. Newer procedures involve widening the airways,
either with the use of oral appliances or by bringing the lower jaw forward
with surgery—a procedure calle d mandibular advancement. More recently ,
hypoglossal nerve stimulation has been introduced as a furth er surgical
option since the approval of the Inspire® hypoglossal nerve stimulator
implant by the US Food and Drug Administration (FDA).51 The implant,
which triggers the tongue to contract, stopping it from falling back into the
airway , has been found to be effective in reducing the symptoms of sleep
apnea.52 A study of 27 participants found that preoperative AHI fell from
an average of 46 down to 4.6 after sur gery.53
While these interventions are relatively successful, it is still important to
address the breathing patterns that underlie the condition. Over the years, I
have seen many  individuals reduce their AHI to near normal levels simply
by applying the breathing exerc ises in this book, practicing nasal breathing
day and night, maintaining a correct resting tongue position, and addressing
their inef fective breathing habits. Research from 2006 demonstrated that mouth breathing is a strong
determinant of OSA in people with no nasal obstruction.54 People with
sleep apnea spend more time breathing orally and oronasally than people
who snore. A strong relationship exists between the AHI (which indicates
the severity of sleep apnea) and time spent breathing fully or partiallythrough an open mouth. This was confirmed in a 2020 paper published in
Laryngoscope  in which worse OSA and greater oxygen desaturation was
associated with mouth breathing than with nasal or oronasal breathing.55
SECRETS OF A HEAL THY AIR WAY
The habit of breathing continuously and solely through the nose during
sleep comes with many positive consequences. These include maintaining a
moist upper airway , harnessing  nasal nitric oxide, creating more stable
breathing pattern s (see “Phenotypes of Sleep Apnea” in bonus Chapter 18
online at www .HumanixBooks.com/ The Breathing Cure), using the
diaphragm, and helping keep the tongue out of the throat. All of these
benefits have the added effect of improving and preventing the symptoms
of sleep  apnea. Conversely , mouth breathing can be a trigger and
perpetuating factor in OSA as it increases negative suction pressure and
dries out the nose, mouth, and throat. The loss of moisture inherent in
mouth breathing causes inflamm ation in the airways, which, in turn, causes
nasal obstruction, encouraging mouth breathing, and so the cycle continues. The gas nitric oxide (NO) is produced in significant quantities in the
nose and in the paranasal sinuses.56 (The importance of this was discussed
in detail in Chapter Three .) NO acts as a bronchodilator and helps keep the
lower airways open. In general , the role of NO in the regulation of sleep
apnea, though likely significant, is still not completely understood.56,57 It
appears to help reduce obstruc tion of the upper airways and acts as a
transmitter between the nose, throat muscles, and lungs. The lower and upper airways (the lungs and the nose and throat) are
mechanically connected, thus nasal breathing leads to improved lung
volume58 due to greater activation of the diaphragm.59 Increased lung
volume results in tautening and opening of the throat, reducing the risk of
the airway collapsing during sleep.38
Anatomically speaking, breathing through the mouth causes the jaw to
hinge downwar d and the tongu e to fall back into the throat. When this
happens, the airway size is compromised, increasing the risk of collapse
during sleep (imagine a narrower straw). According to airway orthodontist
Dr. William Hang, the difference between a healthy and a poorlyfunctioning airway can be described by comparing the diameter of a garden
hose to that of a pen. Dr. Hang has been instrumental in advancing
awareness of the airway in orthodontics for several decades, and patients
(including myself) often travel great distances to visit his clinic in
California. The airway can be adversely affected when teeth are removed or
jaws retracted to create a “better” smile, so it is vital to research the
implications of this when considering orthodontic treatment. In his 2017 resea rch paper , Dr. Hang explains that many approaches that
result in a reduction of the airway are currently standard practice in
dentistry and orthodontics. He states:
In light of the current epidemic of OSA and OSA related
morbidities, such reduction in airway cannot be justified. Instead of
arguing about whether or not a proposed orthodontic treatment
protocol involve s extraction of teeth . . . , we must substitute the
question about how it af fects the airway .60
When it comes to the modern human airway , there is not much room for
error . Any infringement on that already narrow space is likely to be
detrimental to health. Thankfully , there is a growing awareness of this issue, largely driven by
the general public. Initiatives such as RightT oGrow .org in Canada and the
Prevent Crooked  Teeth campaign in the United Kingdom are helping people
to recognize the importance of retaining all 32 teeth and instilling good
breathing habits  to promote lifelong health. Methods sympathetic to airway
health and function, such as expansion of the jaws to make room for
existing teeth, ensure a beautiful-looking smile without any negative
consequences for respiration, sleep, or overall well-being. Conventionally , if a patient has a problem with their nose, a referral is
made to the ear, nose and throat (ENT) department. Chronic lung problems
such as recurren t chest infections, wheezing, or coughing necessitate a visit
to the respiratory consultant or pulmonologist. However , researchers are
now recognizing that the nose and lungs constitute the same airway . Since
inflammatory mediators and infectious pathogens can be transported along
the respiratory mucosa and through the airways58, inflammation in the
lungs, which is prevalent in asthma sufferers, can travel up to the nose.Equally , inflamm ation in the nose can reach the lungs. Given this, it’s no
surprise that children and adults  with asthma are more likely to experience
problems in the nose. Physiological, epidemiological, and clinical evidence
now support a unified airway model .58
Asthmatics are likely to experience nasal congestion that causes them to
breathe through an open mouth. This results in a faster respiratory rate and
shallow , upper chest breathing. It is this very same breathing pattern that
contributes to SDB. People with asthma are more likely to experience
fatigue too,61 especially when they are suffering from asthmatic symptoms
such as chest tightness, wheezing, or coughing. Obstructive sleep apnea and asthma are common respiratory disorders. They are also frequently comorbid,62 meaning that they occur
simultaneously but not necessarily as a result of each other . Undiagnosed or
inadequately treated OSA may adversely affect control of asthma and vice
versa.63 In one study , researchers demo nstrated that approximately 74% of
those with asthma also experience nocturnal symptoms of airflow
obstruction64 and that when an asthmatic is experiencing asthma symptoms,
they are more likely to also experience OSA.63
Much can be learned about breathing patterns in sleep apnea by looking
in more depth at the breathing habits of people with asthma. The exercises
in this book have been shown to improve asthma control. Given the
relationship between asthma and sleep apnea, these techniques are also
likely to be helpful in reducing OSA. HOW T O SLEEP BETTER
Gravity plays a role in both snoring and sleep apnea. When you lie on your
back, there is no restriction to breathing, so breathing volume increases and
snoring becomes more severe. Sleeping on your back also encourages the
mouth to open, causing the lower jaw to hinge downward and the airway to
narrow . OSA sufferers who sleep on their back experience a higher number
of apneas per night and stop breathing for longer during those apneas. In
one study of 574 patients with sleep apnea, participants had at least twice as
many instances of apnea or hypopnea when sleeping on their back as they
did when lying on their side. Researchers concluded that “Body positionduring sleep has a profound effect on the frequency and severity of
breathing abnormalities in obstructive sleep apnea patients.”65
A similar assessment of 2,077 OSA patients over a period of 10 years
found that nearly 54% experi enced at least twice as many breathing
abnormalities when sleeping on their back than when sleeping on their side. The paper acknowledged that “Avoiding the supine posture during sleep
may significantl y improve the sleep quality and daytime alertness of many
positional patients.”65
The techniques that follow will help you achieve better quality sleep. BREA THE LIGHT AND SLOW
You can do this while watching some light television or relaxing in bed. • Place one hand on your chest and one hand on your abdomen. • Gently soften and slow down your breathing to create a slight hunger for air . • Continue the practice for approximately 15 minutes. This is an excel lent way to help with SDB. It also promotes relaxation and
enables you to fall asleep more easily . MOUTH T APE FOR NASAL BREA THING
We’ve already described why it is vital to breathe through your nose during
sleep, but how can you make sure it happens? When you wake up in the morning, your mouth should be naturally
moist. If you have been breathing through your mouth at night, you will
wake up with a dry mouth. You may also find that you have smelly
breath.66 Mouth breather s have a higher incidence of gum disease, halito sis,
and tooth decay than nasal breathers. If you tend to mouth breathe during the night, you can try taping the
mouth, following these guidelines. Taping the mouth at night may seem like a scary prospect at first. However , the method has been used with great success by Oxygen
Advantage trained instructors and in Buteyko Breathing Clinics around the
world. It may be reassuring to know that it does not take long to get used to. If you struggle  to keep your mouth closed at night, placin g MyoT apearound your mouth before you go to sleep is an excellent way to eliminate
SDB and encourage full-time nasal breathing. The tape, which I designed
especially for this purpose, is placed around the lips rather than across the
mouth and is designed to act as a reminder , using elastic tension to prompt
you to close your mouth if it falls open. I have no doubt that the single best thing I ever did to improve my sleep
was to tape my mouth at night. MyoT ape can be easily purchased online at
MyoT ape.com. You may also like to try a Micropore paper tape, which you
can pick up at any pharmacy , or Lip-Seal Strips, which can be bought
online from Simply Breathe. To overcome any initial anxiet y about having your mouth taped, try
wearing the tape for 20 minutes  before you go to bed. Also be aware that if
you are accusto med to breathing through your mouth, the tape is likely to
fall off during the first couple of nights. This will resolve fairly quickly . Within a few days, your body will relearn its natural nasal breat hing pattern
and the tape will remain in place. Y ou may then begin to experience the best
sleep you have ever had. If your nose is partially blocked before going to bed, use the nose
unblocking exercise to clear it before taping your mouth. Rest assured,
however , that if you are wearing the lip tape at night, your nose will never
become complet ely blocked. This is because nasal breathing actually helps
dilate the nasal passages. If you breathe heavily during the night while wearing the tape, your
nose may partially block. If this is the case, you may also find it helpful to
wear a nasal dilator , which you can purchase online or from your chemist. This small plastic dilator is placed inside the nose to open the nasal
passages and alleviate snoring . In time, if you follow the breathing
exercises and techniques in this book and as your nasal congestion
improves, you will be less likely to require a nasal dilator . In a recent study that tested the application of lip tape to assess
difficulties with nasal breathing , researchers found that 83.5% of habitual
mouth breathers  were able to breathe comfortably through the nose with the
mouth taped. Remember , your nose will only ever become completely
blocked if you revert to mouth breathing.67If, durin g the night, you find it difficult to breathe while using the tape,
gently reduce your breathing until you feel comfortable. Try to acclimatize
to the tape rather than removing it. Without it, you are likely to revert to
mouth breathing  during sleep, and this will only make your symptoms
worse. Important: This method is not suitable for childr en under four
years old. While MyoTape does not cover the mouth, meaning that it is still
possible to communicate while wearing it, any child taping their mouth at
night must be able to remove the tape if they feel the need to. Do NOT  use MyoT ape or any other lip tape at night if you are
feeling nauseou s or have been drinking alcohol. If your child has a
tummy upset or is likely to vomit, you must NOT tape his or her mouth
during sleep. Check your BOL T Scor e
To find out whether you are overbreathing during the night, measure your
BOL T score before you go to bed and again when you wake in the morning. If your BOLT score is lower upon waking than it was the night  before, this
means that you have been breathing too hard or mouth breathing during
sleep. ENSURE BETTER CP AP COMPLIANCE
If you use a CPAP machine, mouth breathing during sleep compromises the
effectiveness of your treatment.68 If you commonly mouth breath e at night,
you may also find it necessary to wear MyoT ape with your CPAP device. Some people find it difficult to wear a mask all night, and the full-face
mask is naturally more uncomfortable. Acceptable CPAP adherence or compliance is defined as 4 hours  use per
night,69 at least 70% of the time.70 But studies show that different levels of
compliance lead to better or worse results and that adherence of more than
six hours a night is necessary to reduce the risk of cardiovascular
mortality .69 Given that we need between seven and eight hours sleep every
night, four hours of compliance is obviously less than ideal. Also, if you
drive or fly for a living, it’s worth noting that you are required to share yourCPAP compliance data with the relevant authorities70 and that if your
treatment compliance is inadequate, you may lose your job. Throughout this book, we explore the connections between SDB and
many different aspects of health. There are links with conditions including
diabetes, sexual dysfunction, heart failure, and high blood pressure. Clinical
interventions like CPAP can help prevent and, in some instances, reverse
these problems, but only when the device is used effectively , which means
all-night compliance. To achieve that, it is necessary to address mouth breathing, which is the
primary cause of CPAP noncompliance.68 Mouth breathin g allows air to
leak out through the open mouth before reaching the airways. This often
causes the user to wake, which  contributes to sleep fragmentation. When
you breathe nasally during sleep, the air supplied by the CPAP device
makes it to the airway as intended. It’s so simple but just by closing your
mouth, you improve your chance of staying asleep. There are various products such as chin straps on the market designed to
keep the mouth closed at night. These can be problematic. They fit tightly
around the head, fixing the jaw closed, and can cause side effects including
temporomandibular joint pain. This is another instance in which taping the
mouth during sleep is the best solution. Whether you choose MyoT ape or an
alternative produ ct, mouth tape is a gentle way to ensure CPAP compliance. It easily prevents oral air leaks without causing jaw pain, interfering with
your CPAP mask, or adding a level of discomfort that stops you from
sleeping. Another problem with CPAP is that air leakage can cause irritation to
the eyes. This is especially true for people who have floppy eyelid
syndrome—loose upper eyelids that easily fold back, leavi ng the eye
unprotected.71 Sleep apnea is known to be an independent risk factor for
blindness due to glaucoma,72 and although the reason for the relationship is
unknown, studies have found associations between OSA and various eye
diseases including floppy eyelid syndrome,73 Using mouth tape to prevent
oral air leaks, there is less chance of eye irritation. PREP ARING FOR A SLEEP STUDYWhen you have been practicing breathwork for a while, you may find that
your symptoms lessen and it’s time to discuss reducing your CPAP use with
your doctor. The best way to determine whether your sleep apnea is under
control is by attending a sleep study . You should only ask to take part in a sleep study once your BOL T score
has been  greater  than 20 seconds for at least 2 weeks. You should have been
practicing light, slow, deep nasal breathing with your tongue in the correct
resting position and your lips closed. For men, another indicatio n of healthy
breathing during  sleep is that you begin to notice yourself waking up with
an erect ion each morning. The reason for this is covered in much more
detail in Chapter Eleven  when we look at the link betw een breathing and
sex, but for now it’s just worth understanding that “mornin g wood” is
indicative of good cardiovascular health. On the night of the sleep study , before you go to sleep, practice slowing
down your breathing for 15 to 20 minutes to create air hunger . Then tape
your lips using MyoT ape. Over the years, I have advised many of my
students to wear lip tape during the sleep study . The technicians organizing
the study are often curious but have never , to my knowledge, vetoed use of
the tape. This is important, because during the sleep study , you want to
determine the severity of sleep apnea when breathing is throug h the nose,
slow and low . THE BASICS OF GOOD SLEEP HYGIENE
There are severa l best practices for going to sleep that are considered the
basics of good sleep hygiene. You can start by avoiding eating a large meal
or drinking alcohol late at night. Although alcohol can send you off to sleep
more quickly , it is actually a stimulant, which results in poor quality sleep
and waking in the middle of the night. Eating too close to bedtime creates
similar problems as it leaves the body needing to expend considerable
energy digesting food while in a state of semirelaxation. Reserve the bedroom, where possible, for sleeping, relaxation, and
making love. Your bedroom should not be a place to watch telev ision, work
on the laptop, or browse the Internet on your mobile phone. In fact, having
as little technology as possible in the bedroom will help ensure good quality
sleep. Technology is increasingly implicated in contributing to poor sleep.Even the age-old ritual of reading before falling asleep has been
compromised as backlit tablets and phones replace traditional paper books. When our eyes are exposed to bright light, especially blue light, such as that
produced by these devices, the brain stops secreting the relaxation hormone
melatonin, whic h is responsible for creating feelings of sleepiness. The
human body is designed to be awake during daylight and to sleep when it
gets dark. According to a Harvar d Health Letter  entitled “Blue light has a
dark side,” it is advisable to refrain from using a laptop or electronic device
for at least three  hours before sleep.74 If this is not possible for you, it is a
good idea to invest in a pair of blue-light-blocking glasses to wear when
using your computer or phone in the evening. CABIN PRESSURE: USING BREA THWORK IN A LOW
OXYGEN ENVIRONMENT
An email I received from a client who is a professional pilot provides an
interesting persp ective on the subject of breathing and sleep. Remember the
report from the British Airline  Pilots’ Association about pilots who fell
asleep while in char ge of a plane? According to my client, fatigue, disrupted
circadian rhythms, jetlag, sleep disturbance, and body-clock disruption are
all part of the job, along with a high level of pressure and responsibility . These are significant, unavoidab le issues that must be managed and closely
monitored if performance is to be maintained at the necessary levels
throughout the flight. My client explained:
At a major airline like mine, which is notorious for its diverse
operating schedule and network, these issues are amplified even
further . A quick  look at my logbook reveals that on average, 40% of
my fligh ts are operated at night and back-of-the-clock hours. This
cannot be taken lightly . In one month, I can typically fly one ultra-
long-haul, two or three medium-haul trips and multiple short-haul
return flights. In order to optimize my mental performance, I need to take a
number of steps to ensure I am well-rested and able to operate at anadequate cognitive level. This is in addition to the stringent rules
and regulations employed by the industry , which ensure that our
rosters are compiled and managed safely . Since discovering breathwork, and its convincing benefits in
terms of sleep, energy, and wellbeing, I have used this to my
advantage consi stently . I have a daily breathwork routine that allows
me to sleep better , recover betw een flights, and perform optimally
during a flight. It all starts with sleep. In my experience, this is the most
important variab le to manage, whether I’m at home, staying in a
hotel around the airline’ s netw ork, or during critical rest periods
onboard ultra-long-haul flights. I use the principles behind Pranayama breathing, and the
scientifically backed exercises from The Oxygen Advantage  to
create a sleep-management routine which consists of the following:
• Taping my mouth at night to ensure nasal breathing and deeper more restful
sleep. • A sleep hygiene routine consisting of a dark room, eye shades, and ear plugs. • Presleep breathing exercises or meditation, to relax and activate the
parasympathetic response. These include long deep and slow diaphragmatic
breaths that emphasize longer exhalations to relax my body . • Keeping hydrated before bed. • Trying to be as consistent as I can and staying on a fixed “home time-zone” as
best as possible. My real-time breathwork practices during flights include:
• Box breathing using small breath holds after inhalation and exhalation. (Y ou will
find this exercise in Chapter T wo.) • Long slow and deep cycles of breathing, using the diaphragm, which is pretty
much a habit now anyway . • Consistent nose breathing to ensure maximum oxygen uptake. • These techniques are essential during flights because we operate in a low
oxygen environment of poor quality recirculated air . The exercises have obvious
benefits not only for the operating crew , but also for passengers who are not
used to the environment. In ef fect, we are already at a disadvantage because of
the low air oxygen levels and the altitude of approximately 6,000 feet. This is
compounded by the fact that a high percentage of the population has
dysfunctional breathing habits.My postflight exercises include:
• Any breathwork I feel like doing that emphasizes nasal and diaphragmatic
breathing. I especially like to practice this before bed. • Focusing on parasympathetic recovery and lowering my arousal levels, which are
usually quite high after flights due to lengthy periods of elevated concentration. I’m very aware of how physical and mental stress affects the
quality and speed of the breathing. I use the breath as a powerful
tool to control my state of mind, arousal, and general self-
awareness. It is a two-way street. The mind can control the breath,
and the breath can control the mind. This works particularly well in
high-pressure training situatio ns. These simulations, which  we
practice every three months, are similar to real-time combat training
in the military special forces and police tactical groups. The benefits I receive from breathwork are powerful and
effective. I can literally help my body and mind change and adapt as
I need it to, using the breath. OceanofPDF .comBCHAPTER EIGHT
DEVELOPING HEALTHY AIRWAYS IN
CHILDREN
WHA T CAUSES CHILDHOOD MOUTH BREA THING? ack in 1909, an article, “Habitual Mouth-Breathing and Consequent
Malocclusion of the Teeth,” was published in The Dental Cosmos . In it, DeLong described how mouth breathing can cause the sleeper
to wake with a dry mouth and throat in the morning, often accompanied by
headache:
A restless sleep, [and] much tossing in bed and snoring will be
observed. The face is usually elongated, the bones of the face are
underdeveloped, as the air spaces do not have the proper circulation,
the nostrils are small.1
DeLong goes on to list other detrimental effects of mouth breathing,
including recession of the chin and a high narrow palate with crooked teeth. Children who breathe through their mouths are observed as looking dull and
expressionless and may be accused by their teachers of being inattentive in
class.1 When I first discovered this article, over 100 years after it was
written, I could not help but feel a sense of disappointment that mouth
breathing is still not taken more seriously by the dental and medical
professions. Humans were never designed to mouth breathe. In fact, in the entire
animal kingdom, there are only a few creatures for which mouth breathingis norma l. Diving birds, such as penguins and pelicans, whose respiratory
apparatus differs from that of humans and other mammals, will take in a
gulp of air before descending below water to hunt. Even dogs, while they
are often  depicted with their mouths open and tongues lolling , only ever
pant to regulate body temperature. From birth, a tiny baby will instinctively breathe through the nose. You
may notice that a baby’ s tummy moves easily up and down with each
inhalation and exhalation as the diaphragm engages. However , at just a few
months old, many children switch to mouth breathing. Unfortunately , this is
a habit that stick s. Mouth breathing is classified as a pathological condition,
yet it is one that more than 50% of children exhibit. It is present in 60% of
boys and 40% of girls.2
Mouth breathing in children has a variety of causes, all falling into two
basic categories ; obstruction to the airway and behavior .3 The two most
common trigger s are chronic allergies and enlar ged tonsils and/or adenoids. The adenoids are glands located toward the back of the nasal cavity where
the nose connects to the throat. They form part of the immune system and
produce white blood cells to help fight infection. Enlar ged adenoids are
common among children aged  between two and seven years, typically
shrinking by adolescence. Other genetic and environmenta l factors that lead to mouth breathing in
children include a high narrow palate, tongue-tie, lip-tie, a small nose,4
constricted upper airways, asthm a, bottle feeding, insuf ficient breastfeeding
in infan cy, and an overheated home. Habits such as thumb sucking,
excessive use of pacifiers, overeating or eating too much processed food,
lack of physical exercise, and even wearing too many clothes also play a
part. A child with a high narrow  palate is nearly three times more likely to
breathe through an open mouth.5 Equally , something as simple as the use of
a conven tional pacifier can increase the probability of mouth breathing by
25% for each year of use.5
Of all these influences, swelling of the adenoids (adenoid hype rtrophy)
is the primary reason for mouth breathing in children. Untreated adenoid
hypertrophy results in adenoid facies  or long face syndrome, an alteration
in facial development characterized by an elongated, open-mouthedappearance. I see children with faces like this all the time. Tragically , it can
hold them back in their lives. HOW THE AIR WAYS DEVELOP
A 1991 study published in the American Journal of Orthodontics and
Dentofacial Orthopedics  compared the breathing of normal and long-faced
adolescents.6 The purpose of the research was to assess tidal volume and
ratio of nasal breathing in 32 children between the ages of 11 and 17. Those
with long faces (vertical dentof acial morphology) due to juvenile adenoid
hypertrophy had a significantly  different lower face form than those who
had developed normally . While the results showed that both groups of
adolescents had similar tidal volumes, the long-faced subjects were much
less likely to breathe nasally . Children who develop adenoid facies have
smaller nasal airways.6 This is an irreversible, lifelo ng consequence of
mouth breathing during early development. I live in the small village of Moycullen on the west coast of Ireland. Every few months, I visit my local dentist. He is in his early thirties and
was educated at Trinity College in Dublin. During one of our conversations,
I asked him about the implicatio ns of mouth breathing during childhood for
oral-facial development. I was surprised to discover he doesn’ t believe
mouth breathing contributes to crooked teeth or any negative development
of the face. Give n that he is a recent graduate, I expected that, if there were
a relatio nship between mouth breathing and crooked teeth, he would know
about it. Apparently , despite the topic having been hotly debated in
dentistry for over a century , this is not the case. Unfortunately , the well-
being of millions of children and adults is being sacrificed due to the
unwillingness of the dental and medical professions to reach agreement
about the connection. I am living proof of the effects of mouth breathing on the deve lopment
of the face. I have the same features described in the Dental Cosmos  article. My palate is very high, my jaws were set back, and my teeth were crooked. It could  be a coincidence, but it may not be. It is indeed still difficult to
reach conclusions on several points. It is unclear how much nasal
obstruction is necessary to cause mouth breathing, and there is as yet nocomprehensive evidence to show  how long a child’ s mouth breathing must
persist in order to cause a lifelong problem or at what age mouth breathing
does the most damage. There is, however , relevant research we will look at
later, regarding the rate of crani ofacial development in children  at different
ages. In my case, it could be that I was born with a narrow facial structure
that resulted in my mouth breathing. Or my mouth breathing may have
caused my face to develop poorly . Either way, what I do know is that I was
a mouth-breathe r during childhood, as is evident in many family photos,
and that my dentist could have spotted this early on and advised  my parents
about the importance of nose breathing. The problem of my small jaws
could have been easily addre ssed within months by using functional
appliances to widen my palate. What pediatric health profession als must realize is that dentists are in an
ideal position to help children with these same facial structures and mouth
breathing habits . With this understanding, procedures could be put in place
to gently widen the jaws, to help promote forward development  of the face,
and to shape the airway . I believ e that, if this were done, each child would
be better placed to reach his or her full potential. THE INFLUENCE OF DISORDERED BREA THING ON
LEARNING POTENTIAL
A stuffy nose will adversely affect a child’ s sleep. After a night spent
breathing heavily through the mouth, the child will wake up exhausted. This
manifests as poor concentration and frustration in school. If this inability to
focus continues  for a length of time, a psychological evaluation and
possible diagnosis of attention deficit disorder (ADD) or attention deficit
hyperactivity disorder (ADHD) may follow . Notably , scientists have
demonstrated that it is common for children with ADHD to experience
nasal congestion and hay fever .7 Also, 40% of children who experience
sleep disorders, including snoring or sleep apnea, develop ADD, ADHD, or
a learning disability .8 In fact, resear chers have found that, if a child is
snoring by the age of 8 and the problem is left untreated, there is an 80%
chance that the child will consequently develop a permanent 20% reductionin mental capacity .9 A 2012  paper by pediatric sleep expert Karen Bonuck
demonstrated that mouth breathing, snoring, and apnea at 6, 18, and 30
months of age significantly increases the risk of neurobehavioral and
neurocognitive disorders at ages 4 and 7.10
A 2017 study by pediatric behavioral and sleep scientists described the
case of a 5-year -old girl named Carly .11 Carly was brought for an
interdisciplinary evaluation because her behavior at home and school
suggested ADHD. Carly demon strated average verbal, visual- spatial, and
fluid reasoning IQ scores durin g psychological testing, but her processing
speed and working memory were below average. Executive function skills
(processes that monitor behavior) returned mixed results, and her working
memory was borderline. The ratings given by her parents implied worse
symptoms of ADHD and executive function than her test results showed. While factors such as the separation of her parents and inconsistent
disciplinary approaches were noted, the researchers felt that her nightly
mouth breathing and snoring were most significant. Carly displayed
enlar ged tonsils and a high, arched palate. A sleep study indicated that she
also had OSA. Carly underwe nt an adenotonsillectomy , after which her ADHD
symptoms noticeably improved. However , her behavioral problems recurred
one year after surgery.11 The paper does not record whether Carly also
reverted to mouth breathing after the operation, but it could be reasonably
assumed that a failure to restore nasal breathing resulted in the recurrence
of OSA.12
Unfortunately , doctors treating ADD or ADHD rarely consider nasal
obstruction as a possible cause and are unaware that the condition can be
greatly helped without medicati on or psychological therapy .9 When I speak
to any parent who has a child diagnosed with ADD, my first suggestion is
to check the child’s sleep habits. Is your child breathing through the mouth,
twisting and turning during the night and waking up with the bedclothes
tangled in the morning? Do they snore or stop breathing during sleep? Is
their breathing audible during sleep? To experience quality sleep, nasal
breathing is of the utmost importance. Any adult understands the knock-on
effect that a poor night’ s sleep has on mood, so how can a child be expected
to face the day with boundless ener gy if their sleep is inadequate?While no parent wants to see their child feeling constantly tired and
frustrated, more  serious consequences are at issue. Children who breathe
through an open mouth have a strong tendency to experience cognitive
disorders and problems with memory , concentration, attention, and learning
ability .9 Those with sleep problems are much more likely to have special
educational needs (SEN). The Avon Longitudinal Study of Parents and
Children, also known as Childr en of the 90s, is a detailed and ongoing birth
cohort study of children born in the United Kingdom between  April 1991
and December 1992. The Avon research has shown substantial correlations
between sleep-disordered breathing (SDB) and cognitive impairment in
children.13 Parents enrolled in the study reported on their children’ s snoring,
witnessed apnea , and mouth breathing at 6, 18, 30, 42, and 57 months. SDB
symptom trajectories, or cluster s, were derived from the resultant data. By
the time the children reached 8 years old, parental reports for 11,049
children with SDB indicated that children with SDB were 40% more likely
to have special educational needs.13 These statistics are echoed by a 2013
study in which 48 children had complete ear, nose, and throat examinations. Results showed that children with enlar ged adenoids experienced greater
learning difficulties than those with normal adenoids.14 Likewise, a 2015
study from the faculties of dentistry at Havana and Aden Universities found
that children with excessive daytime sleepiness were almost 10 times more
likely to have learning dif ficulties.3
Another 2011 paper compared cognitive function in children with
varying severitie s of SDB again st a control group with no history of sleep
problems. In total, 137 children between the ages of 7 and 12 took part. It
was found that there was a lower general intellectual ability in all children
with SDB. This was the case whether or not the problem was severe enough
to manifest as snoring or sleep apnea—children should not be snoring or
even breathing heavily during sleep.15 Childre n with SDB also show ed
higher levels of impairment in both executive and academic functioning. The first important study to look at the potential link between OSA and
its damaging effects on cognitiv e ability was published in 1998 . The paper
examined 297 first-grade children whose academic performance was in the
lowest 10th percentile of their class. These children were found to have
significantly higher incidence of OSA than their higher -achieving peers.The academic results of those children who received treatme nt for OSA
improved considerably in the following year, while children who had OSA
but were not treated showed no improvement.16
Another point regarding the cognitive and behavioral effects of OSA is
demonstrated by a 2011 paper that examined the methods used to evaluate
SDB in children.17 The study reported that many children who suffered
OSA at a level that was not picked up by traditional testing were  on various
medications to alleviate symptom s, all of which could be explained by poor
sleep. Some children were prescribed a sedative at night and a stimulant
during the day. Others were on a range of medicines including
antidepressants, antiheadache, antialler gic, antigastroesophageal reflux, and
antihypertensives. After treatment for SDB, 43 out of 99 childr en had their
drugs withdrawn by their physicians. NONSURGICAL INTER VENTIONS
The good news is that sleep specialists are becoming increasingly
concerned abou t the impact of open mouth breathing during sleep,
especially in children. Dr. Christian Guilleminault, who had discovered in
the 1970 s that blood pressure dramatically increased when patients stopped
breathing during sleep18 and made many further discov eries in the field of
sleep medicine, states in one 2015 paper , “The case against mouth breathing
is growi ng, and given its negative consequences, we feel that restoration of
the nasal breathing route as early as possible is critical.” The paper goes on
to expla in that “Restoration of nasal breathing during wake and sleep may
be the only valid ‘complete’ correction of pediatric sleep-disordered
breathing.”12 After his death in 2019, Dr. Guilleminault was recognized for
his pioneering work on sleep apnea and his contributions to the
understanding of the negative impacts of mouth breathing during
childhood.19
As we’v e already seen, the causes of mouth breathing during childhood
can vary and may be related to nasal congestion or enlar ged adenoids. When my daughter Lauren was four, I noticed her having disturbed sleep. I
quickly made an appointment with the ear, nose, and throat (ENT)
department at the Bon Secours hospital in Galway , Ireland. On examination,it was found that her tonsils were enlar ged and in all probability , so were
her adenoids. A date was set for her to have her tonsils and adenoids
removed and to have her tongue-tie and lip-tie released. The operation went
as planned, but the procedure was traumatic for Lauren and for us as
parents. In the following month s, there was no postop followu p, and at no
point was there any mention that the procedure might bring only short-term
benefits to Lauren’ s sleep unless nasal breathing was restored.20
Soon after this episode, I sent papers to the ENT surgeon regar ding the
importance of restoring nasal breathing post-tonsillectomy and
adenoidectomy . I received a thank-you email in reply . In hindsight, I would
not now follow the advice to have my daughter ’s tonsils and adenoids
removed without first having pursued less-invasive techniques such as
developing her jaws.
_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:

        People
who consistentl y get too little sleep are more likely to be obese11 and
physically inactive, to smoke, or to suffer with heart disease,12 depression,
diabetes, asthma, and other disorders. 13 Sleep deprivati on is considered a
public health epidemic, with more than a third of American adults regularly
getting by on too little sleep. 14 Due to a culture  where lightbulbs, computer
screens, and stressful schedules make it difficult to find a reason to switch
off, the study claims that between 35% and 50% of adults worldwide show
symptoms of insomnia. 15 Many cases of insomnia are thought to be theresult of hyper -arousal, a disorder that is present during both day and
night. 16
As well as the cost to health, there are practical concerns regarding this
chronic sleep deprivation. Around 109,000 road traffic collisions resulting
in injury and 6,400 fatal crashes occur every year in the United States
because of a drowsy driver. 17 Sleep deprivation costs the US economy $411
billion annually due to poor productivity and sick leave. 18 Approximately
4% of Americans take prescribed hypnotic sleep aids,19 drugs that, along
with a wealth of unpleasant and unhealthy side ef fects, can be habit-forming
and cause disturbed sleep patterns. 20
The authors of the 2019 insomn ia study suggest that slow breath ing can
be used along with sleep hygiene techniques to reverse disturbed sleep, and
this may provide a more desirable and effective long-term solut ion than the
over prescription of hypnotic drugs. To explain the effects of slow breathing
on insomnia, the study investiga tes the origins of the disorder in the context
of “evolutionary  mismatch. ” This is a term to describe diseases that result
from evolved characteristics that were beneficial to our ancestors but due to
the pace of change in the human environment and lifestyl e, are now
maladaptive1. It has been suggested that insomnia is one such disorder. The
study’ s authors propose that a significant proportion of insomnia cases may
be due to a chronically overacti ve sympathetic nervous system  (SNS) or a
depressed paras ympathetic nervous system (PNS). This autonomic hyper -
arousal can be counteracted with slow, diaphragmatic breathing practice. As
the slow-wave sleep state promotes parasympathetic tone,21 a regular cycle
of healthy sleep stabilizes the autonomic nervous system (ANS), bringing
the body back into a calmer state. Slow breathing also causes the body to produce melatonin. 22 This is an
essential sleep-inducing hormone that has been proven to improve vagal
tone and inhibit the activation of the SNS. 23 Melatonin levels are lower in
people with insomnia and even further depleted in chronic insomnia,
indicating that the longer the sleep disorder is present, the more severe it
becomes. 24
This can create a vicious cycle of worsening insomnia in which stress
increases, perpetuating hyperarousal of the SNS. New research also
suggests that slow breathing may help orchestrate oscillatory brain activity,providing a mechanism to alter brain waves. This has implicat ions for the
potential modulation of brain activity to promote sleep. 1
The researchers behind this extensive study conclude that slow
breathing to regulate the ANS  may be a more effective way to combat
insomnia than the prevailing “standard care” pharmaceutical interventions. There is still limited research into the use of slow, deep breathin g, although
significant evidence points to its efficacy in treating insomnia. The paper ’s
authors express the hope that their work will inspire more investigation into
the effectiveness of slow breathing in relieving hyperarousa l and thus
treating insomnia. There is a strong connection between insomnia and menta l health
disorders, includ ing depression. It is quite normal for people suffering from
depression to experience const ant fatigue. While there is no doubt that
depression contr ibutes to feelings of tiredness and exhaustion, the question
arises: Could it also be that poor quality sleep arising from  insomnia,
snoring, or sleep apnea may contribute to both depression and fatigue. In
answer to this, I cannot help but think of a young woman in her early
thirties who attended my clinic seeking relief from depression. She looked
totally washed out. When I asked her how she felt upon waking up, she told
me that she was exhausted most mornings. I asked whether her doctor, or
any doctor in the past, had ever referred her for a sleep study, and she
answered, “No. ”  It seems obviou s to me that there may be many people in a
similar situation. The bottom line is, if you are feeling constantly tired, it is
likely that your sleep quality is poor. Research has shown that obstructive sleep apnea (OSA) can contribute
to the development of depression. 25,26 Up to 67% of people with OSA also
experience insomnia, and depression scores are higher in individuals
presenting with both insomnia and OSA. 25,26 This means that people with
sleep apnea may be at higher risk of depression because of the comorbid
insomnia symptoms. It makes sense, then, that some patients with a primary
diagnosis of depression should also be considered for a sleep study. The diagnostic criteria for insomnia disorder include daytime fatigue,
irritability, and difficulty concen trating. These are often the symptoms that
prompt patients to seek treatment for their mental health. They are also all
well-known consequences of both depression and OSA. 25 When symptomsare similar across several conditions, a little more investigation is needed to
determine the root cause. There is a direct interplay between breathing, the emotions, and sleep:
• If your breathing patterns are poor, mood regulation, and sleep will be poor. • If sleep quality is inadequate, the emotions are unbalanced, you feel tired and
anxious, and breathing is dysfunctional. • If the emotions are high, you may have dif ficulty falling asleep or suf fer from
insomnia, and breathing will be fast, in the upper chest and ef fortful. Poor breathing is closely linked with stress and anxiety and increases
the risk of SDB. This is one reason why people with asthma are also more
likely to experience higher levels of anxiety and fatigue. Another factor that contributes to insomnia is fast breathing during
wakefulness. 27 This means that, if you breathe  too fast, you are more likely
to be aroused from sleep. In a 2017 paper published in Science, researchers
identified a neural circuit within a brainstem region called the pre-Bötzinger
complex, a part of the brain that may be responsible for generating
respiratory rhyth m in mammals. 28 They suggest that this neural circuit may
have evolved as a defense mech anism, “mobilizing the animal in the face of
rapid, irregular, or labored breat hing. ” The researchers point to the fact that
fast, irregular breathing increase s alertness and can cause panic and anxiety
in humans27. Simila rly, increased activity  in the area of the brain
responsible for respiratory rhythms, hyperventilation, and sighing appears
to trigger arousal during sleep. 27 This contrasts with the practic e of slow,
conscious, contr olled breathing, which is known to promote relaxation via
the PNS and is ef fective in treating stress disorders. 27
This would seem to tie in with the theory that insomnia may be caused
by hyperarousal during wakefulness, and that an overactive sympathetic
nervous system may contribute to the problem. An earlier study from 1992
supports the theory that hyperventilation or “increasing ventilation”
prompts arousal from sleep, regardless of the stimulus that causes the
increase in breathing. 29 Insomnia is a widespread problem not adequately
resolved by doctors and generall y addressed with medication. Knowing that
fast breathing and hyperventilation causes us to wake from sleep can be key
for people with insomnia and sleep apnea. Light, disturbed sleep leads to feelings of lethar gy, decreased
productivity, and heightened stress levels. 30 In terms of physical well-being,
researchers have consistently reported a relationship between poor sleep
and high blood pressure, a connection that may be explained by the
physiological load that insuf ficient sleep adds to the nervous system31. Ultimately, poor sleep results in a reduced quality of life. The good news is
that disturbed or inadequate sleep is frequently connected to the way you
breathe at night, and that is something I can help you change. DOES COUNTING SHEEP HELP. Insomnia can manifest in two different ways: difficulty falling asleep and
waking suddenly after four or five hours’ sleep. If you struggle to get to sleep, practice Breathe Light  exercises during
the day. Exercise only with your mouth closed and improve your BOL T
score to over 20 seconds. Just before you intend to sleep, practice Breathe
Light  to create a tolerable feeling of air hunger for 15 minute s. Use
MyoT ape to ensure nasal breathing during sleep. If you wake after a few hours’ sleep, this may be due to heavy  snoring
or sleep apnea. If your airways narrow sufficiently during sleep to create an
increase of negative pressure and a buildup of carbon dioxi de, you are
likely to wake. The techniques in this book can be very helpful for snoring
and sleep apnea and for preventing this type of insomnia. Once you are awake, it can be very challenging to get back to sleep. The
mind is sufficiently alert to wander, but too groggy to get you out of bed. You can end up lying there for hours, worrying about how tired you will be
when you eventually have to get up in the morning. In both types of insomnia, the practice of “counting sheep” has
historically been  considered helpful. The idea is to count one imaginary
sheep after another as they jump across a fence in your mind’ s eye. There is
an early reference to this technique in the context of an anxiou s landowner
in an 1832 book Illustrations of Political Economy  by Harriet Martineau. 32
The idea of counting sheep may be somewhat of an old wives’ tale, but
interestingly, scientists have demonstrated that it works. A team at Oxford
University explored the use of an imagery task in reducin g presleepcognitive activity and found that “imagery distraction” took up sufficient
brain power to prevent unwanted thoughts and worries. Researchers
examined 41 people with insomnia who were given either an imagery
distraction task, a general distraction task, or no instruction. The imagery
group were told to imagine a situation they found interesting, engaging,
pleasant, and relaxing. 33 They were asked to spend two minutes picturing
this scene in as much detail as possible. It was found that this task helped
people fall asleep more quickly. If counting sheep works for you, great, but if you struggle with visual
imagery, cognitive tasks such as complex mental arithmetic problems also
improve sleep latency by preventing the brain from engaging with negative,
unwelcome thoughts. 34 If neither of these methods work, it is also helpful to
bring your atten tion away from your mind and into your body. Unless the
mind is calm, sleep will continue to elude you. Try bringing your attention
to a small part of your body, such as your hand or foot, and hold your
attention there. If you find that easy, practice expanding your focus to
include a larger area of the body, say, perhaps, your feet and legs. Some
people find a body scan meditation helpful. When you bring your attention
into your body, it helps to bring space between your thoughts, quiet the
monkey mind, and allow you to fall asleep. Another way to calm the mind  is to focus on and gently slow your
breathing. It is normal for the mind to wander. When it does, quietly bring
your attention to your breath. This becomes easier with practice. As you go
about your day, make it a habit to bring attention to your breathi ng for short
periods. It is more important to do this regularly throughout the day, than it
is to be able to sustain the attention for a long time. SNORING AND OBSTRUCTIVE SLEEP APNEA
Snoring occurs when a large volume of air passes through a narrow space,
causing turbulence in the nose, mouth, or back of the throat. There are two
reasons this might happen: either the snorer is breathing too hard during
sleep, or the upper airway—the nose, mouth, and throat—is too narrow. Traditional snoring treatments, such as nasal dilators or surgical
procedures, are generally desig ned to increase space in the upper airway. These focus solely on the airway, ignoring the role of breathing. It is
common for children and adults  with asthma, anxiety, and faster breathing
habits to snore. Fast, hard breathing during the day translates into fast, hard
breathing during sleep. This is what creates the turbulence. To get clear about the link betw een breathing and snoring, it is helpful
to deliberately make the sound of a snore through your mouth. Open your
mouth, tighten your throat, and draw air fast into your mouth. You will feel
the turbulence at the back of your mouth where it meets your throat. Now,
close your mouth. Try to snore  through your mouth when your mouth is
closed. It might sound obviou s, but this will prove to you that mouth
snoring stops completely when you breathe only through your nose. Next, make the sound of a snore through your nose. Nose snoring is also
created by fast breathing throug h a narrow space. At this point, it is worth
slowing down the speed of your breathing. Take a soft breath in through
your nose and allow a slow, relaxed breath out. As you continue to breathe
slowly through your nose, try to make the sound of a snore. You will find
that when you breathe slowly through your nose, you are much less likely
to snore. Snorin g is not solely due to narrow or collapsed airways. Fast,
hard breathing also contributes. To reduce nasal snoring, breathe only through your nose during  the day,
and practice Breathe Light  to improve your BOL T score to at least 20
seconds. For many people, this is enough to stop nasal snoring. If you have
a compromised nasal airway or small nose, your snoring may continue at a
lower intensity. If you wake up with a dry mouth in the morning, indicating that you
have been breathing through an open mouth, a support such as MyoT ape
can be very ef fective for maintaining lip closure during sleep. Snoring can also lead to sleep apnea, a more severe symptom of SBD,
where the sleeper involuntarily stops breathing during sleep. Obstructive
sleep apnea  (OSA) is becoming increasingl y widespread. Statistics suggest
that the conditio n affects up to 9% of women and 26% of men between 30
and 49 years old, and up to 27% of women and 43% of men aged between
50 and 7035. OSA is charac terized by breathing that stops during sleep. People with OSA tend to snore very loudly, and they experience frequent
episodes of shallow breathing (hypopnea ) and pauses in breathing (apnea )lasting 10 seconds or more. 36 Aside from the apneas themselves, symptoms
that indicate OSA may include:
• Daytime tiredness
• Limited ability to concentrate
• Sudden awakening, sometimes with a racing heart or feeling of breathlessness
• Dry mouth on waking
• Night sweats and a frequent need to urinate
• Waking with a headache
• Impotence and erectile dysfunction in men36,37
When we inhale, air is drawn into the lungs, producing negative  suction
pressure in the upper airways. During the day, our upper airways are held
open by various dilator muscles, but when we sleep those muscles become
“lazy” and the airway is more vulnerable to collapse. 38 Collapse occurs
when negative suction pressure exceeds the ability of the upper airway
dilator muscles to maintain an open airway. There are four possible places
where the airway may collapse during sleep:
• The soft palate can fall against the back of the throat
• The tongue can fall back into the airway
• The walls of the throat can collapse
• The epiglottis may close the airway39
To really visualize how breathin g stops during sleep, I find it helpful to
use the analogy of a paper straw. If you place one end of a straw into your
mouth and suck air forcefully  through it, the walls of the straw will
collapse. If you then continue trying to inhale through the straw once it has
collapsed, it will be impossible to do so. However, when you suck air into
the straw  more gently, the straw will maintain its shape and air will pass
through it. As soon as you increase the speed of airflow, the straw becomes
unable to withstand the increase in negative suction pressure. In essence, that is what happens during OSA. As the inhalation begins,
the nega tive suction pressure created by the effort to pull air into the lungs
causes the walls  of the upper airways to collapse. As the interruption in
breathing continues, the body no longer gets enough oxygen. 36 The
respiratory center in the brain sends increasingly urgent messages to the
diaphragm, prom pting it to resume breathing. As the diaphragm contracts todraw air into the lungs, this further increase in negative pressure reinforces
the inability to breathe. Event ually, the oxygen saturation of the blood
becomes low enough to partially wake the brain, and the sleeper starts
breathing again with a loud gasp, followed by a series of heavy and intense
breaths. This can trigger another collapse of the airways, and so the cycle is
repeated throughout the night, often preventing the sufferer  from ever
entering deep sleep. 36
Most people with OSA go undia gnosed and untreated. 40–42 This may be
partly due to a lack of confidence in existing treatment options, but, in some
cases, patients avoid diagnos is out of concern for their lifestyle or
livelihood. I recently took a ride with a cab driver in California. During our
conversation, he told me that he suffers from OSA. He had visited the
hospital to under go a sleep study, but, when he arrived, it was made clear to
him that the licensing authoritie s would be notified if he tested positive. He
was essentially told that a diagnosis necessary for his overall well-being
might lose him his driver ’s license and therefore his job. Upon hearing this,
he naturally turned around and walked straight back out the door. Bearing in mind the percentage of road traffic accidents that are related
to driver  fatigue, sleep studies should not be a deterrent to drivers getting
help. The results of a 2020 study suggested that more than a quarter of
drivers hospitalized after motor vehicle crashes were at high risk for OSA. 43
Researchers concluded that diagnosed or undiagnosed OSA is an
established hazard for drivers and represents a significant public health
concern. This is relevant to other professions too. There have, for example,
been numerous accounts of pilots falling asleep while flying. In 2013, the
British Airline Pilots’ Associat ion reported that more than half of pilots
have fallen aslee p when in charge of a plane, with 29% reporting that they
had woken up to find their copilot asleep as well. 44
Other risk factor s are associated with OSA, not least being the danger of
sudden death. A 2015 study found that patients with OSA are more likely to
die during the night than people without the disorder. Scientists observed
112 adults over a period of 16 years. Sudden cardiac death (SCD), a
condition in which the patient suffers a fatal loss of heart function, was
recorded in 46% of OSA patien ts, compared with 21% of people without
OSA. 45 OSA more than doubled the risk of SCD. The severity of sleepapnea was found  to relate directl y to the relative likelihood of SCD between
midnight and 6 a. m. When the results were evaluated in terms of sleep-
wake cycles, researchers found that 54% of OSA patients died while asleep,
compared with only 24% of non-OSA sufferers. 45 In this study, the severity
and duration of apneas was linked with an increased incidence of high
blood pressure and abnormal heart rhythms45. While the factors leading to
increased risk of sudden cardiac death in sleep apnea are unclear, the
scientists concluded that,
apnea, hypoxemia, and hypercapnia act syner gistically to elicit
sympathetic activation, which is thought to be a major mechanism
underlying elevated risk of adverse cardiovascular consequences
and mortality. Vagal response s to apnea are also critical in triggering cardiac
arrhythmias. 45
In a 2019 study  published in the American Journal of Respiratory and
Critical Care Medicine,  researc hers discovered an inverse relationship
between the duration of apneic events and overall risk of mortality in sleep
apnea. 46 That study indicated that the people who are most at risk are not
those with severe sleep apnea or those who stop breathing for a minute or
more. Instead, they are the light sleepers who awake easily by slight
abnormalities in their breathing,  when CO2 levels rise or negative pressure
in the airways increases. 46 The constant interruptions to sleep are quite
literally killing those people. That paper shows the importance of good
quality deep sleep with few if any awakenings. In the case of prolonged apneas, research from 2007 demonstrates that
the increased levels of CO2 may actually contribute to improved oxygen
uptake and delivery through mechanisms including vasodilation, actually
protecting the brain against injur y caused by lack of oxygen (hypoxia). This
paper concludes that the hypercapnia (high blood CO2), which occurs
during apneas, might be the body’ s way of adapting to severe, chronic,
intermittent sleep hypoxia. 47
During snoring and sleep apnea, the sleeper may not even be conscious
of the noise created by their breathing. It is usually their sleep ing partnerwho lies awake,  sometimes too fearful or exasperated to sleep. After some
time, and often with a little persistence from their partner, the suf ferer might
attend a sleep clinic. Here, the doctor or nurse will normally begin the
consultation by requesting the completion of a questionnaire  called the
Epworth Sleepiness Scale. If the scale is positive, a referra l for a sleep study
is likely. While the Epworth Sleepiness Scale  is a validated questionnaire used by
many sleep centers, I have observed that it does not capture everyone
presenting with OSA. The probl em with a questionnaire such as this is that
some people are unaware of just how exhausted they are. Not everyone who
suffers from a sleep disorder experiences or recognizes symptoms of
tiredness—25% of patients with moderate obstructive sleep apnea have
neither subjective nor objective sleepiness. 39 Also, up to 50% of people
with OSA are not obese. These people are falling between the cracks of
sleep medicine. The test for OSA is overnight polysomnography in a sleep center. Polysomnography involves monitoring both sleep and respiration, with the
primary measur e being the number of apneas and hypopneas per hour of
sleep. An apnea is categorized  as a total collapse of the upper airway,
during which the patient completely ceases to breathe for 10 seconds or
more. A hypopn ea is a partial collapse of the upper airway that causes a
reduction in the amount of air taken into the lungs lasting for 10 seconds,
with a correspo nding decrease in blood oxygen of 3% or more, or EEG
arousal. The number of apneas and hypopneas during the sleep test are
added up and divided by the number of hours spent sleeping. The severity
of sleep apnea in adults is then defined by the following scale:
• Mild sleep apnea: 5 to 15 respiratory events per hour
• Moderate sleep apnea: 15 to 30 respiratory events per hour
• Severe sleep apnea: more than 30 respiratory events per hour
While the apnea hypopnea index  (AHI) is the measurement of choice
for most sleep clinics, it is not without its limitations and should, at best, be
considered a crude and imprecise measure of OSA. 48 Apneas and
hypopneas have  fundamentally different effects on the individual, but the
index does not differentiate between the two. It could be argued that anapnea, which involves comple te collapse of the upper airway, is more
severe in its physiological impact than a hypopnea, which involves only
partial collapse. 48 Furthermore, a hypopnea with a 4% drop in blood
oxygen saturatio n is less severe than one that causes an 8% to 10% drop,
but the index does not take this into account either. Apneas and hypopneas
can occur evenly throughout the night or cluster during one period of sleep. If the sufferer experiences several events in a short period of time, it might
still be possible to also manage 4 or 5 hours of decent quality sleep. This is
a very different experience than that of the individual who experiences
symptoms throughout the night, resulting in few, if any, hours of quality
sleep. Finally, the AHI correlates poorly with the key causes and
consequences of the disease. 49,50
Traditional treatment of OSA normally focuses on the use of a CPAP
machine (continuous positive airway pressure)—a device that splints the
airway open at night. Newer procedures involve widening the airways,
either with the use of oral appliances or by bringing the lower jaw forward
with surgery—a procedure calle d mandibular advancement. More recently,
hypoglossal nerve stimulation has been introduced as a furth er surgical
option since the approval of the Inspire® hypoglossal nerve stimulator
implant by the US Food and Drug Administration (FDA). 51 The implant,
which triggers the tongue to contract, stopping it from falling back into the
airway, has been found to be effective in reducing the symptoms of sleep
apnea. 52 A study of 27 participants found that preoperative AHI fell from
an average of 46 down to 4. 6 after sur gery. 53
While these interventions are relatively successful, it is still important to
address the breathing patterns that underlie the condition. Over the years, I
have seen many  individuals reduce their AHI to near normal levels simply
by applying the breathing exerc ises in this book, practicing nasal breathing
day and night, maintaining a correct resting tongue position, and addressing
their inef fective breathing habits. Research from 2006 demonstrated that mouth breathing is a strong
determinant of OSA in people with no nasal obstruction. 54 People with
sleep apnea spend more time breathing orally and oronasally than people
who snore. A strong relationship exists between the AHI (which indicates
the severity of sleep apnea) and time spent breathing fully or partiallythrough an open mouth. This was confirmed in a 2020 paper published in
Laryngoscope  in which worse OSA and greater oxygen desaturation was
associated with mouth breathing than with nasal or oronasal breathing. 55
SECRETS OF A HEAL THY AIR WAY
The habit of breathing continuously and solely through the nose during
sleep comes with many positive consequences. These include maintaining a
moist upper airway, harnessing  nasal nitric oxide, creating more stable
breathing pattern s (see “Phenotypes of Sleep Apnea” in bonus Chapter 18
online at www. HumanixBooks. com/ The Breathing Cure), using the
diaphragm, and helping keep the tongue out of the throat. All of these
benefits have the added effect of improving and preventing the symptoms
of sleep  apnea. Conversely, mouth breathing can be a trigger and
perpetuating factor in OSA as it increases negative suction pressure and
dries out the nose, mouth, and throat. The loss of moisture inherent in
mouth breathing causes inflamm ation in the airways, which, in turn, causes
nasal obstruction, encouraging mouth breathing, and so the cycle continues. The gas nitric oxide (NO) is produced in significant quantities in the
nose and in the paranasal sinuses. 56 (The importance of this was discussed
in detail in Chapter Three. ) NO acts as a bronchodilator and helps keep the
lower airways open. In general, the role of NO in the regulation of sleep
apnea, though likely significant, is still not completely understood. 56,57 It
appears to help reduce obstruc tion of the upper airways and acts as a
transmitter between the nose, throat muscles, and lungs. The lower and upper airways (the lungs and the nose and throat) are
mechanically connected, thus nasal breathing leads to improved lung
volume58 due to greater activation of the diaphragm. 59 Increased lung
volume results in tautening and opening of the throat, reducing the risk of
the airway collapsing during sleep. 38
Anatomically speaking, breathing through the mouth causes the jaw to
hinge downwar d and the tongu e to fall back into the throat. When this
happens, the airway size is compromised, increasing the risk of collapse
during sleep (imagine a narrower straw). According to airway orthodontist
Dr. William Hang, the difference between a healthy and a poorlyfunctioning airway can be described by comparing the diameter of a garden
hose to that of a pen. Dr. Hang has been instrumental in advancing
awareness of the airway in orthodontics for several decades, and patients
(including myself) often travel great distances to visit his clinic in
California. The airway can be adversely affected when teeth are removed or
jaws retracted to create a “better” smile, so it is vital to research the
implications of this when considering orthodontic treatment. In his 2017 resea rch paper, Dr. Hang explains that many approaches that
result in a reduction of the airway are currently standard practice in
dentistry and orthodontics. He states:
In light of the current epidemic of OSA and OSA related
morbidities, such reduction in airway cannot be justified. Instead of
arguing about whether or not a proposed orthodontic treatment
protocol involve s extraction of teeth. , we must substitute the
question about how it af fects the airway. 60
When it comes to the modern human airway, there is not much room for
error. Any infringement on that already narrow space is likely to be
detrimental to health. Thankfully, there is a growing awareness of this issue, largely driven by
the general public. Initiatives such as RightT oGrow. org in Canada and the
Prevent Crooked  Teeth campaign in the United Kingdom are helping people
to recognize the importance of retaining all 32 teeth and instilling good
breathing habits  to promote lifelong health. Methods sympathetic to airway
health and function, such as expansion of the jaws to make room for
existing teeth, ensure a beautiful-looking smile without any negative
consequences for respiration, sleep, or overall well-being. Conventionally, if a patient has a problem with their nose, a referral is
made to the ear, nose and throat (ENT) department. Chronic lung problems
such as recurren t chest infections, wheezing, or coughing necessitate a visit
to the respiratory consultant or pulmonologist. However, researchers are
now recognizing that the nose and lungs constitute the same airway. Since
inflammatory mediators and infectious pathogens can be transported along
the respiratory mucosa and through the airways58, inflammation in the
lungs, which is prevalent in asthma sufferers, can travel up to the nose. Equally, inflamm ation in the nose can reach the lungs. Given this, it’s no
surprise that children and adults  with asthma are more likely to experience
problems in the nose. Physiological, epidemiological, and clinical evidence
now support a unified airway model. 58
Asthmatics are likely to experience nasal congestion that causes them to
breathe through an open mouth. This results in a faster respiratory rate and
shallow, upper chest breathing. It is this very same breathing pattern that
contributes to SDB. People with asthma are more likely to experience
fatigue too,61 especially when they are suffering from asthmatic symptoms
such as chest tightness, wheezing, or coughing. Obstructive sleep apnea and asthma are common respiratory disorders. They are also frequently comorbid,62 meaning that they occur
simultaneously but not necessarily as a result of each other. Undiagnosed or
inadequately treated OSA may adversely affect control of asthma and vice
versa. 63 In one study, researchers demo nstrated that approximately 74% of
those with asthma also experience nocturnal symptoms of airflow
obstruction64 and that when an asthmatic is experiencing asthma symptoms,
they are more likely to also experience OSA. 63
Much can be learned about breathing patterns in sleep apnea by looking
in more depth at the breathing habits of people with asthma. The exercises
in this book have been shown to improve asthma control. Given the
relationship between asthma and sleep apnea, these techniques are also
likely to be helpful in reducing OSA. HOW T O SLEEP BETTER
Gravity plays a role in both snoring and sleep apnea. When you lie on your
back, there is no restriction to breathing, so breathing volume increases and
snoring becomes more severe. Sleeping on your back also encourages the
mouth to open, causing the lower jaw to hinge downward and the airway to
narrow. OSA sufferers who sleep on their back experience a higher number
of apneas per night and stop breathing for longer during those apneas. In
one study of 574 patients with sleep apnea, participants had at least twice as
many instances of apnea or hypopnea when sleeping on their back as they
did when lying on their side. Researchers concluded that “Body positionduring sleep has a profound effect on the frequency and severity of
breathing abnormalities in obstructive sleep apnea patients. ”65
A similar assessment of 2,077 OSA patients over a period of 10 years
found that nearly 54% experi enced at least twice as many breathing
abnormalities when sleeping on their back than when sleeping on their side. The paper acknowledged that “Avoiding the supine posture during sleep
may significantl y improve the sleep quality and daytime alertness of many
positional patients. ”65
The techniques that follow will help you achieve better quality sleep. BREA THE LIGHT AND SLOW
You can do this while watching some light television or relaxing in bed. • Place one hand on your chest and one hand on your abdomen. • Gently soften and slow down your breathing to create a slight hunger for air. • Continue the practice for approximately 15 minutes. This is an excel lent way to help with SDB. It also promotes relaxation and
enables you to fall asleep more easily. MOUTH T APE FOR NASAL BREA THING
We’ve already described why it is vital to breathe through your nose during
sleep, but how can you make sure it happens. When you wake up in the morning, your mouth should be naturally
moist. If you have been breathing through your mouth at night, you will
wake up with a dry mouth. You may also find that you have smelly
breath. 66 Mouth breather s have a higher incidence of gum disease, halito sis,
and tooth decay than nasal breathers. If you tend to mouth breathe during the night, you can try taping the
mouth, following these guidelines. Taping the mouth at night may seem like a scary prospect at first. However, the method has been used with great success by Oxygen
Advantage trained instructors and in Buteyko Breathing Clinics around the
world. It may be reassuring to know that it does not take long to get used to. If you struggle  to keep your mouth closed at night, placin g MyoT apearound your mouth before you go to sleep is an excellent way to eliminate
SDB and encourage full-time nasal breathing. The tape, which I designed
especially for this purpose, is placed around the lips rather than across the
mouth and is designed to act as a reminder, using elastic tension to prompt
you to close your mouth if it falls open. I have no doubt that the single best thing I ever did to improve my sleep
was to tape my mouth at night. MyoT ape can be easily purchased online at
MyoT ape. com. You may also like to try a Micropore paper tape, which you
can pick up at any pharmacy, or Lip-Seal Strips, which can be bought
online from Simply Breathe. To overcome any initial anxiet y about having your mouth taped, try
wearing the tape for 20 minutes  before you go to bed. Also be aware that if
you are accusto med to breathing through your mouth, the tape is likely to
fall off during the first couple of nights. This will resolve fairly quickly. Within a few days, your body will relearn its natural nasal breat hing pattern
and the tape will remain in place. Y ou may then begin to experience the best
sleep you have ever had. If your nose is partially blocked before going to bed, use the nose
unblocking exercise to clear it before taping your mouth. Rest assured,
however, that if you are wearing the lip tape at night, your nose will never
become complet ely blocked. This is because nasal breathing actually helps
dilate the nasal passages. If you breathe heavily during the night while wearing the tape, your
nose may partially block. If this is the case, you may also find it helpful to
wear a nasal dilator, which you can purchase online or from your chemist. This small plastic dilator is placed inside the nose to open the nasal
passages and alleviate snoring. In time, if you follow the breathing
exercises and techniques in this book and as your nasal congestion
improves, you will be less likely to require a nasal dilator. In a recent study that tested the application of lip tape to assess
difficulties with nasal breathing, researchers found that 83. 5% of habitual
mouth breathers  were able to breathe comfortably through the nose with the
mouth taped. Remember, your nose will only ever become completely
blocked if you revert to mouth breathing. 67If, durin g the night, you find it difficult to breathe while using the tape,
gently reduce your breathing until you feel comfortable. Try to acclimatize
to the tape rather than removing it. Without it, you are likely to revert to
mouth breathing  during sleep, and this will only make your symptoms
worse. Important: This method is not suitable for childr en under four
years old. While MyoTape does not cover the mouth, meaning that it is still
possible to communicate while wearing it, any child taping their mouth at
night must be able to remove the tape if they feel the need to. Do NOT  use MyoT ape or any other lip tape at night if you are
feeling nauseou s or have been drinking alcohol. If your child has a
tummy upset or is likely to vomit, you must NOT tape his or her mouth
during sleep. Check your BOL T Scor e
To find out whether you are overbreathing during the night, measure your
BOL T score before you go to bed and again when you wake in the morning. If your BOLT score is lower upon waking than it was the night  before, this
means that you have been breathing too hard or mouth breathing during
sleep. ENSURE BETTER CP AP COMPLIANCE
If you use a CPAP machine, mouth breathing during sleep compromises the
effectiveness of your treatment. 68 If you commonly mouth breath e at night,
you may also find it necessary to wear MyoT ape with your CPAP device. Some people find it difficult to wear a mask all night, and the full-face
mask is naturally more uncomfortable. Acceptable CPAP adherence or compliance is defined as 4 hours  use per
night,69 at least 70% of the time. 70 But studies show that different levels of
compliance lead to better or worse results and that adherence of more than
six hours a night is necessary to reduce the risk of cardiovascular
mortality. 69 Given that we need between seven and eight hours sleep every
night, four hours of compliance is obviously less than ideal. Also, if you
drive or fly for a living, it’s worth noting that you are required to share yourCPAP compliance data with the relevant authorities70 and that if your
treatment compliance is inadequate, you may lose your job. Throughout this book, we explore the connections between SDB and
many different aspects of health. There are links with conditions including
diabetes, sexual dysfunction, heart failure, and high blood pressure. Clinical
interventions like CPAP can help prevent and, in some instances, reverse
these problems, but only when the device is used effectively, which means
all-night compliance. To achieve that, it is necessary to address mouth breathing, which is the
primary cause of CPAP noncompliance. 68 Mouth breathin g allows air to
leak out through the open mouth before reaching the airways. This often
causes the user to wake, which  contributes to sleep fragmentation. When
you breathe nasally during sleep, the air supplied by the CPAP device
makes it to the airway as intended. It’s so simple but just by closing your
mouth, you improve your chance of staying asleep. There are various products such as chin straps on the market designed to
keep the mouth closed at night. These can be problematic. They fit tightly
around the head, fixing the jaw closed, and can cause side effects including
temporomandibular joint pain. This is another instance in which taping the
mouth during sleep is the best solution. Whether you choose MyoT ape or an
alternative produ ct, mouth tape is a gentle way to ensure CPAP compliance. It easily prevents oral air leaks without causing jaw pain, interfering with
your CPAP mask, or adding a level of discomfort that stops you from
sleeping. Another problem with CPAP is that air leakage can cause irritation to
the eyes. This is especially true for people who have floppy eyelid
syndrome—loose upper eyelids that easily fold back, leavi ng the eye
unprotected. 71 Sleep apnea is known to be an independent risk factor for
blindness due to glaucoma,72 and although the reason for the relationship is
unknown, studies have found associations between OSA and various eye
diseases including floppy eyelid syndrome,73 Using mouth tape to prevent
oral air leaks, there is less chance of eye irritation. PREP ARING FOR A SLEEP STUDYWhen you have been practicing breathwork for a while, you may find that
your symptoms lessen and it’s time to discuss reducing your CPAP use with
your doctor. The best way to determine whether your sleep apnea is under
control is by attending a sleep study. You should only ask to take part in a sleep study once your BOL T score
has been  greater  than 20 seconds for at least 2 weeks. You should have been
practicing light, slow, deep nasal breathing with your tongue in the correct
resting position and your lips closed. For men, another indicatio n of healthy
breathing during  sleep is that you begin to notice yourself waking up with
an erect ion each morning. The reason for this is covered in much more
detail in Chapter Eleven  when we look at the link betw een breathing and
sex, but for now it’s just worth understanding that “mornin g wood” is
indicative of good cardiovascular health. On the night of the sleep study, before you go to sleep, practice slowing
down your breathing for 15 to 20 minutes to create air hunger. Then tape
your lips using MyoT ape. Over the years, I have advised many of my
students to wear lip tape during the sleep study. The technicians organizing
the study are often curious but have never, to my knowledge, vetoed use of
the tape. This is important, because during the sleep study, you want to
determine the severity of sleep apnea when breathing is throug h the nose,
slow and low. THE BASICS OF GOOD SLEEP HYGIENE
There are severa l best practices for going to sleep that are considered the
basics of good sleep hygiene. You can start by avoiding eating a large meal
or drinking alcohol late at night. Although alcohol can send you off to sleep
more quickly, it is actually a stimulant, which results in poor quality sleep
and waking in the middle of the night. Eating too close to bedtime creates
similar problems as it leaves the body needing to expend considerable
energy digesting food while in a state of semirelaxation. Reserve the bedroom, where possible, for sleeping, relaxation, and
making love. Your bedroom should not be a place to watch telev ision, work
on the laptop, or browse the Internet on your mobile phone. In fact, having
as little technology as possible in the bedroom will help ensure good quality
sleep. Technology is increasingly implicated in contributing to poor sleep. Even the age-old ritual of reading before falling asleep has been
compromised as backlit tablets and phones replace traditional paper books. When our eyes are exposed to bright light, especially blue light, such as that
produced by these devices, the brain stops secreting the relaxation hormone
melatonin, whic h is responsible for creating feelings of sleepiness. The
human body is designed to be awake during daylight and to sleep when it
gets dark. According to a Harvar d Health Letter  entitled “Blue light has a
dark side,” it is advisable to refrain from using a laptop or electronic device
for at least three  hours before sleep. 74 If this is not possible for you, it is a
good idea to invest in a pair of blue-light-blocking glasses to wear when
using your computer or phone in the evening. CABIN PRESSURE: USING BREA THWORK IN A LOW
OXYGEN ENVIRONMENT
An email I received from a client who is a professional pilot provides an
interesting persp ective on the subject of breathing and sleep. Remember the
report from the British Airline  Pilots’ Association about pilots who fell
asleep while in char ge of a plane. According to my client, fatigue, disrupted
circadian rhythms, jetlag, sleep disturbance, and body-clock disruption are
all part of the job, along with a high level of pressure and responsibility. These are significant, unavoidab le issues that must be managed and closely
monitored if performance is to be maintained at the necessary levels
throughout the flight. My client explained:
At a major airline like mine, which is notorious for its diverse
operating schedule and network, these issues are amplified even
further. A quick  look at my logbook reveals that on average, 40% of
my fligh ts are operated at night and back-of-the-clock hours. This
cannot be taken lightly. In one month, I can typically fly one ultra-
long-haul, two or three medium-haul trips and multiple short-haul
return flights. In order to optimize my mental performance, I need to take a
number of steps to ensure I am well-rested and able to operate at anadequate cognitive level. This is in addition to the stringent rules
and regulations employed by the industry, which ensure that our
rosters are compiled and managed safely. Since discovering breathwork, and its convincing benefits in
terms of sleep, energy, and wellbeing, I have used this to my
advantage consi stently. I have a daily breathwork routine that allows
me to sleep better, recover betw een flights, and perform optimally
during a flight. It all starts with sleep. In my experience, this is the most
important variab le to manage, whether I’m at home, staying in a
hotel around the airline’ s netw ork, or during critical rest periods
onboard ultra-long-haul flights. I use the principles behind Pranayama breathing, and the
scientifically backed exercises from The Oxygen Advantage  to
create a sleep-management routine which consists of the following:
• Taping my mouth at night to ensure nasal breathing and deeper more restful
sleep. • A sleep hygiene routine consisting of a dark room, eye shades, and ear plugs. • Presleep breathing exercises or meditation, to relax and activate the
parasympathetic response. These include long deep and slow diaphragmatic
breaths that emphasize longer exhalations to relax my body. • Keeping hydrated before bed. • Trying to be as consistent as I can and staying on a fixed “home time-zone” as
best as possible. My real-time breathwork practices during flights include:
• Box breathing using small breath holds after inhalation and exhalation. (Y ou will
find this exercise in Chapter T wo. ) • Long slow and deep cycles of breathing, using the diaphragm, which is pretty
much a habit now anyway. • Consistent nose breathing to ensure maximum oxygen uptake. • These techniques are essential during flights because we operate in a low
oxygen environment of poor quality recirculated air. The exercises have obvious
benefits not only for the operating crew, but also for passengers who are not
used to the environment. In ef fect, we are already at a disadvantage because of
the low air oxygen levels and the altitude of approximately 6,000 feet. This is
compounded by the fact that a high percentage of the population has
dysfunctional breathing habits. My postflight exercises include:
• Any breathwork I feel like doing that emphasizes nasal and diaphragmatic
breathing. I especially like to practice this before bed. • Focusing on parasympathetic recovery and lowering my arousal levels, which are
usually quite high after flights due to lengthy periods of elevated concentration. I’m very aware of how physical and mental stress affects the
quality and speed of the breathing. I use the breath as a powerful
tool to control my state of mind, arousal, and general self-
awareness. It is a two-way street. The mind can control the breath,
and the breath can control the mind. This works particularly well in
high-pressure training situatio ns. These simulations, which  we
practice every three months, are similar to real-time combat training
in the military special forces and police tactical groups. The benefits I receive from breathwork are powerful and
effective. I can literally help my body and mind change and adapt as
I need it to, using the breath. OceanofPDF. comBCHAPTER EIGHT
DEVELOPING HEALTHY AIRWAYS IN
CHILDREN
WHA T CAUSES CHILDHOOD MOUTH BREA THING. ack in 1909, an article, “Habitual Mouth-Breathing and Consequent
Malocclusion of the Teeth,” was published in The Dental Cosmos. In it, DeLong described how mouth breathing can cause the sleeper
to wake with a dry mouth and throat in the morning, often accompanied by
headache:
A restless sleep, [and] much tossing in bed and snoring will be
observed. The face is usually elongated, the bones of the face are
underdeveloped, as the air spaces do not have the proper circulation,
the nostrils are small. 1
DeLong goes on to list other detrimental effects of mouth breathing,
including recession of the chin and a high narrow palate with crooked teeth. Children who breathe through their mouths are observed as looking dull and
expressionless and may be accused by their teachers of being inattentive in
class. 1 When I first discovered this article, over 100 years after it was
written, I could not help but feel a sense of disappointment that mouth
breathing is still not taken more seriously by the dental and medical
professions. Humans were never designed to mouth breathe. In fact, in the entire
animal kingdom, there are only a few creatures for which mouth breathingis norma l. Diving birds, such as penguins and pelicans, whose respiratory
apparatus differs from that of humans and other mammals, will take in a
gulp of air before descending below water to hunt. Even dogs, while they
are often  depicted with their mouths open and tongues lolling, only ever
pant to regulate body temperature. From birth, a tiny baby will instinctively breathe through the nose. You
may notice that a baby’ s tummy moves easily up and down with each
inhalation and exhalation as the diaphragm engages. However, at just a few
months old, many children switch to mouth breathing. Unfortunately, this is
a habit that stick s. Mouth breathing is classified as a pathological condition,
yet it is one that more than 50% of children exhibit. It is present in 60% of
boys and 40% of girls. 2
Mouth breathing in children has a variety of causes, all falling into two
basic categories ; obstruction to the airway and behavior. 3 The two most
common trigger s are chronic allergies and enlar ged tonsils and/or adenoids. The adenoids are glands located toward the back of the nasal cavity where
the nose connects to the throat. They form part of the immune system and
produce white blood cells to help fight infection. Enlar ged adenoids are
common among children aged  between two and seven years, typically
shrinking by adolescence. Other genetic and environmenta l factors that lead to mouth breathing in
children include a high narrow palate, tongue-tie, lip-tie, a small nose,4
constricted upper airways, asthm a, bottle feeding, insuf ficient breastfeeding
in infan cy, and an overheated home. Habits such as thumb sucking,
excessive use of pacifiers, overeating or eating too much processed food,
lack of physical exercise, and even wearing too many clothes also play a
part. A child with a high narrow  palate is nearly three times more likely to
breathe through an open mouth. 5 Equally, something as simple as the use of
a conven tional pacifier can increase the probability of mouth breathing by
25% for each year of use. 5
Of all these influences, swelling of the adenoids (adenoid hype rtrophy)
is the primary reason for mouth breathing in children. Untreated adenoid
hypertrophy results in adenoid facies  or long face syndrome, an alteration
in facial development characterized by an elongated, open-mouthedappearance. I see children with faces like this all the time. Tragically, it can
hold them back in their lives. HOW THE AIR WAYS DEVELOP
A 1991 study published in the American Journal of Orthodontics and
Dentofacial Orthopedics  compared the breathing of normal and long-faced
adolescents. 6 The purpose of the research was to assess tidal volume and
ratio of nasal breathing in 32 children between the ages of 11 and 17. Those
with long faces (vertical dentof acial morphology) due to juvenile adenoid
hypertrophy had a significantly  different lower face form than those who
had developed normally. While the results showed that both groups of
adolescents had similar tidal volumes, the long-faced subjects were much
less likely to breathe nasally. Children who develop adenoid facies have
smaller nasal airways. 6 This is an irreversible, lifelo ng consequence of
mouth breathing during early development. I live in the small village of Moycullen on the west coast of Ireland. Every few months, I visit my local dentist. He is in his early thirties and
was educated at Trinity College in Dublin. During one of our conversations,
I asked him about the implicatio ns of mouth breathing during childhood for
oral-facial development. I was surprised to discover he doesn’ t believe
mouth breathing contributes to crooked teeth or any negative development
of the face. Give n that he is a recent graduate, I expected that, if there were
a relatio nship between mouth breathing and crooked teeth, he would know
about it. Apparently, despite the topic having been hotly debated in
dentistry for over a century, this is not the case. Unfortunately, the well-
being of millions of children and adults is being sacrificed due to the
unwillingness of the dental and medical professions to reach agreement
about the connection. I am living proof of the effects of mouth breathing on the deve lopment
of the face. I have the same features described in the Dental Cosmos  article. My palate is very high, my jaws were set back, and my teeth were crooked. It could  be a coincidence, but it may not be. It is indeed still difficult to
reach conclusions on several points. It is unclear how much nasal
obstruction is necessary to cause mouth breathing, and there is as yet nocomprehensive evidence to show  how long a child’ s mouth breathing must
persist in order to cause a lifelong problem or at what age mouth breathing
does the most damage. There is, however, relevant research we will look at
later, regarding the rate of crani ofacial development in children  at different
ages. In my case, it could be that I was born with a narrow facial structure
that resulted in my mouth breathing. Or my mouth breathing may have
caused my face to develop poorly. Either way, what I do know is that I was
a mouth-breathe r during childhood, as is evident in many family photos,
and that my dentist could have spotted this early on and advised  my parents
about the importance of nose breathing. The problem of my small jaws
could have been easily addre ssed within months by using functional
appliances to widen my palate. What pediatric health profession als must realize is that dentists are in an
ideal position to help children with these same facial structures and mouth
breathing habits. With this understanding, procedures could be put in place
to gently widen the jaws, to help promote forward development  of the face,
and to shape the airway. I believ e that, if this were done, each child would
be better placed to reach his or her full potential. THE INFLUENCE OF DISORDERED BREA THING ON
LEARNING POTENTIAL
A stuffy nose will adversely affect a child’ s sleep. After a night spent
breathing heavily through the mouth, the child will wake up exhausted. This
manifests as poor concentration and frustration in school. If this inability to
focus continues  for a length of time, a psychological evaluation and
possible diagnosis of attention deficit disorder (ADD) or attention deficit
hyperactivity disorder (ADHD) may follow. Notably, scientists have
demonstrated that it is common for children with ADHD to experience
nasal congestion and hay fever. 7 Also, 40% of children who experience
sleep disorders, including snoring or sleep apnea, develop ADD, ADHD, or
a learning disability. 8 In fact, resear chers have found that, if a child is
snoring by the age of 8 and the problem is left untreated, there is an 80%
chance that the child will consequently develop a permanent 20% reductionin mental capacity. 9 A 2012  paper by pediatric sleep expert Karen Bonuck
demonstrated that mouth breathing, snoring, and apnea at 6, 18, and 30
months of age significantly increases the risk of neurobehavioral and
neurocognitive disorders at ages 4 and 7. 10
A 2017 study by pediatric behavioral and sleep scientists described the
case of a 5-year -old girl named Carly. 11 Carly was brought for an
interdisciplinary evaluation because her behavior at home and school
suggested ADHD. Carly demon strated average verbal, visual- spatial, and
fluid reasoning IQ scores durin g psychological testing, but her processing
speed and working memory were below average. Executive function skills
(processes that monitor behavior) returned mixed results, and her working
memory was borderline. The ratings given by her parents implied worse
symptoms of ADHD and executive function than her test results showed. While factors such as the separation of her parents and inconsistent
disciplinary approaches were noted, the researchers felt that her nightly
mouth breathing and snoring were most significant. Carly displayed
enlar ged tonsils and a high, arched palate. A sleep study indicated that she
also had OSA. Carly underwe nt an adenotonsillectomy, after which her ADHD
symptoms noticeably improved. However, her behavioral problems recurred
one year after surgery. 11 The paper does not record whether Carly also
reverted to mouth breathing after the operation, but it could be reasonably
assumed that a failure to restore nasal breathing resulted in the recurrence
of OSA. 12
Unfortunately, doctors treating ADD or ADHD rarely consider nasal
obstruction as a possible cause and are unaware that the condition can be
greatly helped without medicati on or psychological therapy. 9 When I speak
to any parent who has a child diagnosed with ADD, my first suggestion is
to check the child’s sleep habits. Is your child breathing through the mouth,
twisting and turning during the night and waking up with the bedclothes
tangled in the morning. Do they snore or stop breathing during sleep. Is
their breathing audible during sleep. To experience quality sleep, nasal
breathing is of the utmost importance. Any adult understands the knock-on
effect that a poor night’ s sleep has on mood, so how can a child be expected
to face the day with boundless ener gy if their sleep is inadequate. While no parent wants to see their child feeling constantly tired and
frustrated, more  serious consequences are at issue. Children who breathe
through an open mouth have a strong tendency to experience cognitive
disorders and problems with memory, concentration, attention, and learning
ability. 9 Those with sleep problems are much more likely to have special
educational needs (SEN). The Avon Longitudinal Study of Parents and
Children, also known as Childr en of the 90s, is a detailed and ongoing birth
cohort study of children born in the United Kingdom between  April 1991
and December 1992. The Avon research has shown substantial correlations
between sleep-disordered breathing (SDB) and cognitive impairment in
children. 13 Parents enrolled in the study reported on their children’ s snoring,
witnessed apnea, and mouth breathing at 6, 18, 30, 42, and 57 months. SDB
symptom trajectories, or cluster s, were derived from the resultant data. By
the time the children reached 8 years old, parental reports for 11,049
children with SDB indicated that children with SDB were 40% more likely
to have special educational needs. 13 These statistics are echoed by a 2013
study in which 48 children had complete ear, nose, and throat examinations. Results showed that children with enlar ged adenoids experienced greater
learning difficulties than those with normal adenoids. 14 Likewise, a 2015
study from the faculties of dentistry at Havana and Aden Universities found
that children with excessive daytime sleepiness were almost 10 times more
likely to have learning dif ficulties. 3
Another 2011 paper compared cognitive function in children with
varying severitie s of SDB again st a control group with no history of sleep
problems. In total, 137 children between the ages of 7 and 12 took part. It
was found that there was a lower general intellectual ability in all children
with SDB. This was the case whether or not the problem was severe enough
to manifest as snoring or sleep apnea—children should not be snoring or
even breathing heavily during sleep. 15 Childre n with SDB also show ed
higher levels of impairment in both executive and academic functioning. The first important study to look at the potential link between OSA and
its damaging effects on cognitiv e ability was published in 1998. The paper
examined 297 first-grade children whose academic performance was in the
lowest 10th percentile of their class. These children were found to have
significantly higher incidence of OSA than their higher -achieving peers. The academic results of those children who received treatme nt for OSA
improved considerably in the following year, while children who had OSA
but were not treated showed no improvement. 16
Another point regarding the cognitive and behavioral effects of OSA is
demonstrated by a 2011 paper that examined the methods used to evaluate
SDB in children. 17 The study reported that many children who suffered
OSA at a level that was not picked up by traditional testing were  on various
medications to alleviate symptom s, all of which could be explained by poor
sleep. Some children were prescribed a sedative at night and a stimulant
during the day. Others were on a range of medicines including
antidepressants, antiheadache, antialler gic, antigastroesophageal reflux, and
antihypertensives. After treatment for SDB, 43 out of 99 childr en had their
drugs withdrawn by their physicians. NONSURGICAL INTER VENTIONS
The good news is that sleep specialists are becoming increasingly
concerned abou t the impact of open mouth breathing during sleep,
especially in children.
The text does not explicitly state the specific health risks of chronic sleep deprivation, but it does mention that sleep deprivation costs the US economy $411 billion annually due to poor productivity and sick leave.
What are the potential health risks associated with chronic sleep deprivation?
The text does not explicitly state a direct relationship between sleep apnea and depression, but it does mention that people with sleep apnea are more likely to experience depression.
What is the relationship between sleep apnea and depression?
The text does not provide a specific recommendation for CPAP device use. However, it does mention that a minimum of 6-8 hours of sleep is recommended.
What is the recommended duration for a CPAP device?
The text explains that nasal breathing is essential for proper airway function and that mouth breathing can lead to a range of negative consequences, including the development of sleep disorders.
What is the connection between sleep and nasal breathing?
The text suggests that chronic mouth breathing in children can have a profound impact on their cognitive and behavioral development, citing a 1998 study that found a correlation between mouth breathing and decreased cognitive abilities.
Can mouth breathing in children lead to long-term effects on their cognitive and behavioral development?