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Dental sleep- breathing retraining - spreecast tess graham - raphael center - oct 2014

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Tess Graham's lecture on the Airway and Facial Development spree cast 10/27/14

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Dental sleep- breathing retraining - spreecast tess graham - raphael center - oct 2014

  1. 1. Breathing Dysfunction, Sleep and Airway Issues The breathing retraining approach Tess Graham Physiotherapist, Breathing Educator BSc. Grad Dip Physiotherapy; Dip Buteyko Breathing Method 1
  2. 2. Physiological norm – awake • Rhythmic, regular • Silent • Nasal • Diaphragmatic • RR: 8-12 breaths/minute • TV: 500 mls/breath • MV: 4-6 litres/minute • CO2: 40-45mmHg 2
  3. 3. Physiological norm – asleep (1) • Nose-breathing • Diaphragmatic • Regular -NREM; some irregularity-REM • RR: some increase in REM, NREM • TV and MV reduce • Decreased tone pharyngeal dilators • O2 asleep < awake • CO2 increases 3-7mmHg 3
  4. 4. Dysfunctional breathing - awake • Irregular – sigh, yawn, cough • Audible, noisy • Mouth-breathing • Upper-chest breathing • > 14 breaths/minute • TV - 950 mls/breath OSA • MV - 8.8 L/min ‘simple’ snorers - 15 L/min OSA - 14L/min OHS 4
  5. 5. Dysfunctional breathing - asleep • Irregular, chaotic • Audible, noisy • Mouth-breathing • RR: 17-38 breaths/min • TV: increases • MV: to 20L CSA; 22L OSA 5
  6. 6. Comparison Normal Sleep apnea Respiration Rate 8-12 16-38 (Graham) Tidal Volume 500mls 950mls (Radwan) Minute Volume 4-6 L 13L (Awake – Esquivel CSA) 14L (Awake - Redolfi OHS) 15L (Awake - Radwan OSA) 20-22L (Asleep - Xie, Graham) Insp. Flow Rate 280mls/sec (Douglas) 620 mls/sec (Radwan) CO2 40-45mmHg Hypocapnia, Hypercapnia, Normocarbia 6
  7. 7. Comparison V Lunn-Rockliffe 2014 7
  8. 8. V Lunn-Rockliffe 2014 8
  9. 9. Overbreathing and disease • Asthma 14 L/min (Bowler) • Heart disease 15 L/min (Dimopoulou) • Diabetes 15 L/min (Tantucci ) • Epilepsy 13 L/min (Esquivel) • Panic disorder 12 L/min (Pain) • Obstructive Sleep Apnea (OSA) 15 L/min (Radwan) Normal breathing 4-6 L /min 9
  10. 10. How ‘normals’ breathe today Dr. Artour Rakhimov (www.NormalBreathing.com Dr. Artour Rakhimov (www.NormalBreathing.com) 10
  11. 11. 11 What disturbs breathing? • Stress • Coughing, crying • Over-heating • Over-eating • Poor diet (inflammatory) • Illness, infection • Slumped posture • Mouth-breathing habit • Wrong advice, faulty instruction
  12. 12. V Lunn-Rockliffe 2014 12
  13. 13. Overbreathing V Lunn-Rockliffe © 2014 13
  14. 14. Mouth-breathing Strong correlation with • narrow facial structure • crowded, crooked teeth • open bite • gingivitis, dental decay • orofacial muscle dysfunction • aberrant swallow • TMD • bruxism 14
  15. 15. 15
  16. 16. Mouth-breathing / Airway problems In children - directly linked to: • asthma • recurrent ear infections • bedwetting • snoring • OSA • ADHD 16
  17. 17. Carbon dioxide Roles: • balances and regulates pH • stabilises mast cells • regulates breathing • synthesis antibodies, hormones, enzymes • calms nervous system • smooth muscle dilator • facilitates release of oxygen (Bohr effect) 17
  18. 18. Overbreathing effects (1) Physical / mechanical • Dehydration: mucosal dryness • Airway trauma: inflammation, edema • Enlarged uvula, tonsils, adenoids • Vibration, turbulence, snoring • -ve pressure, suction, collapse V Lunn-Rockliffe 2014 18
  19. 19. Overbreathing effects (2) Physiological / biochemical • mast cells leak histamine • smooth muscle spasm • tissue hypoxia (Bohr effect) • adrenaline, cortisol increase • sympathetic nervous system stimulated • blood pH increases • central apnea, hypopnea • mixed apnea • instability in central control 19
  20. 20. Effects of low CO2 on the brain 40% reduction in O2 after 1-minute hyperventilation MRI Scan: red = most O2 dark blue = least O2 Litchfield1999 20
  21. 21. Revved up nervous system 21
  22. 22. Symptoms of overbreathing Neurovascular: Central: disturbances of consciousness, faintness, dizziness, unsteadiness, impairment of concentration and memory, feelings of unreality, "losing mind" Peripheral: Paraesthesia, numbness, tingling and coldness of fingers, face and feet Musculoskeletal: diffuse or localised myalgia and arthralgia, tremors and coarse twitching movements, carpopedal spasm and generalised tetany (infrequent) Respiratory: cough, chronic throat tickle, shortness of breath, atypical asthma, tightness in or about chest, sighing respiration, excessive yawning Cardiovascular: palpitations, skipped beats, tachycardia, atypical chest pains, sharp precordial twinges, dull precordial or lower costal ache, variable features of vasomotor instability Gastrointestinal: oral dryness, globus, dysphagia, left upper quadrant or epigastric distress, aerophagy, belching, bloating, flatulence Psychological: anxiety, tension and apprehension, inappropriate pseudocalmness (hysterical subjects) General: nocturia, easy fatigability, generalised weakness, irritability and chronic exhaustion, frightening dreams, sleep disturbances Adapted from Breath Connection - Fried R. 1990 22
  23. 23. Points of view “Open-mouth posture” • Restricted airway • Mechanical dysfunction • Orofacial developmental issues “Mouth-breathing” • All the above • Physiological consequences • Biochemical • Multi-system dysfunction 23
  24. 24. Mouth-breathing IS OVERBREATHING What drives overbreathing? • Stress • Inflammatory diet • Habit • Need What fixes overbreathing? 24
  25. 25. Breathing Retraining Restoring a physiologically normal breathing pattern • breathing at the correct rate and rhythm and volume • with the correct use of the breathing muscles • at rest, during activity, speech, sleep and sport • retraining respiratory centre’s breathing ‘set point’ 25
  26. 26. Assessment – Observation (1) • Feel • Rhythm • Route • Nares flare • Sound • Lips and Tongue • Location • Posture 26
  27. 27. Assessment (2) • Respiration rate • Heart rate • ‘Comfort’/ ‘Control’ Pause • ETCO2 • Nose-breathing tolerance time • Symptom picture • 3-day food diary 27
  28. 28. Breathing retraining process (2) Education Exercises and strategies Lifestyle recommendations Review 28
  29. 29. Goal of breathing program Relief from Snoring and Sleep Apnea T. Graham; Illustrator © A Calvert 29
  30. 30. 30 Goal To turn the dial back to normal
  31. 31. 31 Nine healthy breathing habits 1. Awareness 2. Nose-breathing 3. Upright posture 4. Regular breathing 5. Diaphragm breathing 6. 8-12 breaths per minute 7. Silent invisible breathing 8. Breathing control during speech and singing 9. Breathing well during exercise Relief from Snoring and Sleep Apnea ©Tess Graham
  32. 32. 32 Efficacy Before and after • Breathing assessment • Symptom Trackers • Partner / parent observations • Capnometry • Sleep studies
  33. 33. Case Study Age 14 100% mouth-breather Upper chest Audible breathing RR 16 HR 83 CP 17 secs NBT 11 secs Sleep apnea 33
  34. 34. Symptom Tracker Symptoms Assessment 1 Assessment2 Assessment 3 Assessment 4 Day 2 Day 5 Day 14 Sleep apnea observed XXXX XX X Heavy, irregular breathing in sleep XXXX XX XX -- Toilet visits overnight 1 1 Waking with gasp 2-3 Blocked nose XXXX X Waking with dry mouth XXXX XX X Restless legs XXX XX X Breath holding in day, sighing, yawning XX Short of breath – resting XX Frequent urination XX Poor concentration XX X X Mouth-breathing - night XXXX XXX XX XX Mouth-breathing – day XXXX XX Total symptom score 39 16 8 2 % reduction symptoms 59% 79% 95% 34
  35. 35. Before After 35
  36. 36. Before After 36
  37. 37. What you can do Assess • breathing pattern • posture • symptoms • drive to breath • triggers Triage 37
  38. 38. 38 Triage Category 1: awareness and nose-breathing practice – mouth-breathing – habit, not need – easily wear appliance Category 2: refer to breathing educator – mouth-breathing – need and habit – mild-mod overbreathing and symptoms – struggle to wear appliance Category 3 : refer to (Buteyko-trained) breathing educator – mouth-breathing entrenched – chronic overbreathing, mod-severe symptoms – co-morbidities – struggle/ cannot wear appliance
  39. 39. Teaching basic skills • Awareness, understanding • Nose-breathing practice • ‘Unfold’ posture • Less sugar • Sleep position 39 V Lunn-Rockliffe © 2014
  40. 40. Nose-breathing chart DATE 10 seconds 20 seconds 40 seconds 60 seconds 90 seconds 120 seconds NOSE BREATHER Example 1st try Example 2nd try 40
  41. 41. 41 Resources Relief from Snoring and Sleep Apnea Penguin Aus; Amazon US Breathing Exercise Instruction Audio CD and MP3 versions – BreatheAbility.com Practitioner Training admin@BreatheAbility.com

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