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Nasal Breathing Part 2: Deconstructing Obstructive Sleep Apnea

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How Well Do You Sleep?

We spend about one-third of our lives sleeping, and yet most of us don’t give it a second thought.  Most medical and health professionals pay just as little attention to sleep as the average person.  Yet it is a foundational component of health.  Without healthy sleep you cannot be the healthiest version of yourself.  End of story.  

Sleep deprivation is one of the most significant roadblocks to healing.  One can argue a good night’s sleep is the single most important ingredient to good health.  Today, too many people are relying on sleep aids and still not feeling rested in the morning.  The key is to let the body sleep, not force it to sleep.  Medication-induced rest just isn’t the same because the body often does not get into deep sleep which has the most health benefits. Nothing beats natural sleep. 

The primary reason people don’t get world-class sleep is due to nervous system dysregulation, but other causes include hormonal imbalances, poor breathing patterns, nutritional deficiencies, stress, pain, and digestive problems.  Each of these must be monitored and addressed as needed. 

There are signs you can look for to identify those who likely have poor sleep habits (see last week’s blog post).  Many patients are open about the quality of their sleep habits if you ask the right questions.  However, I do believe that it is one of the most difficult habits to change.  

Part of that is due to a culture that views sleep as an inconvenient nuisance that limits productivity.  The irony is most of these people would be MORE productive if they got solid sleep.  Another part of it is the Modern Human’s addiction to caffeine and other stimulants.  Other recreational drugs like cannabis and alcohol also negatively impact sleep.  Most Modern Humans are disconnected with Nature and have poor circadian health.  Another is blue light stimulation, especially at night.  

You can’t supplement or drug these things away.  They require real changes if you’d like to see real improvement.   

Sleep specialists still represent but a small fraction of the medical profession.  Even if you spend an hour with your doctor, naturopathic physician, or functional medicine provider, there’s only so much you can get to in a short amount of time.   

My goal today is to give you the tools to help you identify if sleep apnea may be contributing to nagging health ailments you might be experiencing.  I’ll explain why this happens and give you actionable exercises to get started. 

Broken Sleep

In 1957, William Dement came out with a revolutionary paper detailing the specific sleep stages that form what we now call the sleep cycle.  His depiction is still largely used today.

There are two main types of sleep, rapid eye movement (REM) sleep and non-REM sleep.  Non-REM sleep includes what is known as slow wave sleep, also known as deep sleep.  We typically dream during REM sleep.  Each night, you go through three to five cycles of non-REM and REM sleep.  How well you function each day is driven by not only how much total sleep you get, but also if you are getting enough of each type.

The typical sleeping pattern starts with a gradual descent into deep sleep.  Stages 3 and 4 are called “deep sleep” or non-REM sleep.  It is also known as “delta sleep” or “slow-wave sleep” (SWS).  The bulk of deep sleep occurs earlier in the night, while REM sleep increases in frequency and duration as morning approaches.  We will dive deeper into this in future blogs on sleep specifically.  However, you should know that most of the repair, rebuilding, and detoxification the body performs occurs during deep sleep.  When this gets disrupted, we are simply not as efficient in our sleep and our health suffers.

Sleep fragmentation is the disruption of normal sleeping rhythms by any cause, which includes obstructive sleep apnea (OSA).  This occurs because as we sleep, the muscles that keep the airway open are more relaxed and can collapse at night.  This occurs because these muscles are not under conscious control like they are when we are awake.

While you’re aware, the airway is held open by the high activity of the numerous upper airway dilator muscles.  This is why those who have OSA may not know it, because the symptoms only occur while sleeping. 

However, after the onset of sleep, muscle activity is reduced, and the airway collapses.  Collapse of the airway occurs if the negative upper airway pressure is stronger than the inspiratory pump muscles.  CPAP (continuous positive airway pressure) machines force the airway open by supplying a positive pressure of air.  While this forces air into the lungs, it does not help identify or treat the root cause of OSA in any way.

Sleep Disordered Breathing

Last week, we touched on sleep disordered breathing, and discussed some of the physiology behind how we breathe.  I suggest reading that here before diving into this post.

While sleep disordered breathing (SDB) does not have a true definition, it does include snoring, obstructive sleep apnea (OSA), and central sleep apnea (CSA).  OSA makes up a large portion of SDB.

Sleep apnea is a potentially serious sleep disorder in which breathing repeatedly stops and starts.  Open-mouth breathing during sleep is a risk factor for obstructive sleep apnea (OSA) and is associated with increased disease severity and upper airway collapsibility.

Unobstructed breathing throughout the night is essential for high-quality health.  Unfortunately, most mainstream and conventional medical providers do not always view OSA as a frequent contributor to chronic ailments.

Certainly, many providers inadvertently enhance airway function through approaches like addressing the mind-body connection, reducing inflammation, weight loss, or alleviating throat muscle tension.  However, this is only part of the story, and we need a more holistic view of what is going on.

The Details on OSA

OSA involves repetitive pharyngeal collapse during sleep.  Pharyngeal collapse could be…

Full or partial collapse of the upper airway results in hypoxemia, or decreased oxygen levels.  However, it also leads to increased airway resistance and can culminate in an event known as a “microarousal.”   A microarousal is a brief waking that typically goes unnoticed by the individual.  Microarousals serve to restore breathing at the expense of sleep continuity at a neurological level.  In other words, it negatively impacts our deep sleep.  

Frequent interruptions to sleep reduce the healing powers of sleep and can hamper its restorative properties, regardless of how long you are in bed.  

Indeed, a lack of oxygen will lead to an increased effort from your breathing muscles, like the diaphragm, to make up for the lack of oxygen.  This has more recently been dubbed Upper Airway Resistance Syndrome (UARS), and some clinicians believe it may be a precursor to OSA.

Open-mouth breathing is associated with reduction of the retropalatal and retroglossal areas.  In other words, you have less area for air to flow.  Less air flow means less oxygenation.

Measuring Sleep Apnea

In the classic definition of OSA, sleep is interrupted by apneas and hypopneas.  An apnea is defined as no airflow for at least 10 seconds followed by hypoxemia or arousal.   A hypopnea is typically defined as reduced airflow for at least 10 seconds followed by minor hypoxemia or arousal.  Unfortunately, there is no standardized definition for hypopnea, which makes the matter a bit more confusing.

The best test for obstructive sleep apnea is overnight polysomnography in a laboratory with the primary outcome measure of apnea–hypopnea index (AHI).

The AHI measures the number of apneas plus hypopneas per hour of sleep.

At best, AHI is considered a crude measurement.  Apneas & hypopneas are not biologically equal, yet measured as such.  To add to the confusion, the hypopnea threshold is arbitrary.  For example, a hypopnea with a 4% oxygen desaturation is considered biologically equivalent to a hypopnea that has an 8-10% oxygen desaturation.  Of course, the greater the hypoxemia, the greater the effect.  

To make the matter a bit more challenging, apneas & hypopneas can occur evenly throughout the night or in clusters, meaning there may not be a standard time interval between events. 

Those who mouth breathe or oronasally breathe (combination of oral and nasal breathing) are more likely to have higher AHI than those who breathe nasally.  Nasal breathers have higher oxygen saturation.  It is also worth noting that airway dimensions are greater in nasal breathers vs. mouth-breathers.

Getting in Rhythm

Getting the right amount of sleep can improve your mental and physical health, as well as your athletic performance!   When you sleep, your body works to support healthy brain function and maintain your physical health. 

Each of us has a 24-hour body clock, known as the circadian rhythm.  The circadian rhythm controls your sleep and wake cycles each day.  This rhythm affects every single cell in the body, and how they work.  If you are not getting enough sleep, or are sleeping at incorrect times, it is very unlikely your energy levels will be great the following day.  If poor sleep habits persist, chances are your health will begin to decline.

There are also certain chemicals that play a role in how well you sleep.  Cortisol is the body’s main stress hormone, and is highest in the morning, aiding in waking us up in the morning.  Melatonin, on the other hand, rises at night, and helps us get to sleep.

The goal is to find this proper balance between them.  When they are thrown off their regular cycles, you will not get the best sleep possible.

If you want great sleep, and you may be struggling with sleep apnea, you need to keep upper airway muscles strong!

OSA Statistics

The tricky part about OSA is that, unless you share a bed with a partner, you might not be aware of it.  Even in those cases, some partners may not want to share that information because it might be embarrassing or put a strain on the relationship.

Today, OSA is more common than ever.  One study found that 9% of women and 26% of men (30 to 49-years-old), and 27% of women and 43% of men (50 to 70-years-old) suffer from OSA.  Some research also suggests that more than 80% of cases remain undiagnosed!  The truth is most people with OSA are undiagnosed and untreated!

Why does this happen?

Consider a person who works a job where he or she needs to operate a vehicle.  The loss of a driver’s license is a real issue.  In the US, laws prohibit patients with uncontrolled OSA from driving.  But again, many people avoid the testing because it can put their jobs in jeopardy.  This is partially why some experts believe OSA diagnosis statistics are an underestimate.

There also aren’t exactly any exciting conventional treatment options- ask anyone who shares a bed with a CPAP machine user.  Even then, CPAP machines do not treat sleep apnea.  They do not address the root causes of why the apneas are occurring.  They are merely a crutch.

But sometimes, it is simply hard to recognize.  Up to 25% of those with OSA do NOT have subjective or objective signs of sleepiness.  In many cases, OSA is not usually explored if one’s BMI isn’t very high.  

While this may seem dreary, there are risk factors one can look for to clue yourself in:

You might be thinking, “Hey!  Everyone probably has at least ONE of these, right?”  In today’s world, many do.  Many of them might find it difficult to improve.  I believe that poor sleep and poor breathing patterns are one of the major factors that few clinicians address in practice.

I don’t blame the clinicians though.  Many of these symptoms are non-specific, so it takes buy-in from both the clinician and patient to address this, even though it doesn’t “seem” like an immediate contributor.  But it almost always is. There’s only so much time in appointments, and many of these changes require active participation from the patient.  

They also require the patients to be honest with themselves, adjust their current lifestyles, and take this seriously.  It takes time and effort to see results.  In my practice, I’ve seen positive change occur anywhere between 1-3 months on average, and you must give yourself at least 15-20 minutes per day to perform the exercises.  

Patients often become accustomed to their usual sleeping routines.  Others may attribute their condition to factors like stress, aging, or medication side effects.  Certain health-conscious people may resist or deny the notion that their sleep is suboptimal, even when presented with evidence.  I was one of them.  Some have never truly known what restful sleep is.

What Happens if You Do Nothing?

The immediate effects of OSA are similar to those of sleep deprivation:

While these might not be so impactful in the short-term, their severity will increase gradually over time.   The long-term consequences are legitimate problems if OSA or sleep deprivation are not addressed.  Chronic sleep deprivation produces systemic inflammation, heightening susceptibility to a spectrum of chronic ailments:

As you can see, some of the downstream outcomes can be devastating and life altering not only for the patient, but their families.  When you consider how infrequently OSA is treated, I believe that it should be considered a major public-health priority.  The good news is that much of it is preventable and reversible if you put the effort in, and it would be well worth your time to do so.

Snoring & Sleep Apnea

Snoring is a sign that should be taken seriously.

If you snore, there is a very good chance that you may have some form of sleep apnea or sleep disordered breathing.  The snoring sound is created by turbulent airflow.  Noisy breathing during sleep is caused by the exchange of a large volume of air through a narrowed space.  This causes tissues in the nose and throat to vibrate.

There are two main types of snoring:

For some context, sleep deprivation contributes to around 109,000 road traffic collisions resulting in injury and 6,400 fatal traffic accidents annually in the US.

Arousal Threshold

The arousal threshold can sometimes be a useful measurement for those who suffer with OSA.  In its simplest terms, arousal threshold simply refers to your propensity to be a light sleeper or a deep sleeper.

More technically speaking, it is defined by the level of intra-esophageal pressure and the amount of change in the concentration in arterial CO2 required to trigger arousal.

Low arousal threshold and poor upper airway recruitment will wake someone up before the dilator muscles have activated to open the airways.  This means those with low arousal thresholds will experience frequent, unnecessary arousals.

These arousals can have some far-reaching effects.  Depression, anxiety, fatigue, low arousal threshold, and OSA seem to be linked in some way.  One study claims that 67% of those who suffer from OSA also suffer from insomnia.  It is possible that poor sleep alone could contribute to the onset and severity of depression.  With all this in mind, we know that poor sleep quality can lead to poor emotional health.  That connection is very clear.

Bottom line, we need to strengthen the airway muscles if we want to get truly restful sleep.  If the upper airway dilator muscles are not functioning properly, sleep that is too deep can also present a problem.

If the arousal threshold is so high that the person fails to arouse during an apnea, the breathing can stop for a long time.  This can lead to greater oxygen desaturation and poorer sleep.

Breathing Re-Education

If you want to get incredible sleep, nasal breathing is non-negotiable.  Problem is, some of us aren’t aware of mouth breathing at night.  I’ve been there!  Considering you’re going to be spending about one-third of your life sleeping, how you breathe during that time is kind of important.  Here are just some of the benefits of nasal breathing.

Mouth breathing, on the other hand, can cause some problems…

The Methods used in the Breathe Easy Method have shown to be successful in helping improve a number of breathing related problems including:

How Should We Breathe?

Functional breathing involves breathing in and out through the nose.  The breath should be light, regular, effortless, and with the primary movement from the diaphragm.

There is a common belief that the more air we breathe, the healthier we are.  Few people realize that in order to increase blood flow and oxygen delivery to the tissues, breathing should be slowed down so that less air enters the body. 

You know that you are taking less air into the lungs than normal when you experience a tolerable feeling of air hunger. You may feel body temperature increases to indicate an improvement to blood circulation or an increase to saliva production – traditionally observed in Yoga as activation of the body’s relaxation response.

Treatment of pediatric obstructive-sleep-apnea (OSA) and sleep-disordered-breathing (SBD) means restoration of continuous nasal breathing during wakefulness and sleep.

Take it from this quote from a lecture at Stanford University Sleep Medicine Division:

“The case against mouth breathing is growing, and given its negative consequences, we feel that restoration of the nasal breathing route as early as possible is critical. In fact, restoration of nasal breathing during wake and sleep may be the only valid “complete” correction of pediatric sleep disordered breathing…”

With that in mind, I’ll explain a couple of the exercises that I use in my course and with clients.

Breathwork Exercises

I recommend establishing your Control Pause time before getting started.  This is a quantifiable measure you can use to track your progress.  I discuss how to perform the exercise in this blog.  

An optimal CP is > 40 seconds.  Those with a CP < 20 seconds may be struggling with chronic health concerns.  However, you should notice significant improvements in your health with every increase of 5 seconds.  For most people, they will typically see an improvement in their CP of 1-2 seconds per week, assuming they are performing the exercises daily.

Exercise 1: Decongest the Nose

As you might expect, this exercise is very helpful for decongesting a blocked nose.  You may need to repeat this up to six times, with 30-60 second breaks in between each rep.  You can also use this exercise to improve your CP.

IMPORTANT: Take care, as this exercise involves holding the breath until a strong air hunger is experienced. It is not suitable for people with high or low blood pressure, anxiety, panic disorder or cardiovascular issues, or during pregnancy.

Exercise 2: Breathe Light

All Breathe Light exercises should be practiced with mouth closed, correct tongue posture (placed on the roof of the mouth), lips together, jaws relaxed, breathing in and out through the nose.

Three dimensions are targeted:

  1. Biochemistry: Reduce the chemosensitivity of the body to the build-up of carbon dioxide. (Breathe Light)
  2. Biomechanics: Breathe using greater amplitude of the diaphragm. (Breathe Low)
  3. Cadence or paced breathing: Stimulate vagus nerve and exercise baroreceptors with cadence of six breaths per minute. (Breathe Slow)

There are several variations to this exercise:

  1. Hands on chest and tummy (biochemical)
  2. Feather breathing (biochemical)
  3. Hands cupping face (biochemical)
  4. Finger blocking nostril (biochemical)
  5. Cadence breathing to six breaths per minute (biochemical, biomechanical, cadence)
  6. You may use a guided meditation if that helps

Use the acronym PAST for all variations:

Awareness

Awareness of the breath is very important to improve breathing patterns. Only when people can see, feel, hear, or follow their breath can they change it. By focusing on the area just inside the nose, it is easier to soften breathing without tensing the body or deliberately interfering with breathing muscles.

Awareness of the breath is important to make changes to breathing. Sometimes, it can take a couple of sessions for the student to become aware of their breathing.  When you are aware of the breath, proceed to slow down or shorten the breath.  The goal is to allow breathing to soften, to slow down, and reduce breathing using thoughts and concentration.  Breathing volume should be reduced through a combination of relaxation and encouraging thoughts, not by tensing the breathing muscles.

Tolerable Air Hunger

The goal is to create a feeling that you would like to take in more air; to feel an air hunger.  To create air hunger, your breathing now should be less than what it was before you started.  You should feel a want for air, or a feeling that you would like to take in a deeper breath. If your breathing muscles contract or if they start to feel tense, then the air hunger is too strong.

When this happens, take a rest for 15 seconds and start again. It is normal at the beginning to take a rest a few times during the exercise. With practice, it becomes easier to sustain the air hunger for longer periods of time.  Practice softening your breath to the point of air hunger.

While there are a number of ways to describe the feeling of air hunger, students can interpret it differently.  Some may feel they are not getting enough air.  Others may feel that they would like to take in a deeper breath.

Signs to look out for while performing this exercise:

•         Glassy eyes

•         Increased saliva in mouth

•         Nose may run

•         Hands get warm

•         Some people feel sudden calmness, others may feel slight panic

If you notice any of these signs, then stop performing the exercise and come back to it at a later time.  You may want to dial back the intensity as well.

Exercise 3: Box Breathing or Triangle Breathing 

Believe it or not, box breathing was originally used by military personnel to help regulate the autonomic nervous system.  It is designed to create a state of relaxed alertness- a sort of “getting in the zone.”  As you can tell from the diagram above, the method is very straightforward:

  1. Breathe in through the nose for X seconds
  2. Hold for X seconds
  3. Breathe out through the nose for X seconds
  4. Hold for X seconds
  5. Repeat Steps 1-4 for up to 5 minutes.

You can use this with four second intervals at each “side” of the box, but you can adjust up or down depending on your fitness level.  The important part is that each “side” is equal in length.  As you do this, it will improve over time, and you can increase X.

In my opinion, this is a fantastic choice for beginners because it gets you in tune with your breath and breathing patterns.

However, there is an alternative to box breathing that I think is better for sleep, what I call Triangle Breathing.  Box breathing can help calm the autonomic nervous system, but it is meant for focus and alertness.  This is a more calming version of box breathing, putting you into a more parasympathetic state.  The instructions are as follows:

  1. Breathe in through the nose for X seconds
  2. Hold for X seconds
  3. Breathe out through the nose slowly for 2X seconds
  4. Repeat Steps 1-3 for up to 5 minutes.

If we wanted to add numbers to this, an example may look like…

  1. Breathe in through the nose for 4 seconds
  2. Hold for 4 seconds
  3. Breathe out through the nose slowly for 8 (2×4) seconds
  4. Repeat Steps 1-3 for up to 5 minutes.

It has been my experience that having an exhale that is longer than the inhale at rest creates better outcomes.  It is also more calming.  To me, this is a better alternative for sleep because it is better at deactivating the sympathetic nervous system, which is what you want towards the end of the day. 

Unlocking the Breath

The breath is the life force for our physical body.  If we stop breathing, we die. I do find the relationship between humans and plants interesting.  Humans breathe in oxygen, and get carbon, hydrogen, and nitrogen from plants.  

We then exhale carbon dioxide, which plants use to continue the cycle.  The air that we breathe (which is created by plants and trees) is alkaline, while the carbon dioxide by-products we exhale are acidic.  It is vital that we learn to breathe properly and spend some time deep breathing.  

Optimizing breathing patterns charges the system with negative ions creating a cationic condition in the body, whereas shallow breathing creates over-acidity and sympathetic dominant situations in the body.  Oxygen and simple sugars are the main fuels for our cells, as carbon dioxide is one of the main fuels for plants.

Most humans were never taught to breathe properly.  This can affect children at young ages, and even dictate their facial development, to a degree.  We have become “shallow breathers.”

Slow, controlled nasal breathing energizes the system, increasing circulation and lymph flow.  It also clears the mind and settles the emotions, allowing us to feel more at peace with ourselves and with Nature.  

The breath, in spiritual traditions, has been called the prana, chi, ki, life force, spirit, mana, the ECK, and many other names. Breathing is an act of cleansing.  I have worked with people in the past who can experience cleansing reactions just by improving their breathing patterns using the techniques I teach in my Breathe Easy Method.

I highly recommend performing these exercises to take your breathwork and your health to the next level!

What Can You Do?

Start relearning how to breathe!

Massive improvements can be made in as little as twelve weeks when incorporating breath holds and the methods used in the Breathe Easy Method.

This is the same method used by thousands, from elite athletes looking to gain the extra edge, to children who struggle with sleep apnea.  

If you have low energy, struggle with sleep apnea, snore, or just simply want the competitive edge over the competition, this course is for you.  

Check it out using this link!  

More to come on sleep and breath.  But you can start building a strong foundation today!

I wish you the best of health!

Dr. Vincent Esposito

Want More?

Whenever you’re ready, there are two ways I can help you:

  1. Massive improvements can be made in as little as twelve weeks when incorporating breath holds and the methods used in the Breathe Easy Method.  This is the same method used by thousands, from elite athletes looking to gain the extra edge, to children who struggle with sleep apnea.  If you have low energy, struggle with sleep apnea, snore, or just simply want the competitive edge over the competition, this course is for you.  
  1. I take a comprehensive, individualized, one-on-one approach with every single person I work with.  Perhaps you have tried so many different routes to better yourself, but not see the progress you desire.   If you want clear action steps and a guide to help you lay the foundation for healing and feel confident in your body, this is for you.  If you want a partner who is committed to helping you master your own wellness, then schedule a FREE 15-minute call with my team to apply to get your health on the right track.
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