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Introduction

Obstructive sleep apnoea (OSA) is a sleep disorder where repeated upper airway obstruction during

sleep leads to a decrease in blood oxygen saturation and disrupted sleep.

Current treatment options include oral appliances, surgery, and/or the use of a continuous positive

airway pressure (CPAP) machine.

However, breathing retraining with the Buteyko Institute Method (BIM) is a safe, effective and

convenient approach to OSA that could help eliminate the need for surgery or CPAP.

This paper examines the role of breathing retraining in OSA and presents a case study to illustrate its

effectiveness.

By Mary Birch

Obstructive sleep apnoea and

breathing retraining

About the author

Mary Birch, RN, BA, MBioE, Grad Dip Soc, is a registered Buteyko practitioner.

Hyperventilation, OSA and

breathing retraining

During his medical studies in 1953,

Russian doctor, Professor Konstantin

Buteyko, was asked to do a project on

breathing. Through his research,

Professor Buteyko concluded that

hyperventilation

or

over-breathing

caused many conditions, including

asthma and OSA.

Until his death in 2003, Professor

Buteyko dedicated his life to researching

and developing breathing retraining

techniques. The method Professor

Buteyko

developed

spread

internationally in 1991, and is now used

throughout the world for a number of

conditions.

1,2

OSA profile

In obstructive sleep apnoea, the muscles

of the soft palate relax during sleep,

leading to oro-pharyngeal and uvular

collapse, causing obstruction of the

airway and a drop in oxygen saturation.

OSA is characterised by the periodic

cessation (apnoea) or reduction

(hypopnoea) of airflow during sleep.

3

Apnoea is defined as the total cessation

of airflow at the nose and mouth, lasting

at least 10 seconds, associated with a

decrease in oxygen saturation of 4% or

more. Hypopnoea is generally taken to

mean a greater than 50% reduction in

airflow lasting 10 seconds or more,

associated with a 4% or greater fall in

oxygen saturation.

4

However,

the

difference between the two is of little

clinical importance since both events

have similar pathophysiology.

There is no clear consensus in medical

literature as to why OSA occurs,

although it is thought to be associated

with ageing, obesity or airway anatomy.

Both children and adults, however, can

suffer from OSA, and many people who

do are of normal weight.

Although the cluster of symptoms which

occur with sleep apnoea has been

described in medical literature for

thousands of years, it is only in the last

three decades the significance of this

sleep disorder has begun to be

recognised, according to a National

Health and Medical Research Council

report.

5

Constant reductions in oxygen saturation

and wakening or semi-wakening from

sleep lead to daytime symptoms

associated with lack of quality sleep.

People with OSA find they are constantly

tired, irritable, sleepy during the day,

lack concentration and suffer from

headaches.

Dysfunctional breathing and OSA

Hyperventilation is considered to be the

fundamental cause of OSA, according to

Professor Buteyko’s theory. He argues

the apnoeas or pauses in breathing

which occur in OSA are the body’s

defence mechanism against the

excessive loss of carbon dioxide due to

hyperventilation and consequent hypoxia

(see illustration).

clinicalupdate

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AUGUST 2004

2 clinicalupdate

Hyperventilation

When a person hyperventilates, they

exhale excessive amounts of carbon

dioxide (CO

2

). Lowered CO

2

levels in the

body are critical in many conditions.

The optimal level of CO

2

in the air sacs is

around 6.5%. If the CO

2

level falls below

this due to hyperventilation, there is a

gradual alkaline reaction in the lungs.

When alveolar CO

2

is lowered, this

gradual alkaline reaction in the lungs is

carried through to the blood and total

blood CO

2

will also decrease.

6

Oxygen (O

2

) in the blood is carried by

means of a haemoglobin (Hb) molecule.

When CO

2

is low due to over-breathing,

O

2

is bound tighter than normal to the Hb

molecule due to a chemical bond. For

this bond to loosen, CO

2

levels need to

increase and the blood pH needs to

become less alkaline.

As blood pH decreases, the Hb/O

2

bond

decreases in strength, hence more O

2

is

available to the tissues. Therefore, when

CO

2

levels rise to normal, O

2

is more

readily released from haemoglobin and it

can then oxygenate the body and

maintain homeostasis.

This phenomenon, called the Bohr effect,

the Verigo-Bohr effect, or oxygen-

haemoglobin disassociation curve, is

described in standard physiology

textbooks.

A case study

When John, (not his real name) a 44

year-old man, attended the Buteyko

Breathing Centre in Melbourne, his

medical history included asthma from

childhood and OSA of 18 months

duration.

His symptoms included

shortness of breath, frequent deep

breaths, snoring, frequent waking at night

sweating, irritability, lack of concentration,

and abdominal bloating.

John’s medication was Seretide 250/50,

one puff at night (an asthma medication

consisting of fluticasone and salmeterol).

Sleep studies taken 18 months previously

indicated John suffered from severe

OSA. He was prescribed a CPAP

machine, but found it was not effective in

controlling the OSA symptoms.

John’s doctor had also mentioned the

possibility of surgery to alleviate his OSA.

Despite using the CPAP machine, John

found his condition was getting worse so

he only used the CPAP intermittently.

Assessment

When John first attended the breathing

centre, he displayed signs of sleep

deprivation. His speech was very rapid

and incoherent at times, he was

obviously tired and distressed, unable to

concentrate or listen effectively, and at

times appeared agitated.

He was of lean build and had never been

overweight. John’s initial pulse was high

(at 96) and his respiration rate was 20 per

minute.

There was also evidence of over-

breathing, ie. mouth-breathing constantly,

taking large breaths while talking,

breathing loudly at times, sighing,

yawning, shoulders raised, and breathing

from the upper chest (not from the

diaphragm).

BIM breathing retraining

Following an explanation of what was

involved, John enrolled to attend a

Buteyko breathing retraining course of

five consecutive daily sessions of 90

minutes per day, plus follow-up.

John’s course included breathing

techniques to unblock the nose, promote

nasal breathing and control symptoms

(eg. when waking at night, when feeling

short of breath or when having asthma

symptoms during the day), and

guidelines and techniques to enhance

sleep quality and to improve breathing

while performing daily living activities and

exercising.

John was also asked to perform a series

of breathing exercises three times per

day. These exercises, totalling around 15

minutes per session, included breathing

pauses and other techniques to reduce

breathing and thereby retain CO

2

.

John was asked to record his results

on a daily diary sheet, and to list any

symptoms, plus medication used,

including use of the CPAP.

John’s progress

John’s sleep and asthma gradually

improved from day two of the course. On

day three, he was still having sleep

problems but felt a little better.

By day four, his breathing had improved

considerably. He was sleeping much

better and the night sweats had stopped.

He was using the CPAP for part of the

night only and stated that he was feeling

much better.

His concentration was also much

improved as were his asthma symptoms.

By day four he had seen his physician

and the Seretide had been withdrawn.

He was now taking Flixotide (fluticasone)

250mcg once daily and not requiring

O

2

?

HYPERVENTILATION

CO

2

deficit

(hypocapnia)

pH shift:

(respiratory

alkalosis)

Bohr Effect

Bohr Effect

pH normalised

CO

2

increase

BUTEYKO THEORY AND

OBSTRUCTIVE SLEEP APNOEA

Compensation:

Apnoea

O

2

(hypoxia)

?

clinicalupdate

any bronchodilators. This reduction in

asthma medication is consistent with

results obtained in the first clinical trial of

the Buteyko method in the western world,

and recently confirmed by a further

study.

7,8

By day five, John was looking well and

had used the CPAP for only two hours the

previous night.

One month later, John attended the

centre for review. He looked very much

improved. His pulse rate was now down

to 64 and he was sleeping well

throughout the night without the CPAP.

His breathing had improved significantly,

his tiredness had gone, and his speech

patterns and concentration appeared

normal. He was advised to continue the

breathing exercises three times per day.

After five months, John phoned, rather

elated, to say: ‘I’ve had repeat sleep

studies done and I don’t have apnoeas at

all. Based on the results, I don’t need

surgery. The snoring has gone from loud

to mild. I used to wake myself up with

snoring… that’s all gone. My oxygen

saturation is up to 97%; before it was

around 87%.’

Reviewed by telephone two years after

the course, John says his current health

status is good. He sleeps well and does

not use a CPAP machine. He does not

do the breathing exercises except when

his nose blocks occasionally, generally

when the weather is cold and dry.

He still continues to use one puff of

Flixotide (very low dose) daily for ‘security

and insurance’.

Incidence, morbidity and mortality

In Australia, a 1995 clinical study found

24% of men and 6% of women over 55

had clinically significant OSA.

9

Studies have also shown that OSA has

been implicated in a number of clinical

conditions, including pulmonary and

systemic

hypertension

and

cor

pulmonale.

There have also been links between

daytime sleepiness associated with

OSA and road accidents. In addition, a

number of studies have suggested that

OSA is associated with premature

mortality, largely as a result of vascular

diseases.

10

OSA Diagnosis

Diagnosis of OSA can be made by

monitoring an individual’s sleep patterns

overnight at a sleep clinic. The number

and duration of apnoeas and hypop-

noeas, stage of sleep (REM/non-REM),

heart rate, oxygen saturation, position

and limb movements are monitored

electronically during sleep, and a

statistical report is provided.

From these details, it can be determined

whether the person suffers from OSA,

and the severity of their condition.

People with severe OSA can have over

20 episodes of apnoea or hypopnoea

per hour.

Treatment options

Current treatment options for OSA

generally involve surgery or nightly

use of oral appliances (such as

mandibular advancement splints), or

CPAP machines.

11

A Cochrane Review of trials of drug

treatments for OSA concluded the data

available do not support the use of drugs

as a therapy for OSA.

12

Further, since the advent of nasal CPAP,

surgical options for OSA are now less

common.

13

Most commonly, moderate to severe

OSA is treated with the use of a nasal

CPAP machine, which forces air through

a nasal mask, thus maintaining the

person’s airway while sleeping.

However, there are problems with

compliance in using nasal CPAPs, as

there are numerous side-effects.

14

These

include dry nose, mouth or throat, rhinitis,

noise, nasal congestion, sore eyes,

headache, mask discomfort and chest

discomfort.

15

The machines require cleaning and

maintenance, users and partners may

find them noisy and intrusive, and people

have the inconvenience of having to take

the machine with them when away from

home.

A Cochrane review of clinical trials for

surgery for OSA found that no completed

trials were identified to compare surgical

interventions for OSA with other surgical

or non-surgical interventions or no

intervention.

16

This review concluded there was an

urgent need for high quality randomised

controlled trials to be carried out in the

field of surgery for OSA, and that more

research should be undertaken to identify

and standardise techniques to determine

the site of airway obstructions.

Conclusion

Breathing retraining with the Buteyko

Institute Method offers a safe, effective,

convenient, and more appealing option

for people with OSA, which can eliminate

the need for surgery, oral appliances, or

CPAP.

The benefits of breathing retraining have

become apparent from many years of

clinical practice in teaching BIM courses

to people with OSA. Unlike other

alternatives, there are no side effects with

breathing retraining.

Trials of breathing retraining have

demonstrated benefits in asthma,

however, there are currently no trials

available for OSA.

Further information:

www.buteykobayside.com

www.bibh.org

References

1 Ameisen P.J. Every breath you take, New Holland

Publishers (Australia) Pty. Ltd., Sydney, 1997.

2 Stalmatski, A. Freedom from asthma, Kyle Cathie

Ltd., London, 2001.

3 Bridgman, S.A., et al. Surgery for obstructive sleep

apnoea, Cochrane Review, Issue 2, 2004. Available

at http://www.cochrane.org/cochrane/revabstr

/AB001004.htm. Accessed 18 June 2004.

4 National Health and Medical Research Council,

Effectiveness of nasal continuous positive airway

pressure (nCPAP) in obstructive sleep apnoea in

adults, 2000. Available at http://www.nhmrc.gov.au/

publications/pdf/hpr21.pdf

5 ibid.

6 Ameisen, P.J. op. cit. pp.87-99.

7 Bowler, S.D., et al. Buteyko breathing techniques in

asthma: A blinded randomised controlled trial,

Medical Journal of Australia, December 1998, 169,

pp.575-578.

8 McHugh, P., et al. Buteyko Breathing Technique for

asthma: An effective intervention, The New Zealand

Medical Journal, December 2003, 116:1187.

9 NHMRC, op. cit. p.2.

10 NHMRC, op. cit. p.3.

11 ibid.

12 Smith, I., et al. Drug treatments for obstructive sleep

apnoea, Cochrane Review, Issue 2, 2004. Available at

http://www.cochrane.org/cochrane/revabstr

/AB003002.htm. Accessed 21 June 2004.

13 NHMRC, op. cit. p.36.

14 NHMRC, op. cit. p 4.

15 NHMRC, op cit. p.28.

16 Bridgman, S.A., et al. op. cit.

Correction

Clinical Update ANJ July 2004

Associate Professor Paul Desmond, MBBS FRAC and

co-author of Hepatitis C: A medical and social diagnosis

(Clinical Update 73, ANJ July 2004, pp.23-25) is director

of gastroenterology, St Vincent’s Hospital, Melbourne,

Victoria. The ANJ apologises for its error.

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