Episode 47: Patrick McKeown BA, MA - Nasal Breathing Will Save Your Life

Hi and welcome to episode 47 of the Untethered podcast. Today we have Patrick McKeown joining us. He's a graduate of Trinity College Dublin and the Buteyko Breathing Clinic of Russia. Patrick was a chronic asthmatic for most of his life, experiencing high perceived stress and poor sleep. In 1998, he addressed his breathing pattern disorders, leading to a dramatic improvement to his health. Since 2002, he has taught children and adults simple and effective ways to adopt functional breathing patterns. A TEDX speaker, Patrick's work has touched the lives of thousands and more worldwide. His work has been published by leading publishing houses including HarperCollins in the UK, William Morrow's Press in the USA, Red Wheel Wiser in the US and Sperling in Kupfer in Italy, as well as Kanki Publishing, Inc. In Japan. Journal publications include the American Journal of Respiratory and Critical Care Medicine and Clinical Otolaryngology. Quick Disclaimer all information, content and material of this podcast are the opinions of the speakers and is for the informational purpose only and not intended to serve as a substitute for the consultation, diagnosis and or medical treatment of a qualified healthcare provider. Welcome to the Untethered Podcast. I am your host, Hallie Balkan. I'm a certified orofacial myologist, feeding specialist and mentor. This podcast is all about getting your questions answered and collaborating with colleagues to bring you the most up to date information in the orofacial myofunctional therapy, tethered oral tissue and airway space. I challenge you to keep an open mind and join my mission to get this information out to the masses. Let's get started. Thank you Patrick so much for joining us today. I'm excited to have you here on the podcast.

Thanks very much Hallie. My pleasure.

So let's jump right on in and I would love to know how you got into the Uteko breathing space.

It was primarily by accident. I was a child growing up in asthma and if you have asthma, you don't just have asthma. And that inflammation is not just isolated to the lungs, but it also travels up to the nose. So I had a stuffy nose and I had inflammation on my lungs. And then of course your sleep is impacted and with that then I had higher stress levels. So for me as a kid going through school and going into high school and university, I had problems with concentration, I had problems with memory in terms of I didn't have the focus and the energy levels to be able to, you know, to really hone in on material. And I got my grades, my grades were fine. But it took a lot of work. So I was in the corporate world. My background, my master's degree is in economics. And I read at the time, back in 1997, 98, about a newspaper article. And it was about the work of a Russian doctor. And he spoke about two things. He said, it's really vitally important for human beings to breathe in and out through their nose. And it's also vital that they have light breathing, that their breathing is silent during rest. And that kind of article that struck me because I had neither of that. I was a person with a stuffy nose. I was persistently mouth breathing. I could always hear my breathing. And also I often felt that I wasn't getting enough air. So this is despite, like, the kind of. The strange thing is that I had a nasal operation in 1994, and the surgeons fixed my nose. And I'm not sure exactly what they did, but I think I had turbulent reduction surgery. And I had a correction of a deviated septum, even though my nose is still not fully functioning. But it's not too bad. But the surgeons never told me to breathe through it afterwards. So even though my nose was fixed, I just continued with the habit of mouth breathing. And I think this is inevitable because if you breathe through an open mouth for 20 years, even when you fix the issue or the obstruction, you're not necessarily changing the behavior. And so I was one of those youngsters that fell through the cracks. And this, you know, going to. I was going to my medical doctors every three months or so looking for asthma medication, and I was never encouraged to breathe through my nose. So I read this article, and I did a nose unblocking, clearing exercise, which I was able to find online. This is back in 1998, this is the infancy of the Internet, And I was able to open up my nose. I started switching to nasal breathing. I was feeling very uncomfortable when I first switched to nose breathing because, of course, I developed the habit of breathing too much air, breathing fast and breathing upper chest. And at nighttime, I wore tape across my lips. I wore 3M Macropore tape, but I also wore Brie Wright strips. And on the second day, after taping from the night before, I woke up, and I felt more alert than I had in years. In actual fact, it was just. It was night and day. And also my asthma symptoms were reducing by about 50% in that first week.

Wow.

That was after having asthma since I was about four years of age. So I stayed in the corporate world because that was my training. And then I felt after A couple of years I felt a really need to, you know, get this information out in Ireland. So I contacted the Russian embassy and they were able to get me to contact details of the, the people in Moscow. So I ended up training there and that's it. You know, so my actually fundamental change of my career, going from the corporate world, which was stressful anyway, to teaching breathing, which absolutely I love doing. So that's where I am now at the moment.

That's amazing. I mean, I think we all have our story and oftentimes the reason why we fall into things that we're extremely passionate about is because we've had a personal experience ourselves. So I don't think I knew that about you. And I think that's, that's really, it's amazing and it goes to show why you're so passionate about it.

Yeah. And you know, I think it's really important. I think also a lot of the dentists that I see who were very passionate about airway, they actually came across it because it was when they were working with their own children. And it's sometimes very interesting that we do. It's our own life experiences which direct whichever route that we go.

Yeah. It was my tongue tied journey with my two kids and then myself. And that's what threw me down my rabbit hole of myofunctional therapy and tots and airway and all those fun things. So I completely agree with that. Yeah. So now I know that you do a lot of. Because as you mentioned, one of the biggest things that stood out to me and a lot of what we teach on this podcast, and just what I preach in general is that you can change structures, but if you don't change the underlying habits like the mouth breathing from a habitual standpoint and create those new patterns, we're not going to have success. Right. We're not going to maintain. So if a child goes and gets their adenoids taken out or their tonsils taken out, but they continue to mouth breathe, you know, we're not going to get the same benefits if that we are not training them on how to nasal breathe. So let's. Can we talk about mouth breathing in children and kind of go down that rabbit hole? Because I know that you, you can speak to both it being a habit or, and, or an obstruction.

Yes. Yeah. When kids come into us and mouth breathing is very common in the literature, the results are a little bit mixed. We're seeing figures from 25% of study children to as high as 50% of study children. So children are coming into me. And I usually teach by small groups. So I have about six children come in, and each child is coming in with their parents. So it's like a classroom environment. And I talk about. I have my anatomical model and we talk about breathing through the nose. And it helps you look intelligent not to be having the mouth open with the tongue hanging out. Helpful for sports, for beautiful faces, for sleep. And of course, for parents, the main motivator is often academics. And about 10 minutes into it, then, I introduce taping for the kids. And I tape up all six children. Sometimes as well, I request the parents to tape up as well. So whatever we're doing with the kids, we're also teaching the parents. And the reason that I tape up the kids is because I want to see can they establish nasal breathing for a period of time. I then start off with a very gentle exercise to get them used to holding their nose. So these kids are often three, four years of age, typically four years of age for a boy, maybe three years of age for a girl. And they can be upwards to about, say, 12 or 13 for the kids course. So I start them off, they're taped up, and then I do small breath holds with them. And then I progress down into the longer breath holds to help open up the front of the nose. And I'm doing that because I want to establish where is the obstruction? Why is the child breathing through an open mouth? Is the child breathing through an open mouth because of habit? Well, if it's just because of habit, they can comfortably breathe through their nose when they're taped, even before I do the exercises, if it's obstruction of the nose, that it's the front of the nose, that it's rhinitis, which is affecting about 40% of American children. I do the nose unblocking exercise to decongest the nose. And then I see, can the child breathe comfortably through it? But after doing the nose unblocking exercise, if the child is still feeling very uncomfortable breathing through the nose, I have to suspect the issue then is enlarged adenoids. Now, with that, I typically give the advice to the parents. I think it's very important to realize that enlarged adenoids themselves don't cause mouth breathing unless the airway is compromised. Here is why I say this. There's very little research on it. One paper was published in 2010. It was published in the American Journal of Respiratory and Critical Care Medicine. And the paper starts as, the efficacy of tonsillectomy and adenoidectomy in children is unknown. Now, this is a 2010 paper. And when I came across this, because this journal is published by the American Thoracic Society, was shocked. I was shocked on the basis that children are undergoing disperation for decades, even though the efficacy wasn't known. And when they looked, when the researchers looked at 587 children or 578 children, they found that only 27% of them had their obstructive sleep apnea cured. 27%. 73% of them continued to have residual obstructive sleep apnoea post tonsillectomy and adenoidectomy. Now, granted, they did have a significant reduction in their AHI, but at the same time, 73% of them continued to have residual obstructive sleep apnea. We have to ask the question, what is the real issue here is, is it if a child, like not all children with enlarged adenoids, have sleep problems? It's a combination of a narrowed airway and poor craniofacial development with enlarged adenoids that's causing the problem. But the gold standard of treatment is remove the adenoids and tonsils and do nothing about the airway. And we also know from Dr. Christian Guillemino's work that tonsillectomy and adenoidectomy that there's a 65% worsening during chance of a worsening in the AHI index within three years unless nasal breathing is restored. So my take now is, and I went down with my own child, I went down to tonsillectomy and adenoidectomy route. But if I was to do it again, what way would I embark on it? Number one, I would bring my child from six months, seven months and very young, because we recognize the high upper palate with my own child to an osteopath or to a professional who can gently guide the direction of the growth of the jaws just with simple pressure exerted by their thumbs, then at a young age is to embark on functional orthodontics using maybe an alpha appliance, which she did use when she was 4. And it worked tremendously well by directing the development of the face that the child can then breathe through the nose by harnessing nasal nitric oxide, when the air is warmed and filtered, that the adenoids themselves should shrink. So as opposed to that, the gold standard of treatment is remove the adenoids, remove the tonsils, do nothing about the airway. The child still has a compromised airway. And the other thing is, if you look at the paper, there's a dreadful paper by Dr. Christian Guillemano and the Topic is death and maxillary complex in children. And he looked at seven young infants who died with sudden infant death syndrome. And these infants died abruptly in their sleep. And when researchers looked at their airway, all of them had a high, upper, high, narrow palate. So their airway was compromised. And the only thing that preceded death with these young infants were infected runny nose. Now, it was the runny nose that tipped them over the edge, but it was their airway that was compromised. The risk factors for any parent are. And this is where dentists have a tremendous role to play. I'm currently writing a new book and I'm including all of this information. And the reason being is because the general public, number one, they're not aware of it. And number two, I really feel that the medical system has let down children. They let down me as a child growing up. They let down my daughter. They let down millions of kids. And the dental profession has been very slow as well, because disinformation has been debated since 1909. If you look at the journal Dental Cosmos that was around at the time, 1909, you will see the description of what happens, what happens when children persistently breathe through an open mouth. The child is inattentive in school, their academic ability is reduced, they are sleepy, their face is dull and expressionless, you know, and the future of kids, and we know it as healthcare professionals, but it's just unfortunate that it's pockets. So with children coming back to it. So we have the kids anyway in the class, we have them taped up. And then I have them do the nose and blocking exercises. Then I have them running with their mouth closed. I have them running for a minute, walking for a minute, running for a minute, walking for a minute. And then I have them do breath hold exercises to help restore normal breathing patterns. Because what is causing mouth breathing in the first instance? Well, number one, we generally know that if a child experiences air hunger, or an adult for that matter, but if a child experiences air hunger when they try to breathe through their nose, they're not going to continue nasal breathing. What causes air hunger? Air hunger can be caused by obstruction of the nose, whether it's the back of the nose, which is enlarged adenoid with a compromised airway, or the front of the nose, which is rhinitis. But also what causes air hunger is a small nose. So you can have a child with an anatomically perfectly functioning adequate nose, but the nose is small. And in one paper, 97% of individuals with a small nose were classified as mouth breeders, whereas 12% of individuals with a normal sized nose were classified as mouth breeders. So a small nose is enough to do that. And another aspect that we have to take into consideration is breathing patterns. And from time to time, we do see children, if they are predisposed to asthma especially, or if they are predisposed to anxiety. They are the groups that have most commonly breathing pattern disorders. These kids are breathing fast and they are breathing upper chest. That can also create air hunger. So you can have a child with a perfectly functioning nose, but if they have a breathing pattern disorder, that too will cause air hunger because the child is breathing too hard through their nose. And not just with children, also with adults. There was a paper written by Dr. James Bartley. It was published in 2005, I think in the American Journal of rhinology, but I'm not exactly sure the name of the paper. He investigated 14 patients. They were after having two and a half procedures on average to address nasal obstruction. So they had two and a half procedures, but they were still going back to their ear, nose and throat doctor and they were complaining of nasal obstruction. The doctor was examining their airway. Their airway was adequate. Dr. James Bartley concluded these patients all had chronic hyperventilation syndrome. Their average respiratory rate was more than 18 breaths per minute. They were breathing fast and hard, using their upper chest. So it's not just about the airway. We also have to look at flow, and we have to look at flow in terms of sleep because it's really, really important. The whole emphasis in sleep medicine is generally look at the airway. What's the size of the pipe? But if an engineer was looking at the size of any pipe, no engineer is going to look at the size of a pipe without consideration of flow, because flow and airway diameter go together. And oftentimes with adults, I'll say to the adults, you know, make the sound of a snore. And they do this, okay, well, we tape you up. You're going to mouth your mouth. Snoring will stop, but then nose snoring. So what do you do to make that sound? Well, number one is they speed up this. They speed up their breathing. And number two is they generally will constrict their airway. So now I asked them, then, I want you to breathe through your nose, but I want you to breathe really slowly through your nose. So you're taking a very soft and slow breath in and a relaxed and slow gentle breath out. And now as you breathe slowly, I want you to snore. Can you snore when your breathing is slow, and you will find that it's much more difficult. So again, what has been overlooked in sleep management and in sleep disorder, breathing is the breathing component of it. Now, there's a number of different perspectives, both for children and for adults. We have to look at breathing from three dimensions. The first dimension that we look at is the biochemistry. As a result of breathing, if we are breathing too hard and too fast, it can cause a lowering of carbon dioxide in the blood, and carbon dioxide is the stimulus to breathe. Now, if an individual has an increased sensitivity to this gas, their breathing is generally harder. And this does play a role in obstructive sleep apnea. In the last few years, phenotypes have been introduced. One is anatomical, which is of course peakrit, which is the suction pressure at which the airway collapses. But another one is called loop gain. And loop gain is the stability of breathing during sleep. How do you measure loop gain? You measure it in an adult by measuring their breath whole time. We have been using breath hold time to assess breathing for 20 years. We know that somebody with a breathing pattern disorder or with asthma or different groups of anxiety, but if they have labored breathing, their breath hold time is reduced. So to recognize loop gain, you would. In Meissenau's paper, he investigates loop gain by measuring maximum breath hold time. And he also has the individual stop breathing during wakefulness for 20 seconds. And he monitors how do they breathe when they resume breathing, do they breathe with exaggerated ventilation? So individuals with high loop gain, which is 30% of the obstructive sleep apnea population, they have an exaggerated ventilatory response to carbon dioxide. So how does this manifest in sleep? Well, the individual stops breathing. As they stop breathing, their blood oxygen saturation is dropping, and at the same time, carbon dioxide is increasing in the blood. But if they are overly sensitive to the accumulation of carbon dioxide, when they resume breathing, they resume breathing with exaggerated ventilation. This causes their carbon dioxide levels to go from too high to too low. When carbon dioxide levels drops too much. And this can also happen with mouth breathing. The brain doesn't send a signal to breathe. This can initiate a central apnoea. But also when the respiratory output from the brain is reduced, the messaging from the brain to the upper airway dilator muscles is reduced. And this can manifest as an obstructive event. 30% of people with obstructive sleep apnea adults have high loop gain. But I also believe that this phenotype impacts children, because children too can have labored breathing, especially those kids with a tendency towards asthma and those kids with a tendency towards anxiety. So how do you address loop gain? There's no other way to address it other than change their breathing patterns. You measure it, you assess it by using breath hold time. We use the control pause in buteco, we use the same measurement as the bolt score in the oxygen advantage. So I would say to anybody working with people with sleep, sit your adult patient down, look at their breathing. Are they breathing from a mouth or are they breathing through the nose or both? Are they breathing high using their upper chest, or are they breathing low using the diaphragm, using the lower regions of their lungs, what speed are they breathing at? Are they breathing fast and hard? What is the amplitude of the breath? How regular are they breathing? Do you see regular breathing interspersed with size? And also a very good indicator is after the person breathes out, is there a natural pause before they need to breathe in again? Because people who are breathing harder and faster during rest are also going to breathe harder and faster during sleep. And if we think of the turbulence in the airway, whether it's snoring or hypopnea or upper airway resistance syndrome or an apnea, we have to consider the flow, because the negative pressure created during inspiration is going to contribute to resistance to breathing and also contribute to collapse of the airways. And one old definition of obstructive sleep apnea was when the negative pressure created during inspiration exceeds the dilating force of the upper airway dilator muscles. So, in other words, we need those muscles in the throat to do their job, to maintain an open airway during sleep. But, you know, when we look at, we have to also look at in terms of adults and coming back to high loop gain, what Messineau's paper stated was 30% of the sleep apnea population have high loop gain. It just would, you can assess it very simply using breath hold time, but also monitoring the person's breathing and also to reduce high loop gain, change their breathing patterns. And you can change their breathing patterns by looking at the biochemical aspect of breathing, getting them to really slow down their breath order, to reduce the air intake, to increase carbon dioxide in the blood, to reduce the body's sensitivity to the buildup of carbon dioxide. But another way to reduce high loop gain is cadence breathing to six breaths per minute, and cadence breathing to six breaths per minute or 5.5 breaths per minute is an excellent way to influence the autonomic nervous system. But basically, there's pressure receptors inside our major blood vessels in the aorta and the carotid arteries. And these pressure receptors monitor our blood pressure. But if we change our breathing to 5.5 and six breaths per minute, it modifies the baroreceptors, these pressure receptors, and this in turn modifies the chemo reflex, or the body's chemo sensitivity to carbon dioxide buildup. So that's loop gain. Now, I can do a quick summary on the other two phenotypes, because I think they will apply. And the one that has the greatest risk of mortality is, surprisingly, it's not the individual who stops breathing for a minute and a half and his blood oxygen saturation drops down to 60%. One paper that was published investigating the risk factor in terms of the phenotypes of sleep apnea, it was arousal threshold. And arousal threshold is the propensity to wake from sleep if you have somebody who is a light sleeper. And by the way, 67% of people with obstructive sleep apnea also have insomnia. So that's what research is showing. Now, here's where the difficult thing is. You have a patient coming into you and that patient is complaining of fatigue and irritability and cognitive difficulty. But are they having those symptoms because of obstructive sleep apnea or do they have those symptoms because of insomnia? There's no difference. Those symptoms are the same. The symptoms are the same whether it's insomnia or the symptoms for obstructive sleep apnea. So there is a crossover there. Light sleep is a problem in obstructive sleep apnea, and especially if the individual is a light sleeper, that they can experience sleep fragmentation due to the slightest restriction to their breathing. So arousal threshold is the propensity to wake from sleep. And quite simply, you could say in simple terms as how easy is it for the person to get sleep, to experience sleep fragmentation from the slightest of events? This was the greatest cause of mortality or the greatest, you know, indicator of risk of mortality. So these people generally score pretty low on the ahi. And also they don't desaturate very because they're waking up, they have sleep fragmentation before they experience a significant apnea. But that constant sleep fragmentation is what's really having a dramatic negative effect on their health. Now, doctors normally will treat low, will treat arousal threshold with sedatives, but you can also improve your ability to have a deep sleep by changing your breathing. And nasal breathing is huge in this regard. If you are a mouth breather and you're waking up with a dry mouth, you're more likely to wake up tired and feeling unrefreshed. So for insomnia, we have been working with people with insomnia for many years and we work at it from two perspectives. One, I think it's very important to help them activate their parasympathetic tone, parasympathetic response. If individuals are constantly switched on, that their mind is very agitated, that they are worrying, that they are stressed, that they are overly thinking, it's very difficult to fall asleep when the mind is in such a state of agitation. I think most of us will have a bad day every now and again. You know, that's normal, you go to sleep at that night, you're not going to have a good night's sleep. But for most of us that's a one off occasion. But for some people, that's continuing all the time. So these people then, they're twisting and turning, they're sleeping lightly. And one of the best things that I did when I came across this was taping my mouth 20 years ago and I was waking up feeling refreshed. And when you breathe through your nose during wakefulness, your nose imposes a resistance to your breathing that's two to three times that of the mouth. But during sleep, your mouth imposes a resistance to your breathing that's 2.5 times that of the nose. So the architecture of the airway dramatically reduces when you switch to mouth breathing, possibly because that the jaws are going to fall back in against the throat or the tongue is falling into the airway, the soft palate is falling into the airway, the epiglottis is falling into the airway. But there also seems to be some, in some way that mouth breathing is causing fast breathing, and fast breathing is more likely to wake us from sleep. Now, very little research on this one paper. If you Google slow breathing. Stanford Medical School March 2017 in Stanford Medical School, researchers identified a new structure in the brain in the locus coralis. And they said that this structure is spying on your breathing, that if you breathe fast, you're more likely to be aroused from sleep. So they said that this structure is spying on your breathing, and if you breathe fast, your mind is more agitated, but also if you breathe fast, you're more likely to be aroused from sleep. But mouth breathing causes fast breathing, and mouth breathing also causes upper chest breathing. So we have an individual, they go to sleep and they have a breathing pattern disorder. They're breathing through an open mouth and this causes fast breathing and it also causes upper chest breathing. Now, both fast and upper chest breathing is fight or flight. And fight or flight is going to keep that person in a state of agitation, that they're going to have light sleep and not have a deep sleep. Okay, so I'll continue talking for a little bit more.

I mean, this is great. As you're sitting here talking about this, I'm thinking of all my patients, family members, patients, my children. My daughter isn't an elf, and she's four. And so my goal for her was, let's see if we can avoid taking out those enlarged tonsils or see if we can, you know, shrink those inflamed tissues through other means other than surgery. You know, and so just going back on everything you're sharing, I think that some big takeaways for me are one, this reinforces a lot of what I tell my patients. But, you know, I think that what you're talking about also with, you know, the increased breathing and the chest breathing and the faster pace and how you're in more of an agitated state, and that sends you into fight or flight. And I know I have a lot of patients who have a hard time falling asleep, and then once they're asleep, they have a hard time staying asleep. And these are adults and kids. So I think this speaks to both demographics, which is awesome. And my biggest question is, because I'm not somebody who's done the taping, and I know that some people are fearful of it. So what do you rule out before you recommend taping, especially in a child? Are you making sure that we don't have.

Sure, yeah. Yeah, totally. Yeah. Good question. Yeah. So it's coming back. So when I have the kids, then in the clinic, we have them tape up very early on. And the reason being is because I do want to establish, like, why is the child breathing through the mouth? And can they effectively breathe through the nose? So I have them do all of the exercises, and then I have them run with their mouth closed, I have them walk with their mouth closed, and I have them do the steps. I monitor their steps as a measurement, but also as the main exercise for kids. So with children, we don't use the control pause because it doesn't work. Children generally have a strong ventilatory response to carbon dioxide, meaning that their breath hold time. If they just hold, their nose is generally lower. And this decreases as the child gets older. But we use an exercise called the steps exercise. We want the child to try and achieve about 50 to 60 paces, depending on their age. So when I can get the child up, if, say, the child is able to Run with their mouth closed fairly comfortably. And also, as their steps increase to, say, 30, 40 paces, then I know that the child can adequately breathe through their nose. But we first start off with taping during the day, and I introduced taping during the day about two to three years ago because I used to get frustrated working with kids. I'd spend an hour going through all of the exercises with the child, and the child then walks in a week later, and the mouth is hanging open, and, okay, we'll go through all the exercise and why do you breathe through your nose? And I knew the children were able to breathe through their nose. Many of these kids, so anatomically, they didn't necessarily have much of an issue because they were like, we don't have to have the most perfect nose to breathe through it. I don't. And 60% of the adult population have a deviated septum. But we have a rule of thumb. If you can breathe through your nose for one minute, you can do it for life. Even when the children first switch to nasal breathing, if they're feeling a little bit of air hunger, I'm not worried about that because I can alleviate that with doing the breathing exercises. When they go home, we have the kids, especially when they are distracted, they have to wear tape on their lips because I need to change the habit. So it was coming back to this. It was the biggest game changer that we introduced, because before that, I'd have kids coming in. A week later, the mouth was open, go through everything again. A week later, they come in with the mouth open, go through everything again. A week later, they come in with mouth open, and they can absolutely breathe through their nose. But I hadn't changed to have it. So to change the habit, the child then breathes through the nose, wearing tape for at least a half an hour in the first week every day, when they are distracted, when they are doing homework, when they're playing with toys, if they're on mom or dad's iPhone or whatever they're doing, they wear the tape. Now, at nighttime, we were trying different ways of getting the child's mouth closed. We had tape coming up under the chin. We taped surrounding the lips. And, you know, none of it was really working. The only way that was working was if you completely place the tape across the child's mouths. Now, obviously, that presents a risk, and it's not code of practice for healthcare professionals. And unfortunately, a couple of our instructors did get into trouble because they had recommended taping of the mouth across the lips. And as a result, then the patients reported them to the relevant boards and they had to answer to the boards. So we were saying, well, how can we resolve this? It's vital that we get kids breathing through the nose. If you look at Karen Bonach's study, if you look at the available evidence there that children who are persistently mouth breathing leading to sleep disorder breathing, they have a 40% increased risk of special education needs. So you're trying to weigh it up, nasal breathing versus the risk. So I then come up with this, and I've seen somebody using it as well in terms of using kinesio tape. So in our older videos, we were using kinesio tape, but we were putting it around the lips. And then it's having a tape like this, and it's kinesio tape, it's cotton, and it's hypoallergenic. There's one for adults and one for kids. And you simply stretch it by about 20 to 30%, you place it around the mouth. Okay, There is a tension now that this is bringing my lips together, but I can talk. Now, before we were using during the day for the kids, we were getting them to use three micropore tape, but they'd wear the tape for a half an hour, but they couldn't talk for half an hour, or they'd wear a tape for an hour and they couldn't talk for an hour. Now, the thing about this is that it's if a child is wearing MYO tape, if they forget about breathing through their nose, and if they open their mouth, the tape automatically reminds them to bring the lips together. So we now have them wear it during the day. We also have them wear it during sleep. There's no risk associated with during sleep because the tension is light. But at the same time, once you stretch it, the tension is sufficient to bring the lips together. So I would say that once you can establish that the child can breathe through the nose during wakefulness, I would be very comfortable that the child can breathe through their nose during sleep. But start off having the child, because the one thing about the human nose is the more we use it, the better it works. We see it all the time. You know, my own nose was really chronically congested for many, many years. And once you start using it, the two things that open up the nose are physical exercise, which are mouth closed, and breath holding. Since 1923, it has been recognized that if you stop breathing, if you hold your breath, you can open up your nose. Now, this works for both adults and for kids. So for children, to help Open up the nose. We have them taped up, and then we have them breathe in through the nose, breathe out through the nose, hold the nose and gently nod their head up and down, holding their breath for as long as they can. And they continue to do that until they develop a strong air hunger and then to let go and to breathe in through the nose. Or the kids can take a normal breath in and out through the nose, hold their nose, and they can walk around holding their breath, then let go and breathe in through the nose. How does it work? I'm not sure if anybody knows. The precise mechanism is not known. There are some papers showing that when you hold your breath, you stop breathing. Carbon dioxide is increasing in the blood, and it may be the buildup of CO2 that's helping to decongest the nose. So we have the kids breathe through their nose, decongest their nose first of all, then establish nasal breathing during wakefulness, sleep, and physical exercise. And then as their breathing patterns improve, their nasal congestion decreases. And once with the measurement of the steps, if a child is achieving about 50 steps onwards, they will have a remarkable improvement or reduction to their nasal congestion.

That makes a lot of sense. And I really like the visual that you showed us with the MYO tape, because I feel like, you know, if a child absolutely needed to open their mouth and take a breath of air, it's not restricting that in the same way that taping across the mouth might not.

Yes.

Although I understand also the tape usually would pop off if, you know, the mouth forced it to.

Yeah. Like we were using the tape across the lips at night. But, you know, always at the back of my head, I was, okay, it's not ideal. And you're trying to weigh it up. So that's what we, you know, in terms of addressing that.

Yeah. And I think, you know, obviously this is something that myofunctional therapists are assessing. Feeding therapists. I work with a lot of speech pathologists and occupational therapists who do pediatric feeding. And, you know, we're always looking at the airway. Does the airway compromise? Because we can't have safe feeding without it. So I think this is something that would be universally helpful for those that listen to this podcast. So thank you. I'm trying to think what else. We had a lot of questions that came through, and I'm looking over them here. Do you have any opinions on, like, the long term, I guess, the impacts of long term mouth breathing on dental health, especially as it relates to, you know, infants and toddlers? I know we talked about. You mentioned osteopathic care was highly recommended for these infants so that we can start to shape the palate gently and then going into something like an elf to shave the palate as well, like I've done with my daughter, you know. Do you have any other, any tips or thoughts on that as far as mouth breathing? You know, I get a lot of infants that do mouth breathe and so we're gently guiding those lips closed as long as we feel like baby can maintain that and we don't feel there is a true obstruction. But obviously without an instrumental assessment, we don't always know that. So any thoughts on that? And like the infant or toddler population.

Yeah, we are limited. I'm limited in terms of teaching toddlers. The reason being is because the exercises would require some cognitive ability to be able to understand them, to apply them. You know, we've always kind of spoken about that book that was written back in the 1870s. It's called shut your Mouth and Save youe Life by an American painter called George Caitlin. And the practice of when the Native American Indian mother, when they seen the child with the mouth open, they would gently press the child's lips together. I think there's going to be an observation from the point of view of the parent, but I really feel that a healthcare professional who was able to and even to show the techniques to the parent, you know, that the sutures haven't formed, that the maxilla is still pliable, that, you know, if the fingers are put in into the mouth and just gently using of course, you know, hygienic practices and gloves, that gentle light pressure applied to the jaws for 10 seconds or so and then released, helping to guide the child to breathe through the nose. Chewing could be something that's really important here. And those practices which are helping to develop the muscles of the face necessary for craniofacial development. Breastfeeding, of course, is going to be a big one. Recognizing tongue tie is a huge one. So there's practices outside of my field. Typically when we see kids, we see them at about four years of age. And with young girls, if they're a little bit bright, yeah, we can start working with them from, from a younger age. But I always teach with small groups. I find there's a better compliance and there's also better management in terms of the instructor's time. Children are used to a classroom environment and if you have five or six kids together, you have five or six parents together. Parents are exchanging information, but the children also realize that they are not the only ones that have to do the exercises that there is a group, there is a group support and motivation there, especially when children are coming back the next week, end of next week and the next week. So we typically will, you know, I think I would say to anybody is to typically bring kids in for about four sessions or five sessions for about an hour each, you know, an hour each session. But they're small group workshops now. We put all the videos up online anyway. The videos are free online. So if any of your instructors wanted to see how do we teach the kids? Go to buteykoclinic.com buteykochildren and you will see seven or eight different videos there. It's the entire children's program. So it will give you an insight into what do we do now. We use the Myotape. We use it during their exercise as well because we want a child to breathe through the nose. But I think, as you say, it's tremendous that there are healthcare professionals that are really understanding this. What's the long term outcome if children are allowed to persistently mouth breathe? It's terrible. And it's really these kids forward head posture which will tend to stay for the rest of the child's life. Sleep problems, anxiety, their cognitive ability. Yeah, it's bad enough an adult having their mouth open, having disrupted sleep, they can't concentrate the next day. But the child's brain is developing and if you look, I think one of the statistics put out there was if a child is sleep disorder, breathing by age 8 and untreated, the child has an 80% chance that they will have a permanent 20% reduction in their mental capacity. If you look at the incidence of children in the United States, a figure that was, that I came across was 1 in 10 children are now experiencing ADD, ADHD, special education needs. And they're also on different spectrums. Like 1 in 10 children, when has that ever happened before? What's happening with these, with the new generations? And I think it's a combination of environment and genetics and yeah, yeah, I get it and I get, I understand that, you know, doctors want to find out and to know about science and the whole debate in dentistry to some degree was, well, until we can absolutely define mouth breathing. And also there's a few questions that remain unanswered. And because these questions have not been answered, it seems to have slowed down progress. And these questions, some of them are as follows. At what time or what age does a child have to experience nasal congestion for it to cause an issue in terms of craniofacial development, at what age? We don't know that answer. How long should the child or how long does the child have to present with oral breathing or mouth breathing before it creates a problem? We don't know that answer. What degree of nasal obstruction is necessary in order to cause mouth breathing? Again, we don't know that answer. So there's questions that we don't know. And how do you assess mouth breathing in a child? Well, how do I assess it? Well, children come into me. I look at the child for a few minutes, and does the child sit there with their mouth hanging open as they sit in front of me? And, you know, it's not rocket science, but sometimes in our quest to have everything absolutely perfectly laid out, we have to go and we have to use common sense with this one. And I've seen it in conferences whereby I have seen medical doctors get up and say it literally makes no difference if you breathe through your mouth or if you breathe through your nose. And unfortunately, that belief is often out there. But for somebody to say that, I would say to them, go and look at any medical physiology textbook. Look at the functions of the mouth. Do you see breathing listed as any function of the mouth? Because breathing is not a function of the mouth. The primary and physiological mode of breathing in a human being, regardless of age, is through the nose. Our ancestors did it. Mouth breathing is a relatively recent phenomena. No animal is doing it, with the exception of a dog and sick animals. And maybe we should be looking to nature because they have an intelligence that's often greater than what we are often using.

Yeah. And I think for those who are listening, who are going, well, how do I assess for this? Stop overthinking it. I mean, what I do in my assessments, my myofunctional or anytime I get a child in here for feeding. And quite honestly, if I'm assessing for speech or language, because, like we're talking about, you know, there could be a high correlation between children who are having sleep issues and those who present as having attention issues or anxiety or the adhd. I'm always asking, well, first of all, like you said, I just look when they walk in, from the second they walk in the door, I am looking to see, what is that mouth doing? Is the mouth hinged open? How far open is it? Is it open like 3 millimeters and they're usually closing it, or does it look like it's hanging open like 10 millimeters? And once you see enough kids, you can pretty much gauge that with your own eyes without taking an actual measurement. And I find a lot of my kiddos are in that 8 to 10 millimeter range. When they come into me with a myofunctional disorder. Not all of them, but a pretty high amount of them. And I ask them questions. I'll say, okay, I want you just to take it. Just tell me while you're breathing right now, where do you feel like you're breathing from? Do you feel like it's down deep in your belly? Or do you feel like it's up here in your shoulders or your chest? And half of them say, I don't know. Not. They have no clue. But you'd be surprised because sometimes they do tell you, oh, well, I feel it all up here. And I'm like, okay, well, you know. And so. And then I watch them as they sit there, and I watch to see, you know, from the chest and the belly, what do I see? Is it in line with what they're telling me? So those are some of the markers that I immediately look for in my own assessments. But, you know, oftentimes I'll also have parents say, no, they don't snore. No, they don't. Their mouth doesn't open when they're breathing. And then we go through a whole assessment, and I'm like, I need you to check over the next three nights and report back to me. Because I'm not convinced that they're not mouth breathing or, you know, even if you're not hearing them, it's not audible. I'm still not convinced that they're not breathing through their mouth when they're sleeping. The way they present in my office is very different than what you're telling me you're seeing at home. So I think that we also have a job as practitioners to read between the lines, not take everything at face value, and really trust our judgment. Because sometimes we may pick up on these things when, you know, a parent is not trained to do that or they're not even aware prior to coming in. And half my parents will say, I have no clue. I don't know if they have an open mouth when they're watching TV or doing their homework or whatever. So I think that's a really great point. There isn't really a scale. I mean, yes, we can use sleep scales and different, like the Bears for kids, and there's different versions of sleep scales to help get at some of this information, but it's not so cut and dry.

It's more about, like, even to sleep, you know, Any of the questionnaires. It's. You're really getting it from a subjective point of view. And I've seen people even. Do the adults complete the upward sleep scale? You know, do you fall asleep while watching tv? No. And I know well that the individual is. Because I've seen family members, they've filled out the sleep scale. No, no, no, no. Everything is. No. And I've seen the guy falling asleep in front of me and he's having apnea sitting in front of me, you know, so, yeah, I think different. There's always a difficulty filling out forms. Yeah.

And we had a question from one of our listeners who was asking, you know, how do you discuss this with parents? How do you get them on board in terms of, you know, sharing the importance of airway? Because if this is brand new to a parent, we're throwing all this information at them. You know, how do we get them to seek additional help or even just get on board with what we're recommending, you know, I guess to address things like ADHD and poor sleep habits and, you know, what are your thoughts on that?

I think it's really important that we have to realize that sometimes the information we're saying to parents, it's the first time that they've heard it. And sometimes they're thinking, well, if this information is so vital and so important, why haven't I heard this before? So I laughed. And the other thing that I have to take into consideration is that as parents, we can be very defensive about if anybody is saying that our kid isn't developing the way the child should be developing. So I often give my own example and say, when I was in school, and this is where a group workshop works better. Because if I'm working with, say, five or six kids or seven kids, I can talk about this on a whiteboard and I can talk about the possible connections between mouth breathing and how it impacts sleep, how it impacts academics, how it can contribute to bad breath, how it can dry out and cause trauma to the upper airways, which in turn is going to cause inflammation. I get the parents to look down at their chest and I say, okay, take a breath in through your mouth and tell me what part of the body moves. They say, okay, well, mouth breathing is causing my chest to move more than the lower regions. I get the parents to slow down their breathing so that they can feel an improvement to their blood circulation. Because oftentimes breathing pattern disorders in adults culminate in cold hands. So the parent knows that they have a cold hands. They have cold hands. And I want to show them the physiological connection between it. But in a group setting, you're not targeting one individual. You're putting the information out there in a general way. So people are hearing the information. They're not going to get as defensive. Now. They may not believe me. I'm one person. So what we did was I put an article up on buteykoclinic.com and the article is buteycoclinic.com crookedteeth and with that, I included maybe 25 or 30 references. And I looked at the connection between mouth breathing and academic achievement, sleep, speech, sports, craniofacial development. I think there's asthma brought in. So what I tried to do is I tried to write an article, to put out an article there, allow parents to do their own research. And on the right hand side of that paper, that crooked teeth page, I have videos. Dr. Bill Hang is there. WriteToGrow.org is a great video that's out there. Dr. John Mewes Channel 4 documentary is there. And there's other videos on YouTube that I put connections there to. And I think it's really important that parents are educated and that parents, if they feel there's a connection, but I'll hand them the information and I'll say, go read this. This is really worth it. And there's some tremendous papers now coming out. I send you one and one after this. And it's pointing to the effect and it's literally pinpointing exactly what we are saying. But we too need to realize that parents don't have the time. Parents aren't often aware of these issues. And parents aren't aware of the connection between mouth breathing and how it can impact their child's development. And I would say in the group, I say, no child who is persistently breathing through an open mouth is going to reach their full potential. And I can use my own experience to draw on that. And I will give the example that for me to study 10 hours studying to try and take in information, and you literally spend your entire teenage years trying to stay ahead or to keep pace. And the reason being is because a child who's tired cannot focus, don't have the concentration, and of course they are going to get frustrated in school. You know, like we are asking children, well, first of all, we are measuring their academic, their academic ability. We are telling these kids in the school system, are those children intelligent based on what they score on exams? But yet we are not asking, are these children mouth breathing or nose breathing? And Mouth breathing is definitely like. I see in one paper that if you are mouth breathing causing sleep disorder breathing, you have 10 times the risk of learning difficulties. This is not just once or twice. So when I'm talking with the parents, I think this is where the podcasts come in and this is where the books come in. And, you know, part of my reason, putting the chapter on craniofacial development into the oxygen advantage. And by the way, there was resistance. I don't know was it the American version of the book or the English version, but the publishers contacted me and says, we can't include this chapter in the book. It was on craniofacial development. And I said, why can't you include it? And he said, because the reader will get upset. But I said, this is not for the reader. I said, this is for the reader's children. And in Japan it was the same. The Japanese version 2 got an email saying, this doesn't apply to Japanese children. But I was able then to send them on some papers that, yes, it does apply to Japanese kids and we got it published. But I think in the English version of the book, the publisher put the chapter on craniofacial development into the appendix. So it's delicate enough information. And of course, when we're working with teenagers, I have to be very careful that if a young girl or boy is coming in, I'm talking about looking intelligence, but I'm also talking about improved sports performance. Especially if I see them, if they're wearing trainers, if they have a tracksuit on, I say, listen, if you're going around with your mouth open during the day, you're going to gas out too soon, you're going to be running out of air on a football field or whatever sports you do. Because if your breathing is not. If it's not optimal during rest, it's certainly not going to be optimal during physical exercise. And that will manifest as disproportionate breathlessness during physical exercise. I say, you want to be fast, you want to run, you want to do all of these sports. Well, we have to fix your breathing. And I'd say this is part of your physical training. Your coach trains you to make you to be able to run better. And we're now going to bring in breathing and we take in the oxygen advantage because the oxygen advantage is very much. It's elite sports people in the main who are doing it. You know, we have like, for example, here's our manual for the instructor training. So an MMA Bellator fighters is the COVID photo, one of our instructors. And we've also people like special weapons and tactics, some of their members putting it into practice, military putting it into practice, firefighters putting it into practice. Why would they do it? Well, sleep, focus, concentration and physical performance is key components of what they need. And I use this to motivate the kids. We have Olympic athletes putting it into practice. And, you know, it's kind of like I want to bring it to a level that the children are going to embrace it themselves. And again, with the like, I can talk about bad breadth when you have a group of kids, because the kids aren't going to think that you are pinpointing any one child directly, that you're putting the information out there, but at the same time, they're listening.

Yeah, now that's great. And as you're saying this, I'm thinking of all myself because I was diagnosed with ADHD in college. So that was, you know, a whole work up to that point. But I've had teens. I had one who was a swimmer who ended up having to quit swimming because they learned that she had obstructive sleep apnea. And, you know, it just. We go through all these different. So many specialists the child had been to, and nobody had ever looked at sleep until they sat in front of me and we talked about everything that I saw going on. And that was basically the answer. We need to work on airway, we need to work on sleep, and we need, you know, and so. But I get a lot of teens like this where I think that's a great point for these kids, especially who are involved in sports. And, you know, if you can talk about their passion and how it's impacting them. I've had gymnasts where we've talked about, well, you have tethered oral tissues and a restricted airway. And with both of these restricting your function, you're not going to be the best gymnast you can be. It's just not possible until we address these underlying issues. So I think that's a really, really great, great point. And do you. I love that you have that. The crooked teeth reference that you had mentioned, we'll definitely link to that in the show notes. Do you also use that for ents or other professionals, or do you have other resources that you share with other professionals?

It's funny, like, I gave a talk to ear, nose and throat doctors in Madrid last year, and there were 150 ear, nose and throat doctors. They had to divide them into two groups. So 75 came to me on the first day and 75 came to me on the second day. On the first day with ear, nose and throat doctors, I tied in breathing re education for post surgery and I was talking about the follow up there. But also I brought in the phenotypes of sleep apnea. And on the second day I didn't really give them so much science, but I gave them the practical exercise. Opening up the nose, slowing down their breathing to feel warmer. But the feedback come back, the ents from the second day who had experienced the practical exercises, that the feedback was more positive than the science alone. So sometimes it's a case of putting the exercise out there and I still do the same. If I'm teaching with healthcare professionals, if I'm giving say a talk at some conference, I'll actually get people to experience it because I can talk about it. But people often experience they think breathing is breathing and breathing is absolutely not breathing. There's a lot of misinformation out there about breathing. There's a lot of people that are honing in on one perspective of breathing. Like they're teaching diaphragmatic breathing, for example, which is fine. However, you're not going to restore diaphragmatic breathing unless you restore nasal breathing. And all too often some modalities. Restoring diaphragmatic breathing is what the aim of the therapist is. But the therapist is saying nothing about nasal breathing. The therapist is saying nothing about nasal breathing during sleep. You know, as individuals we know that if you're over 40 years of age, you're six times more likely to spend at least 50% of your sleep time breathing through an open mouth. And that's one aspect of it. And the other aspect is that we can't just emphasize and diaphragmatic breathing without considering the biochemistry of the breath. So oftentimes in yoga, I asked the person coming in to me and I say, well, do you hear the breathing of the individual inside the yoga studio? Yeah, everybody, because they're taking these full, big breaths. More air the better. You know, this kind of thing. I say, you shouldn't hear anybody breathe inside a yoga studio. Because the emphasis is that with breathing we've always been kind of stuck in our own little silos. With Buteyko, it was all about biochemistry and not enough, hello, not enough about the biomechanics. With yoga, maybe Pilates, it's looking at the biomechanics, but not necessarily taking into consideration the biochemistry. With heart rate variability practitioners, they're looking at cadence, but they're not looking at the biomechanics and not looking at the biochemistry. And what I want to do is to tie all three together that we can't just look at one in isolation. So in terms of the phenotypes, I put presentations together and I put them up on YouTube, so their video is half an hour long. And I put in the connection between breathing, re education and peacrit. And here's to give you an example. We know as we get older and we put a little bit more weight on, especially with males, you know, we're putting a bit of weight on our belly. We hit 40 and we started to put weight on the torso. We know there's an association between obesity and a worsening of the AHI index. And by the way, I'd like to talk about the AHI index as well. But we have to consider we put on weight. Yes, we have fat deposits on the tongue that encroaches the airway. We also have fat pads on the throat and that is making the airway more narrower. But we don't consider that we're also putting fat on our belly. When we put fat on the belly, it impinges diaphragmatic movement. If we are breathing using the upper chest, there's a reduction to lung volume and the throat is more liable to collapse. So when we are teaching breathing, we have to consider that the entire airway is one airway. The nose, the throat, the trachea, the bronchi, the bronchioles, the diaphragm, it's all one airway. And if there is a problem in one part of the airway, there's also a problem in the other. If we are not using our diaphragm by breathing low, down into the lower regions of the lungs, if you breathe low, it increases lung volume, and when you increase lung volume, there's a stiffening of the throat. Now, bear this in mind. How many people fall asleep mouth breathing, fast breathing, shallow breathing, there's a reduction to lung volume. The throat is more likely to collapse. Mouth breathing is drying out the upper airway. This is causing inflammation, which is reducing airway size. The tongue is not able to remain up in the palate when the mouth is open because, of course, the tongue has to drop to allow air to flow into the lungs. Mouth breathing is fast breathing. This is increasing the negative pressure created during breathing. This in turn is causing increased turbulence. The lower jaw is falling back into the airway. So why is it not that everybody, who is at risk of obstructive sleep apnea, the first thing is teach them nose breathing. Tongue in the correct resting posture, myofunctional therapy. But also change your breathing patterns from a biochemical point of view, a biomechanical point of view. I think it's really, really important. Now I'm going to briefly touch on the AHI index for your adult population. The AHI index is falling short in a number of key areas. Number one, you're bundling apneas and the hypopneas together as a measurement. But an apnea and hypopneas, they're different in their biological effects. An apnea is where there's a total cessation to breathing, and a hypopnea, when there's a reduction to the flow of breathing enough to cause a drop to your blood oxygen saturation by 3 to 4%. An apnea and a hypopnea are different, but yet they are bundled together. That's the first point. The second point is an apnea is when there's, for an adult, a cessation in breathing for at least 10 seconds or more. So you could have one individual who stops breathing for 10 seconds, that's an apnea. But you could have another individual who stops breathing for 90 seconds. It's still an apnea, still one apnea. So the apnea, when you consider the AHI index, we have to be considering for how long is this individual stopping breathing for hypopnea, you could have one individual, their blood oxygen saturation is dropping by 3, 4%. Or you could have another individual, their blood oxygen saturation is dropping by 6, 7, 8, 9, 10%. Another factor is the clustering of events. You could have one individual, they have a lot of their events in a certain time frame during their sleep, but they're getting a few hours of decent sleep. Or you have another individual, their events are distributed throughout the night, and they're getting no quality sleep for a prolonged period of time. And another aspect, we can't either rely on the blood oxygen saturation in the AHI index, because if you look at the oxyhemoglobin dissociation curve when you stop breathing, yes, it is true that your blood oxygen saturation is dropping, but at the same time, carbon dioxide increases. Now, as carbon dioxide increases, it causes a right shift of the oxyhemoglobin dissociation curve. And this in turn is going to cause a drop in the SpO2. So when we see the SpO2 decrease or the SAO2 decrease, we have to consider what effect has the hypercapnic response had here. Because when carbon dioxide increases, it's Allowing increased blood flow to the brain when you stop breathing, it doesn't mean that your brain is necessarily getting reduced blood flow. If I held my breath for a long period of time, yes, I can lower my blood oxygen saturation because we do it with athletes, you know, we purposely drop it. But as your blood oxygen saturation is dropping, carbon dioxide is increasing, and carbon dioxide is causing hemoglobin to release more oxygen to the tissues. But also as your carbon dioxide is increasing, the blood flow to the brain is dilating. So the brain is still. So it's almost that carbon dioxide is in some way compensating for the hypoxic effect happening during obstructive sleep apnea. So I think I would love to see breathing getting some research in osa. It has not happened. Loop gain is one paper, but it's not just about looking at loop gain. Like think of nitric oxide, first identified in the human nasal Airway in 1991. And that's a signaling molecule to the upper airway dilator muscles. And only by breathing through your nose are you going to harness nasal nitric oxide. So if we're talking about the recruitment of the upper airway dilator muscles, which of course myofunctional therapy is doing, well, that's going to go hand in hand with nasal breathing, because nasal breathing and regular breathing patterns, you know, the brain is sending messages to the upper airway dilator muscles, and those messages are influenced by nitric oxide and by carbon dioxide.

Yeah, this is, this is all very fascinating. So, you know, I think a lot of us myofunctional therapists have been trained well, refer your patients for sleep studies. And one thing that I know from speaking with another colleague on the podcast was oftentimes, at least the way that it's done here in the US one night sleep study is also not going to give us a true picture as to what might be going on based on what happened that day. Did they have a glass of wine? Did they go to the gym? Did they. You know, there's so many factors that play into the results of a one night sleep study. So that actually has made me pull back a little bit from referring, unless I feel there's absolutely obstructive sleep apnea in place. And we need to shake things up a bit faster for a patient because from my understanding, like a three night sleep study would be a much better indicator of what's actually going on. So we could advertise together. So do you recommend that people go for sleep studies or do you just kind of jump right on in and start working on the breathing. If you don't feel like there's anything anatomical obstructing the airway.

Yeah, like when I'm working with a client comes in and they have obstructive sleep apnea. If they're on a CPAP machine, I can't of course, tell them to stop it. Now. Sometimes clients will stop using it. They stop it off their own bat. But what I say to them is, I want to get your control pause measurement up to 25 seconds and I want to establish good functional breathing patterns. And then I would like you to go back and do a sleep study to see what change is happening in the AHI index. But when you do the sleep study, I would like you to slow down your breathing for about 15 minutes before the sleep, before sleep. And I also need you to tape your mouth during the sleep study. So I will only tell because I have the person when they're at home. I want them putting this into practice. I want them then to continue with those recommendations into the sleep study because I want to see what impact are we having on the AHI index as a result of putting in breathing intervention. And that's why, like, it doesn't make sense for me. You could have an individual go do a sleep study on a Monday and they could sleep on their back with their mouth wide open and their tongue is falling into the throat and they're nervous about the sleep study. And this is contributing to insomnia. They have arousal threshold. And you know, you could have that same individual go in on the Tuesday with slow breathing, nose breathing, with their mouth closed breathing using their diaphragm and back. I know sometimes with myofunctional therapy it's more so. And I understand don't sleep on your side because it can cause pressures to the face. But we have to bear in mind 50% of people with obstructive sleep apnea, their apneas can double when they lie on their back. Now I know elevating the bed can help to reduce the likelihood of gravity causing the airways to collapse. But I fly a lot and flying is a great way to see when people have breathing, especially on long haul flights. Now you've got guys that are sitting relatively upright and you'll hear them snoring, but you'll also hear them stopping breathing and they are there as upright. I don't fly first class, so I'm not lying back. These are fairly upright. And I'm hearing people that they are stopping breathing. So I'm always curious about, you know, if we were to switch a lot of these people over from their back onto their sides. And yes, some people have to sleep on their back. I get that. I understand it. So, yeah, so when people go and do the sleep study, they wear the tape and I know, but the technicians, by the way, are fine about it. The patient explains that I have to wear the tape. This is what I normally do during my own sleep. And I want them to follow the same procedures. But we have seen AHI indexes really drop dramatically. I've seen in one case an ahi dropping from 50 events per hour down to, I think it was eight or nine. But it was coming from really severe obstructive sleep apnea down to mild obstructive sleep apnea and a phenomenal difference. We had one man, wrote a book in it. It's called Breathless Sleep no More. He's an Australian lawyer and you can imagine a lawyer. They really need to have their mental faculties about them because there's concentration involved. So sleep apnea is going to be a problem. But he got his AHI index. He did Buteyko, then he did a post follow up and he ended up writing a book about it. But he published his sleep studies inside in the book and, you know, you can see it. But yeah, we do need more research. We're definitely falling short, but I would love to see more research because I think there's a very valid treatment here. And also dentists are in such a wonderful position to be talking about sleep because they are looking into the mouths. They're seeing if there's a scalloped tongue. They know, they have a great experience of, you know, monitoring that, the mouth, the space as well and airway size.

Yeah, And I'm very fortunate because I work with a very airway centric dentist, as I call it. It's amazing because we get to share a lot of cases together and I. That's where I always joke on the podcast that dentists are our future pediatricians. They are going to be the front line. I could give us 10 years. And they're going to be the primary practitioner is. And if they're not, they should be because, you know, a lot all illness starts in the mouth. So it all, it all starts right here.

I totally agree.

Yeah. So we had one last question from a listener who had wanted to know your opinion on using Buteyko with patients with epilepsy and do you continue with your protocol for high risk patients, which is what she's been doing. And is there anything important to consider for that patient population?

Yeah, epilepsy. It's funny, my new book, I'm putting a chapter in on epilepsy and I'm also putting a chapter in on type 1 diabetes. We've seen results with both groups. I can't say that chronic hyperventilation and breathing pattern disorders is going to help everybody with epilepsy. There may be some subsets. I think there are some subsets in epilepsy that they are very much affected by chronic hyperventilation. We do have to get them out closed. Now, I don't do the strong breath holds with people with epilepsy, but I do gentle, slow breathing from a biochemistry biomechanical and a cadence point of view. I also get them to wear the tape, but where I was very cautious about wearing the tape across the lips. We get them to use MYO tape because again, the mouth isn't covered. So what I would say is anybody with epilepsy, but I can't. If somebody comes into me with epilepsy, I cannot guarantee that I will help to reduce their seizures. But at the same time, I feel it's really important to get them breathing through the nose to slow down their breathing because it will help them anyway with anxiety. And anxiety can be a precursor. You know, anxiety and stress can aggravate conditions. And also for sleep. And, you know, we have one woman, her name is Jenny Snook, and she read my book, I don't know, a few years ago, I have a book called Anxiety Free. And she read this and she started getting her mouth closed. And her epilepsy, it was the best that she had had in her life. She was getting a seizure before that. One a month. One per month, a seizure. But it was happening during her sleep. And by breathing through the nose, it made a significant impact. So I think there's more to this. And yeah, there's some people have written about the connection between breathing and epilepsy. Robert Fried was one, and there are some papers there again, falling short nasal breathing. Doesn't get all that much research, but I would say absolutely, try it for epilepsy.

Yeah, I can think of a patient that I worked with very closely actually, who every time she would wake up in the middle of the night or she would fall asleep on the school bus coming home, she would go into. She would have a seizure. And, you know, and it was. I have to think back now because this was pre myo days for me when I was working with this patient. But so I was not really looking at her sleep or her airway or telling mom to do that. And on top of that, they're military, which always complicates things too, in getting proper care. But, yeah, I mean, just thinking about this child now with what you were sharing, mom did everything in her power to make sure this child would not fall asleep without actually needing to be asleep, unless it was nighttime and she was supposed to be sleeping because they always had to have the rescue medications right there next to her because it's how severe this child was. And so a school bus ride that was more than 15 minutes was not appropriate because she'd fall asleep and have a seizure. And so it's so interesting. Just the brain connection to, you know, it's just, it's all very fascinating. So thank you for that. That's very helpful. And you've answered a lot of questions that a lot of our listeners had, so I appreciate that too. Is there anything else that we didn't cover that you want to share? I mean, I know I have one last question, which is kind of like the big elephant in the room based on what's going on out in the universe right now, Coronavirus. Is there anything that you would want to share related to coronavirus? Obviously, nasal breathing is the topic of this podcast and I've seen a ton of social media posts and just articles and things on how we need to be nasal breathing, especially right now, given what's going on and how easy it is to contract this virus. Are there any tips or thoughts on that topic?

Yep. I put a video together on COVID 19. I put a video about four days ago and I just checked it on Oxygen Advantage YouTube channel. It had 22,000 views in four days. But I mentioned a number of points on it. Number one is breathlessness is a symptom of COVID 19. And you can assess your breathlessness by measuring your breath hold time. So keep an eye on your breath hold time. Measure your control pause. You'll find how to do the measurement on YouTube free if you just put in bolt score Patrick McKeown or control pause. Another thing, you can change your alveolar ventilation. In other words, the amount of oxygen that gets into the alveoli by simply breathing down to six breaths per minute. So what I would say to people if they feel that they are breathing fast and shallow, it's very inefficient in terms of oxygen uptake or oxygen transfer. Put your hands on your lower two ribs. Just gently breathe in for a count of four seconds. Very, very Slow, don't hear it, and breathe out gently for a count of six. And that's the most efficient way in terms of increasing alveolar uptake. And I've used it with people with chronic heart failure, and I've seen their SpO2 come up from 91 to 96% just by changing their breathing pattern, slowing it down. Nitric oxide. If you Google Clinical Trials USA Nitric Oxide, COVID 19, you will see that there are clinical trials underway. Inhaled nitric oxide is a treatment for COVID 19. Nitric oxide is an antiviral. It's also in a study in 2005 looking at coronavirus SARS, that it inhibits the replication cycle. Because the problem is that when the virus gets into a host, it replicates. And nitric oxide was shown in a laboratory to be able to inhibit the replication of sars. Now, can I say that this is going to apply with COVID 19? Of course I can't. I cannot say that. But I don't know and nobody knows. But I'm really surprised that healthcare authorities are not talking about nose breathing, not just from the point of view like, I was traveling up until very recently. I only got back from Los Angeles on the 17th of March. I was in airplanes, I was in crowded tube stations, I was in groups of people. I was doing everything wrong, but yet I didn't get to condition. And I remember I was in a tube. I was in a train in London and it was packed, it was during rush hour. And this is only about, I don't know, two, three weeks, three weeks ago. And I was in that train for about a half an hour. And I did two things throughout that train journey. Breathed through my nose, but I breathed it so slowly. And I breathed as little air as possible. I did that because I didn't want to take any or I didn't want to be taking much airborne particles into my, into my body. So I reduced what I was inhaling and I felt air hunger throughout. So I felt that I was not getting enough air, which, by the way, is fine because, you know, carbon dioxide is increasing and your blood vessels are opening up, etc. But also if you breathe really slowly, you're harnessing a greater concentration of nitric oxide and the antiviral effects. Now humming. If you hum, so you hum on the exhalation, a prolonged exhalation, humming, nitric oxide is dumped from the paranasal sinuses into the nasal cavity. So you increase the nitric oxide in the nasal cavity from between seven to 20 fold by humming but make sure at the end of the hum that you breathe in through your nose so you're carrying that nitric oxide into your lungs. So I think also people who were infected should be nose breathing. Because if I breathe out through the mouth, I'm breathing out a lot of water vapor there. There's a lot of water particles being emitted on my exhale breath from the mouth. There's 42% greater water loss breathing out through the mouth. And if you think of how this is transmitted airborne, it's not just about sneezing and coughing that's transmitting water particles, but breathing is doing it as well. And mouth breathing is going to transmit more. So if a family member is infected, just make sure that the family member is breathing through the nose, because your nose is going to trap that moisture on the exhale breath. The other thing is, if I go into supermarkets and there's some guy now, we're in lockdown, by the way. We can't move for two weeks. So I'm literally in the middle of nowhere here on the west coast of Ireland. So to give you an example, this is where I'm lucking out on to. I don't know if you can see that. So you see that I'm in total isolation everywhere.

You guys can't even go to the grocery store. Are you allowed to go get food?

We are, yeah, we're allowed to go to the grocery store. But the police as well are having checkpoints too.

So we're on lockdown too. We have a stay in place order in Maryland.

It's amazing. It's so strange times. But, you know, when I go to the grocery store, there's going to be somebody in the aisle. Well, what I'm going to do is I breathe in, breathe out and I hold my breath and I walk past holding my breath so I. I'm really conscious. I think it's so important. Yes, washing our hands is great. Social distancing is great. But how about taking less air into the body? How about harnessing our own antiviral mechanism? And that's going to be based on nasal nitric oxide.

And are you wearing a mask when you go to the grocery store or you're just.

No, no, I don't wear a mask, to be honest with you. No, I haven't gone that far. My wife is going down wearing a mask and she wears the gloves. But no, I would put in my own breathing techniques into practice there.

That's great. Well, we will make sure we share this with everybody and we'll Share the video that you also mentioned that you posted on your website. Because I think that people are working from a place of fear right now, which obviously doesn't help our breathing either. So if we can get a little bit more educated on nasal breathing and what we can do to help, maybe that'll also keep. Keep anxiety down.

Yes. Yeah, yeah. I'll send you on a relaxation as well that people. We give it out to people with insomnia and, you know, the feedback has been good in it, so your listeners might like to play it as well.

Yeah, that'd be awesome. Well, thank you, Patrick. Is there anything else we haven't covered today that you want to share?

No, I think we've covered quite a lot in terms of the connection, you know, and it's always a great opportunity to talk about the potential of restoring nasal breathing both in adults and in children, and that we have to give the nose credence that it performs really important functions in the human body. And do you know, it's happening, Hallie. It's really, really happening. I think there's an awareness of breathing that's after changing in the last four years. And I'm delighted to see it and I'm delighted, I think that eventually it is going to. It will be part. And making a big impact on people.

I agree. I always tell my patients, you know, if they're not paying attention, this goes back to the earlier question of, you know, how do you really drive this home to parents? I tell them, look, we have two big functions in life. We need to breathe and we need to be able to eat. And I said, look, you don't have to eat by mouth. We can eat other ways. But you can also be on a ventilator. However, if you can't breathe and you're not getting ventilated, you're not a ventilator. You're dead. Right? You can't breathe. You're dead. So our first and foremost function in life is breathing. And I think sometimes just that, you know, really that's how I drive it home to some of my parents and they kind of go, oh, yeah, that makes a lot of sense. And so, you know, just getting very, very simple in my explanation sometimes, but very. A little bit morbid too, in a sense, really drives that point home. So this has been great though, because there's a lot of. You shared a lot of really great information. A lot of resources were mentioned. We'll do our best to collect them all, put them all in the show notes. We'll definitely link to your website and myotape and all the videos and everything that you said you have on your website that you shared here. So thank you so much for all those amazing resources. I really appreciate your time.

You're very welcome. Thanks very much. Holly.

Thanks for listening to this podcast. If you want to hear more of these Myo Tots, Airway and Feeding related episodes, be sure to leave a review on Apple Podcasts or pledge a small amount on patreon.com the untetheredpodcast if you found value, others you know in this space will too. So be sure to share this episode on your social media platforms and join us over on Facebook on my Facebook page @halliebulcanbiz, on Instagram Alibulcin, and you can head over to theuntetheredpodcast.com to grab a copy of the Show Notes, where you can also subscribe to be kept up to date on the latest podcast episodes.