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Rediscovering the importance of nasal breathing in sleep or, shut your mouth and save your sleep
Abstract
Recent research, stimulated by the growing awareness of the sleep apnea syndrome, has shown that nasal breathing plays a major role in the regulation of respiration in sleep. These observations are not new; they confirm century-old clinical findings on the importance of nasal breathing in sleep. The earliest account of the deleterious effects of mouth breathing in sleep was made by Lemnious Levinus towards the end of the sixteenth century. Two hundred years later, Catlin dedicated an entire book to the superiority of nasal breathing over mouth breathing in sleep; and in the late 1800's, Cline, Wells, Griffin and others showed that obstructed nasal breathing causes sleep disorders.
... However, the thermistor/thermocouple typically measures the combined oronasal breathing and cannot quantify airflow in a reliable manner, e.g., under-detecting hypopneas (Farre et al., 1998). It is therefore also not suitable for analyzing mouth breathing alone (Lavie, 1987;Koutsourelakis et al., 2006). The pressure transducer typically only measures the nasal breathing, so mouth breathing is not detected per se. ...
... Moreover, our paper utilized the pressure transducer of the A1 device to measure oral flow instead of the flawed oronasal thermistor (Lavie, 1987;Koutsourelakis et al., 2006). For diagnostic purposes, this method was found to be a functional way of measuring mouth breathing. ...
Introduction
Sleep-disordered breathing (SDB) can range from habitual snoring to severe obstructive sleep apnea (OSA). A common characteristic of SDB in children is mouth breathing, yet it is commonly overlooked and inconsistently diagnosed. The primary aim of this study is to construct a deep learning algorithm in order to automatically detect mouth breathing events in children from polysomnography (PSG) recordings.
Methods
The PSG of 20 subjects aged 10–13 years were used, 15 of which had reported snoring or presented high snoring and/or high OSA values by scoring conducted by a sleep technologist, including mouth breathing events. The separately measured mouth and nasal pressure signals from the PSG were fed through convolutional neural networks to identify mouth breathing events.
Results
The finalized model presented 93.5% accuracy, 97.8% precision, 89% true positive rate, and 2% false positive rate when applied to the validation data that was set aside from the training data. The model's performance decreased when applied to a second validation data set, indicating a need for a larger training set.
Conclusion
The results show the potential of deep neural networks in the analysis and classification of biological signals, and illustrates the usefulness of machine learning in sleep analysis.
... Nasal breathing is important for sleep quality, and nasal obstruction contributes to the pathogenesis of OSA. 55,56 Septal deviation, inferior turbinate hypertrophy and internal nasal valve dysfunction can result in increased nasal resistance and mouth breathing. Increased nasal resistance leads to downstream inspiratory collapse of the oropharynx or hypopharynx in susceptible patients. ...
... There are multiple publications on the subject of immediate dental rehabilitation during fibula microvascular reconstruction, and the reader is encouraged to look at the work of Hirsch, Qaisi, Patel, Cheng, Buchbinder and others for a more thorough and expert discussion. [50][51][52][53][54][55] Advancements in microvascular reconstruction have also included anastomotic devices such as venous coupler devices ( figure 11) and arterial vessel everters that have been used for both venous and arterial anastomosis. [56][57][58][59] Additional advancements in microvascular reconstruction have been in the areas of intraoperative and postoperative monitoring using indocyanine green fluorescence, implantable dopplers, flowmeter, laser doppler, spectrophotometry and other emerging technologies [60][61][62][63] (figures 12 and 13). ...
Dental Implants: An Update on Guided Surgery for Full-Mouth Reconstruction
... Intranasal surgery: septoplasty, turbinoplasty, nasal valve surgery Nasal breathing is an important factor for sleep quality, and nasal obstruction does contribute to the pathogenesis of OSA [46,47]. Septal deviation, turbinate hypertrophy, and valve dysfunction can result in increased nasal resistance and subsequent mouth breathing. ...
Sleep surgery is part of a continuum of care for OSA that involves medical, pharmacologic, and behavioral therapy. Upper airway surgery for OSA can significantly improve stability by way of modulating the critical negative closing pressure. This is the same mechanism of action as PAP or oral appliance therapy (OAT). The updated surgical algorithm in this review adds precision in 3 areas: 1) patient selection, 2) identification of previously unaddressed anatomic phenotypes with associated treatment modality, and 3) improved techniques of previously established procedures. While the original Riley and Powell Phase 1 and 2 approach to sleep surgery has focused on individual surgical success rate, this algorithm strives for an overall treatment success with multi-modal and patient-centric treatments.
... Measurements indicate that mouth breathers have lower levels of NO within the respiratory tract compared to nasal breathers [40]. Mouth breathing has been associated with many health issues, including abnormal facial and dental development, cardiovascular disease, fatigue, halitosis, headaches, hypertension, inflammation, sleep apnea, snoring, stress, and tooth decay, to name a few [41][42][43][44]. While most people spontaneously report breathing through the nose, mouth breathing may occur during talking, exercise and sleep or in people with allergies, congestion or nasal obstruction, suggesting that it may be more prevalent than usually appreciated. ...
The nasal cavity and turbinates play important physiological functions by filtering, warming and humidifying inhaled air. Paranasal sinuses continually produce nitric oxide (NO), a reactive oxygen species that diffuses to the bronchi and lungs to produce bronchodilatory and vasodilatory effects. Studies indicate that NO may also help to reduce respiratory tract infection by inactivating viruses and inhibiting their replication in epithelial cells. In view of the pandemic caused by the novel coronavirus (SARS-CoV-2), clinical trials have been designed to examine the effects of inhaled nitric oxide in COVID-19 subjects.We discuss here additional lifestyle factors such as mouth breathing which may affect the antiviral response against SARS-CoV-2 by bypassing the filtering effect of the nose and by decreasing NO levels in the airways. Simple devices that promote nasal breathing during sleep may help prevent the common cold, suggesting potential benefits against coronavirus infection. In the absence of effective treatments against COVID-19, the alternative strategies proposed here should be considered and studied in more detail.
Obstructive sleep apnea (OSA) is a prevalent condition that affects people of all ages. Surgical management has improved with growing understanding of OSA pathophysiology, new methods of airway phenotyping and precision in operative techniques. The classic Stanford phased approach serves as a foundation for the updated algorithm, which places surgery on a continuum with medical and dental care. The last 40 years have seen a burgeoning of effort focused on individual surgical or dental procedural success rates. What lies ahead should be a focus on improving overall treatment success, usually achievable only with multimodal interventions. The goal of treatment success for the OSA patient will foster collaboration across disciplines.
Obstructive sleep apnea-hypopnea syndrome (OSAHS) is characterized by the partial obstruction or total collapse of the upper airway in an intermittent and repetitive manner; in this scenario, surgical management was initially regarded as an alternative for treating this pathology. Nowadays, surgery is highly recognized because it improves tolerance and adaptation to positive pressure therapy; it remains as the first line of treatment, although high rates of effectiveness are not achieved.
The first step before considering any surgical procedure is an adequate topographic diagnosis; therefore, a nasofibrolaryngoscopy should always be performed to identify the obstruction site(s). It is known that 75% of patients have obstructions at multiple levels, so correcting OSAHS by up to 95% is possible when the approach considers all the levels. Current procedures include nasal surgery, soft palate, tonsils, tongue base, hypoglossal nerve stimulator and facial skeletal procedures, as well as adjuvant procedures that include radiofrequency and palate implants.
Inability to breathe through the nose is a recognized cause of disordered breathing during sleep, although the true relationship between sleep-related breathing disorders (SRBD) and nasal obstruction is still unclear. Sleep-disordered breathing can both result from and be worsened by nasal obstruction. Nasal breathing increases ventilatory drive and nasal occlusion decreases pharyngeal patency in normal subjects. The diff erent clinical aspects of SRBD include primary snoring, upper-airway resistance syndrome, obstructive sleep apnea-hypopnea syndrome (OSAS) and hypoventilation syndrome related to obesity [54]. The most studied form of SRBD is OSAS and its incidence is 2-4% in the general adult population [23]. In all circumstances, the nose may have a great impact on the severity of SRBD. Sensitized subjects during high allergen exposure have impaired nasal breathing and likewise everyone who has had a common cold will have experienced poor nasal breathing at night. The consequences of nasal obstruction on sleep are day-to-day discomfort, frequent complaints of poor sleep quality and daytime fatigue; they are well documented. Risk factors for sleep-disordered breathing include central obesity, male gender, smoking habits, alcohol consumption, upper-airway obstruction and craniofacial abnormalities. Nasal obstruction must be considered to be a cofactor in the pathophysiology of SRBD. Although an increased nasal resistance does not always correlate with symptoms of congestion, nasal congestion typically results in a switch to mouth breathing. The switch to mouth breathing that occurs with chronic nasal abnormalities is probably a common pathway for SRDB [56]. But the relationship between cause and eff ect remains a matter of debate.
It has been 30 years since Cottle suggested that "sleeping patterns are in great measure dependent on good nasal function" [1]. During this time, we have identified the OSAHS and related forms of sleep-disordered breathing such as UARS, and better appreciate the clinical sequelae of recurrent arousals and sleep fragmentation. Yet the exact role that obstructed nasal breathing plays in the pathogenesis of such sleep disorders remains presumptive, and robust clinical studies to corroborate this theory remain elusive; however, patients who may benefit most from correction of nasal obstruction as a sole intervention may be those with the mildest forms of sleep-disordered breathing without other significant predisposing anatomic abnormalities. Clearly, more stringently controlled studies [17,105] are needed, particularly in these types of patients. Until such time, it is reasonable to address issues of nasal obstruction as an adjunct to surgical and nonsurgical treatment in all patients who are diagnosed with a sleep-related breathing disorder.
Twenty-five adults with a deviated nasal septum, who complained about excessive daytime sleepiness, chronic fatigue, and nocturnal insomnia, were studied for one to two nights in a sleep laboratory. Recordings disclosed disordered breathing during sleep in the form of pronounced periodic breathing of alternating hypopneas and hyperpneas, isolated hypopneic episodes and central apneas and periodic signs, all combined with electrophysiologic 'microarousals', and a mixture of alpha and delta EEG wave activities. Surgical treatment of the deviated septum in 14 patients resulted in a subjective improvement in the level of diurnal alertness and in the quality of nocturnal sleep in 12 patients. Follow-up sleep recordings in seven of the patients who reported subjective improvement in sleep disclosed notably less waking and abnomal breathing during sleep. These results suggest that increased upper airway resistance can cause nonapneic breathing disorders in sleep and, consequently, sleep disturbances.
Under the organizational aegis of Project Sleep and the Association of Sleep Disorders Centers (ASDC), nearly 5,000 patient records from 11 sleep-wake disorders clinics were analyzed in a cooperative study. These cases represented the diagnostic experience of each of these centers over a two-year period. Each patient underwent polysomnographic study, and his or her condition was diagnosed according to the ASDC classification system, a new, standardized nosology of sleep disorders medicine. The most common major diagnostic category was "disorders of excessive sleepiness (hypersomnia)," 42%; this was followed by "disorders of initiating and maintaining sleep (insomnia)," 26%; "penile tumescence evaluations for impotency," 17%; "parasomnias," 3%; and "disorders of the sleep-wake schedule," 2%. If the impotency evaluations performed in the sleep clinics are removed from the total, leaving only the population that was studied because of sleep complaints, the proportions of the diagnostic categories are hypersomnia, 51%; insomnia, 31%; parasomnias, 15%; and sleep-wake schedule disturbances, 3%. The most prevalent diagnoses in the hypersomnia category were sleep apnea (43%) and narcolepsy (25%). Psychiatric disorders (35%) comprised the most frequent group of insomnia diagnoses, though a variety of other disorders were common. The applications of these results for the practicing physician are discussed.
(JAMA 1982;247:997-1003)
To evaluate the effect of nasal obstruction in infants and young children upon ventilation during sleep, change of ventilation was followed by polygraphic recordings of esophageal pressure, tidal volume and percutaneous oxygen tension when the nostrils were mechanically obstructed in 10 subjects; 3 types of ventilatory changes were noted. In 4 subjects periodic breathing appeared in which hypoventilation was alternated with occasional hyperventilation. Esophageal pressure, tidal volume and PO2 showed concomittant fluctuation. PO2 lowered during hypoventilatory phase was compensated by periodic hyperventilation. In 5 subjects upper airway obstruction was compensated for by increased respiratory endeavor and tidal volume and PO2 remained normal in spite of markedly increased esophageal pressure. In 1 subject tidal volume and PO2 remained decreased with marked increase of esophageal pressure. Largest airway obstruction was noted between the upper and the lower lips.
A microscopic model for impurity uptake at a sharp crystal‐liquid interface during alloy solidification is presented in terms of the bulk properties of the liquid and solid phases. The results for stepwise growth and continuous growth at the same interface velocity differ quantitatively but exhibit the same qualitative features. A transition from equilibrium segregation to complete solute trapping occurs as the velocity surpasses the diffusive speed of solute in the liquid. The location of the transition varies little with equilibrium segregation coefficient, and a kinetic limit to solute trapping is found to be quite unlikely. Comparison is made with other models; critical differences are pointed out. Coupled with a growth velocity equation and with macroscopic heat‐ and solute‐diffusion equations, the model forms a complete description of one‐dimensional crystal growth. The steady‐state solution to this system is indicated for the case of a planar interface. The results are applied to describe regrowth from laser‐induced melting. Preliminary comparison with experiment is made. The steady‐state solution for thermal and impurity transport is suggested for use whenever detailed computer calculations are unavailable or are unnecessarily involved.
Eight heavy snorers underwent nocturnal polygraphic recordings. The principal results are the following: 1. 1. Snoring is an inspiratory (or primarily inspiratory) noise linked to subobstruction of the upper airways. It appears with falling asleep (stage 1) and intensifies progressively through the deepening of slow sleep; in REM sleep it becomes discontinuous and is comparable to stage 2 snoring in intensity. 2. 2. In heavy snorers, obstructive apneas are 3. always present and particularly abundant during light sleep (stage 2) and REM sleep. 4. 3. In heavy snorers during sleep the systemic arterial pressure reaches and remains at levels higher than those of wakefulness instead of diminishing normally. 5. 4. Some degree of alveolar hypoventilation is associated with snoring when the apneas are especially abundant. These findings confirm the existence of significant polygraphic analogies between snoring and hypersomnia with periodic apneas and indicate that snoring may represent the first phase in the development of this syndrome. Moreover, the effects of snoring on alveolar ventilation and the systemic pressure during sleep suggest that heavy, constant snoring has physiopathological implications for the cardio-circulatory apparatus.
Eight children, 5 to 14 years of age, were diagnosed by means of nocturnal polygraphic monitoring with a sleep apnea syndrome similar to that seen in adults. Excessive daytime sleepiness, decrease in school performance, abnormal daytime behavior, recent enuresis, morning headache, abnormal weight, and progressive development of hypertension should suggest the possibility of a sleep apnea syndrome when any of these symptoms is associated with loud snoring interrupted by pauses during sleep. Surgery may eliminate the clinical symptomatology.
We describe a syndrome characterized by acquired micrognathia, hypersomnia, and periodic apneas during sleep. Six patients affected with the syndrome underwent nocturnal and diurnal polygraphic recordings that demonstrated that during sleep there is an uninterrupted succession of apneas, primarily the obstructive type, analogous to those observed in Pickwickian syndrome. Simultaneous recording of pulmonary and systemic arterial pressure during sleep and repeated blood gas analyses have shown that as soon as the apneas appear there is a decisive increase in pulmonary and systemic pressure and serious alveolar hypoventilation. The hemodynamic and ventilatory changes are even more intense during rapid eye movement sleep. Tracheostomy, performed on five of our patients, is the only treatment producing complete clinical remission of the syndrome.