PRIMARY STIMULUS TO BREATHE • There is a large reserve of oxygen in the blood stream, such that oxygen levels must drop from 100mmHg to about 50mmHg 100mmHg to about 50mmHg before the brain stimulates breathing.
HOW SHOULD WE BREATHE? • The threshold for the hypoxic ventilatory response is approximately 60mmHg (Loeschcke & Gertz, 1958), which is reached during exercise at an altitude of about 2500m (Ferretti et al., 1997; Cardus et al) 2500m (Ferretti et al., 1997; Cardus et al) X. Woorons1, P. Mollard1, A. Pichon1, C. Lamberto1,2, A. Duvallet1,2, J.-P. Richalet. Moderate exercise in hypoxia induces a greater arterial desaturation in trained than untrained men. Scand J Med Sci Sports 2007: 17: 431–436
PRIMARY STIMULUS TO BREATHE • Chemical sensors of breathing (chemoreceptors) • Brain stem- controls regular breathing. Responsive to CO breathing. Responsive to CO 2 • Carotid arteries- underneath the angle of the jaw. Responsive to CO 2 and low levels of O 2
PRIMARY STIMULUS TO BREATHE • The brain stem is the most primitive part of the brain. It begins at the base of the skull and extends upwards 6-8 cm. extends upwards 6-8 cm. • In the lower portion of the brain stem is the medulla containing the respiratory center with separate inspiratory and expiratory centers. Timmons B.H., Ley R. Behavioral and Psychological Approaches to Breathing Disorders . 1st ed. . Springer; 1994
PRIMARY STIMULUS TO BREATHE • Normal PCO 2 is 40mmHg • An increase of PCO 2 above this level stimulates the medullary inspiratory center neurons to inspiratory center neurons to increase their rate of firing. This increases breathing to remove more CO 2 from the blood through the lungs. Timmons B.H., Ley R. Behavioral and Psychological Approaches to Breathing Disorders . 1st ed. . Springer; 1994
PRIMARY STIMULUS TO BREATHE • The inspiratory center sends impulses down the spinal cord and through the phrenic nerve which innervates the diaphragm, intercostal nerves and external intercostal muscles- producing external intercostal muscles- producing inspiration. • At some point the inspiratory center decreases firing, and the expiratory center begins firing. Timmons B.H., Ley R. Behavioral and Psychological Approaches to Breathing Disorders . 1st ed. . Springer; 1994
PRIMARY STIMULUS TO BREATHE • On the other hand, a decrease in the PCO 2 below 40mmHg causes the respiratory center neurons to reduce their rate of firing, to below normal- their rate of firing, to below normal- producing a decrease in rate and depth of breathing until PCO 2 rises to normal. Timmons B.H., Ley R. Behavioral and Psychological Approaches to Breathing Disorders . 1st ed. . Springer; 1994
PRIMARY STIMULUS TO BREATH • However, breathing more than what the body requires over a 24 hour period conditions the body to increased breathing volume. increased breathing volume.
CARBON DIOXIDE NOT JUST A NOT JUST A WASTE GAS!
pH CO 2 Link
pH CO 2 Link • Normal pH is 7.365 which must remain within tightly defined parameters. If pH is too acidic and drops below 6.8, or too alkaline rising above 7.8, death can result. Blood, Sweat, and Buffers: pH Regulation During Exercise Acid-Base Equilibria Experiment Blood, Sweat, and Buffers: pH Regulation During Exercise Acid-Base Equilibria Experiment Authors: Rachel Casiday and Regina Frey
pH CO 2 Link CO2 in blood carried three ways: • 5% dissolved in plasma • 30% combined with blood proteins • 65% converted to bicarbonate ions for its transportation in the blood blood - CO2 + H2O = H2CO3 = H+ + HCO3- • CO2 –24 times more soluble in the blood than O2. Similar amounts in lungs and blood. aCO2 depends entirely on ACO2.
pH CO 2 Link • CO2 disassociates into H+ and HCO3- constituting a major alkaline buffer which resists changes in acidity. (reversibly bind H+)
pH CO 2 Link • If you offload carbon dioxide, you are left with an excess of bicarbonate ion and a deficiency of hydrogen ion. • During short term hyperventilation- breathing volume subsequentially decreases to allow accumulation of subsequentially decreases to allow accumulation of carbon dioxide and normalisation of pH.
pH CO 2 Link • However, when over breathing continues for hours/days, bicarbonate excess is compensated by renal excretion. • Hypocapnia and pH shift are almost immediate; adjustment of bicarbonate takes time. (Originally thought hours to days, but can occur within minutes) Lum LC.. Hyperventilation: the tip and the iceberg. J Psychosom Res..1975 ;(19(5-6):375-83
pH CO 2 Link • Thus the chronic hyperventilator's pH regulation is finely balanced: diminished acid (the consequence of hyperventilation) is balanced against the low level of blood bicarbonate maintained by renal excretion. blood bicarbonate maintained by renal excretion. Jenny C King Hyperventilation-a therapist's point of view: discussion paper. Journal of the Royal Society of Medicine. 1988 Sep; 81(9): 532–536.
pH CO 2 Link • In this equilibrium small amounts of over breathing induced by emotion can cause large falls of carbon dioxide and, consequently, more severe symptoms. Jenny C King Hyperventilation-a therapist's point of view: discussion paper. Journal of the Royal Society of Medicine. 1988 Sep; 81(9): 532–536.
Bohr Effect • In 1904, Christian Bohr, a Danish biochemist discovered that “the lower the partial pressure of carbon dioxide (CO 2 ) in arterial blood (paCO 2 ), the greater the affinity of hemoglobin for the oxygen it carries”
Bohr Effect • That is, an increase in blood CO 2 concentration, which leads to a decrease in blood pH, will result in hemoglobin proteins releasing their load of oxygen. • This discovery was named ‘The Bohr Effect’.
Bohr Effect • In other words, the lower the partial pressure of CO2 in arterial blood, the lower the amount of oxygen released by hemoglobin to cells for production of energy.
pH CO 2 Link • There is little difference between CO2 in alveoli and arterial blood. The level of arterial blood depends entirely on alveolar CO2. on alveolar CO2. • Alveolar CO2 depends on breathing volume.
Bohr Effect • By nasal breathing, aCO 2 is higher, the oxygen that is inhaled is more efficiently distributed to fatigued tissues which should in theory improve health and athletic performance and recovery, with practice of the technique. performance and recovery, with practice of the technique.
OXYHEMOGLOBIN DISSOCIATION CURVE • Horizontal axis; PO 2 - Partial pressure of oxygen, which reflects the amount of oxygen dissolved in the blood. Small amount of O 2 . • Vertical axis: SpO 2 - Percentage of oxygenated hemoglobin versus total hemoglobin in arterial blood. (allows 70 times more O 2 to be carried)
OXYHEMOGLOBIN DISSOCIATION CURVE • An exercising muscle is hot and generates carbon dioxide and it benefits from increased unloading benefits from increased unloading of O2 from its capillaries. West J 1995 Respiratory Physiology: the essentials. Lippincott, Williams and Wilkins.
CONSTRICTION OF CAROTID ARTERIES • A primary response to hyperventilation can reduce the oxygen available to the the oxygen available to the brain by one half. Timmons B.H., Ley R. Behavioral and Psychological Approaches to Breathing Disorders. 1st ed. . Springer; 1994. page 7
CO 2 Response to Hyperventilation Arterial carbon dioxide tension and alveolar carbon dioxide are virtually identical and arterial CO 2 is directly proportional to alveolar CO 2 . A decrease in PaCO 2 (arterial) can result from hyperventilation. A decrease in PaCO 2 without a change in the bicarbonate increases the blood pH producing respiratory alkalosis. Lung (1983) 161 : 257-273
CO 2 Response to Hyperventilation The changes in the arterial CO 2 content and tension are greatest during the first 30 to 60 seconds of acute hyperventilation. PaCO 2 can decrease to half the normal value after less PaCO 2 can decrease to half the normal value after less than 30 seconds of hyperventilation. A single deep expiration and inspiration can reduce the PaC02 by 7- 16mmHg. Lung (1983) 161 : 257-273
CO 2 Response to Hyperventilation With a decrease in PaCO 2 and respiratory alkalosis, there is a vasoconstriction of the cerebral arteries and reduced cerebral blood flow. There is a decrease in oxygen delivery to the brain on the basis of both the Bohr effect and the decreased cerebral blood flow. Lung (1983) 161 : 257-273
CO 2 Response to Hyperventilation Diminished cerebral blood flow may be responsible for the dizziness, faintness, visual disturbances, and impaired psychomotor behaviour that are commonly described during hyperventilation. Lung (1983) 161 : 257-273
Wim Hof Method Voluntary activation of the sympathetic nervous system and attenuation of the innate system and attenuation of the innate immune response in humans PNAS | May 20, 2014 | vol. 111 | no. 20 | 7379–7384 IMMUNOLOGY
WHM • Excessive or persistent proinflammatory cytokine production plays a central role in autoimmune diseases. • Acute activation of the sympathetic nervous system attenuates the innate immune response.
WHM • Healthy volunteers were randomized to either the intervention (n = 12) or control group (n = 12). The control group was not trained.
WHM • Subjects in WHM group were trained for 10 d in meditation (third eye meditation), breathing techniques (i.a., cyclic hyperventilation followed by breath retention), and exposure to cold (i.a., immersions in ice cold water).
WHM Breathing techniques, consisting of two exercises. • Hyperventilate for an average of 30 breaths. • Then, exhale and hold breath for 2–3 min (“retention phase”). • Duration of breath hold entirely at the discretion of the subject himself. • Breath hold followed by a deep inhalation breath, that was held for 10s. Subsequently a new cycle of hyper/hypoventilation began.
WHM • Subsequently, all subjects underwent experimental endotoxemia (i.v. administration of 2 ng/kg endotoxin).
WHM • Flu-like symptoms were lower in the intervention group. • Voluntary activation of the sympathetic nervous system results in epinephrine release and subsequent suppression of the innate immune response in humans. suppression of the innate immune response in humans. • These results could have important implications for the treatment of conditions associated with excessive or persistent inflammation, such as autoimmune diseases.
WHM • Biological therapies that antagonize proinflammatory cytokines are very effective and have revolutionized the treatment of autoimmune diseases, such as rheumatoid arthritis and inflammatory bowel disease. • However, these drugs are expensive and have serious side effects.
WHM • The present study demonstrates that, through practicing techniques learned in a short-term training program, the sympathetic nervous system and immune system can sympathetic nervous system and immune system can indeed be voluntarily influenced.
WHM • This study could have important implications for the treatment of a variety of conditions associated with excessive or persistent inflammation, especially excessive or persistent inflammation, especially autoimmune diseases in which therapies that antagonize proinflammatory cytokines have shown great benefit.
WHM
WHM
Kilopascal to Millimeter mercury CO2 4.49 33.67 2.11 15.82 4.01 30.07 2.03 15.22 3.76 28.20 1.69 12.67 3.48 26.10
Kilopascal to Millimeter mercury O2 PO2 (partial pressure of oxygen) reflects the amount of oxygen gas dissolved in the blood. 16.5 123.76 22 165 5.6 5.6 42 42 22.9 171.76 4.8 36 22.6 169.51 3.4 25.50
ASTHMA, SNORING, SLEEP SNORING, SLEEP APNEA,RHINITIS
EXERCISE INDUCED ASTHMA • Exercise-induced asthma affects an estimated 4 to 20 percent of the general population and 11 to 50 percent of certain athlete populations. • Rundell KW, Im J, Mayers LB, Wilber RL, Szmedra L, Schmitz HR. Self-reported symptoms and exercise-induced asthma in the elite athlete. Med Sci Sports Exerc.2001 Feb;33(2):208-13
EXERCISE INDUCED ASTHMA • Routine screening of UK Olympic team before Athens Olympics, the recorded prevalence of asthma was 21%. (double the prevalence rate of the UK population) • The two sports with highest prevalence was swimming and cycling. (both over 40%) • McConnell Breathe Strong, Perform Better
EXERCISE INDUCED ASTHMA • Why should asthma be so high in athletes? • Exercise is believed to trigger bronchoconstriction due to dehydration of the airways. The moisture is ‘sucked out’ of the airway cells causing them to dehydrate. out’ of the airway cells causing them to dehydrate. • Dehydration induces inflammation of the airways. • McConnell Breathe Strong, Perform Better
EXERCISE INDUCED ASTHMA • 55 percent of football athletes and 50 percent of basketball athletes displayed airway narrowing conducive to asthma, athletes from the sport of water polo showed significantly fewer asthma symptoms. polo showed significantly fewer asthma symptoms. • J Strength Cond Res.2012 Jun;(26(6)):1644-50
EXERCISE INDUCED ASTHMA • We speculate that asthmatics may have an increased tendency to switch to oral breathing, a factor that may contribute to the pathogenesis of their asthma. • Kairaitis K, Garlick SR, Wheatley JR, Amis TC. Route of breathing in patients with asthma. Chest. 1999 Dec;116(6):1646-52.
EXERCISE INDUCED ASTHMA • Nasal breathing provides a protective influence against exercise-induced asthma. We hypothesized that enforced oral breathing in resting mild asthmatic subjects may lead to a reduction in lung function. to a reduction in lung function. • Hallani M, Wheatley JR, Amis TC. Enforced mouth breathing decreases lung function in mild asthmatics . Respirology. 2008 Jun;13(4):553-8.
EXERCISE INDUCED ASTHMA • CONCLUSIONS: Enforced oral breathing causes a decrease in lung function in mild asthmatic subjects at rest, initiating asthma symptoms in some. Oral breathing may play a role in the pathogenesis of acute asthma may play a role in the pathogenesis of acute asthma exacerbations. • Hallani M, Wheatley JR, Amis TC. Enforced mouth breathing decreases lung function in mild asthmatics . Respirology. 2008 Jun;13(4):553-8.
EXERCISE INDUCED ASTHMA Laffey, J. & Kavanagh, B. Hypocapnia, New England Journal of Medicine. 4 July 2002.
EXERCISE INDUCED ASTHMA • The major cause of exercise induced asthma (EIA) is thought to be the drying and cooling of the airways during the 'conditioning' of the during the 'conditioning' of the inspired air. • Morton, King, Papalia 1995 Australian Journal of Science and Medicine in Sport. 27, 51-55
EXERCISE INDUCED ASTHMA • Nasal breathing increases the respiratory system's ability to warm and humidity the inspired air compared to oral breathing and compared to oral breathing and reduces the drying and cooling effects of the increased ventilation during exercise. • Morton, King, Papalia 1995 Australian Journal of Science and Medicine in Sport. 27, 51-55
EXERCISE INDUCED ASTHMA • This will reduce the severity of EIA provoked by a given intensity and duration of exercise. . • Morton, King, Papalia 1995 Australian Journal of Science and Medicine in Sport. 27, 51-55
EXERCISE INDUCED ASTHMA • Breathed with their mouths open when instructed to breathe "naturally." • Breathe only through the nose during the exercise, an almost complete inhibition of the post exercise bronchoconstrictive airway response was demonstrated. airway response was demonstrated. • When instructed to breathe only through the mouth during exercise, an increased bronchoconstrictive airway response occurred. . Shturman-Ellstein R, Zeballos RJ, Buckley JM, Souhrada JF. The beneficial effect of nasal breathing on exercise-induced bronchoconstriction. Am Rev Respir Dis. 1978 Jul;118(1):65-73.
OTHER CONSIDERATIONS- ASTHMA • More normal breathing volume leads to less cooling and dehydration of the airways. • Changing breathing volume towards normal, with a • Changing breathing volume towards normal, with a higher BOLT is especially effective at helping to prevent exercise induced asthma and cyclists cough.
SLEEP DISORDERED BREATHING BREATHING
SLEEP DISORDERED BREATHING • Snoring is a sound created from turbulent airflow. It is noisy breathing during sleep caused by the exchange of a large volume of air through a narrowed space, which in turn causes the tissues of the nose and throat to vibrate. turn causes the tissues of the nose and throat to vibrate.
SLEEP DISORDERED BREATHING • Simple snoring - vibration of the soft palate. (mouth snoring) • High upper airway resistance (HUAR) - turbulent airflow in the nasopharynx and oropharynx causing inspiratory in the nasopharynx and oropharynx causing inspiratory flow limitation (IFL)
THE NEXT PROGRESSION FROM SNORING IS FROM SNORING IS SLEEP APNEA
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