There is some good news for people with sleep apnea and snoring. A growing body of research is showing that lifestyle and self help measures including breathing retraining and mouth/throat exercises as supportive therapy for patients with sleep apnea can help.
Sleep apnea and even simple snoring can have profound effects on health. They should not be ignored and effective treatment solutions can transform people’s physical health, sleep and mental/emotional state. However many people with sleep apnea and other types of sleep disordered breathing do not tolerate the gold standard treatment called Continuous Positive Airways Pressure (CPAP) and other options including surgery and the use of dental devices such as Mandibular Advancement Splints (MAS) which can have side effects.
Measures such as weight loss, increased physical exercise, singing, playing musical instruments as well as breathing and throat exercises can really make a difference There is evidence that all these measures can help people with sleep apnea to sleep better, snore less, have better quality of life and in some cases they can help people to tolerate and get better results from CPAP and MAS.
Sleep Disordered Breathing and Health
There have been numerous articles written about research on the health implications of sleep apnea. Increased risk for cardiovascular disease, diabetes and stroke have been of major concern for many years now and even the most conservative medical establishments such as Harvard Medical school consider treatment of sleep apnea to be one of the most important elements needed to reduce the impact and mortality from these diseases –http://healthysleep.med.harvard.edu/sleep-apnea/living-with-osa/health-consequences.
As the years go by, the list of conditions linked with sleep apnea keeps growing and includes conditions such as Alzheimers, ADHD, moodiness, irritability, autonomic nervous system dysfunction, depression, insomnia, fibromyalgia, obesity and insulin resistance to name a few.
Sleep apnea was once thought to be a condition that affected obese older males. It’s now known that sleep apnea occurs in children and adults of all genders, ages and body types and has multiple anatomical and non-anatomical causes. Sleep apnea, once thought to be a relatively rare condition is now known to be quite common. It’s been reported that one in five adults has sleep apnea, one in 15 adults has severe sleep apnea. Much of the time sleep apnea is overlooked, even in the case of severe sleep apnea 75% of individuals are not diagnosed.
Medical and Anatomical Treatment
The two main treatment options for snoring and sleep apnea are Continuous Positive Airway pressure (CPAP) and Mandibular Advancement Splints (MAS).
CPAP is the gold standard of treatment and research shows that that while CPAP is better than MAS for improving sleep apnea symptoms (particularly in people with severe sleep apnea) some individuals do better with MAS, to some extent because they find it more comfortable and are more likely to use it regularly . Many people report life changing benefits from these treatment and other medical treatment such as oral surgery and newer therapies like Hypoglossal nerve stimulation. However drop outs from CPAP and MAS therapy can be as high as 50% and both therapies can have some complications [2-4]. Patients can relapse after surgery and find that their sleep apnea recurs after a few years.
The most well known treatments for sleep apoea and snoring are anatomically focused. The thinking behind them being mostly focused on ways to make the airway bigger.
Non-Anatomical Factors in Sleep Apnea
As knowledge about sleep apnea develops it is becoming increasingly clear that sleep apnea is mutifactorial and not just anatomical. Anatomical factors refer to factors that compromise the size of the airway e.g narrow or receded jaw, large neck size, small size of the upper airway, enlarged adenoids and tonsils, nasal obstruction or tendency for the upper airways to collapse during sleep . Non-anatomical factors have to do with how the muscles of the airway function as well as chemical and neurological factors that affect control and stability of breathing.
Research investigating non-anatomical causes of sleep apnea suggests that these affect 69% of individuals with obstructive sleep apnea OSA . Three key non anatomic factors are:
- Poor responsiveness of throat muscles to changing breathing needs during sleep (36% of people with OSA)
- Low respiratory arousal threshold i.e. waking up prematurely to airway narrowing (37% of people with OSA).
- Respiratory control stability (36% of people with OSA).
A total of 28% of people with OSA were found to have multiples of the above.
Self help measures and Exercises for Snoring and Sleep Apnea
Individuals can apply a number of self-help measures, including various exercises, activities and lifestyle changes to positively impact on anatomical and non-anatomical causes of sleep apnea.
This is probably top of the list as a lifestyle measure to improve sleep apnea. Firstly because there has been so much research and also because even a small amount of weight loss makes a big impact on sleep disordered breathing . Weight loss doesn’t just work because it leads to improved airway size. It also reduces upper airway collapsibility  .
Just increasing physical exercise and not even to the point of producing weight loss or measurably better fitness has been shown to reduce the incidence of sleep apnea [8-10]. However the effects of exercise do seem to be incremental and exercise that improves fitness more seems to also improves overall breathing efficiency and stability . One randomized controlled trial showed that this to be the case in children as well as adults .
Singing and playing wind instruments-
Singing can improve snoring and sleep apnea [13, 14]. As can playing wind instruments such as flute and oboe and also the didgeridoo [15, 16]. The didgeridoo study has received particular attention and people who do about 2.5 hours of this per week can achieve substantial benefits. However not everyone will be motivated to acquire the skills needed to play these musical instruments. Fortunately there is a simpler way. Regular practice of fairly simple breathing, mouth and throat exercises can achieve benefits in line with those achieved with playing musical instruments.
Breathing, Mouth and Throat Exercises-
There are quite a variety of breathing exercises and muscle exercises that are recommended to improve the function of the airway and breathing efficiency and stability. When used appropriately these can reduce snoring and sleep apnea  and also can help people get better results from CPAP , dental treatment  and also surgery .
One systematic review looking at case studies and controlled trials in which adults and children were taught a range of oral (tongue, mouth) and throat exercises found that they produced an average reduction of the number of apnea events by approximately 50% in adults and 62% in children.
Children with snoring and sleep apnea who have enlarged adenoids and tonsils are often treated successfully by surgery to remove them. However not all children respond to this therapy and they may relapse after initial improvement if underlying dysfunctions such as obesity, lack of exercise, allergy, poor breathing, narrow jaws or poor function of the muscles association with mouth function and swallowing are not addressed. Research has shown that teaching children breathing and throat exercises to correct mouth breathing and improve function of the muscles of the tongue and throat significantly improves outcomes and prevents relapse .
There are an abundant number of anecdotal reports of people who managed to resolve sleep apnea with breathing exercises including the Buteyko breathing technique. One published case study describes a 44 year old adult with severe sleep apnea (AHI> 30) with a broad range of sleep and breathing symptoms whose symptoms were not responsive to CPAP. After 6 months of regular practice of breathing exercises a repeat sleep study showed no remaining sleep apnea. This improvement in sleep apnea and other symptoms was maintained at 2 year follow up . A survey of Buteyko method practitioners regarding their experiences in treating a reported 11,000 patients. While this survey does not constitute hard research evidence, it reports that over 95% of people who did breathing retraining had improved sleep and 80% ceased using their CPAP machines. Patients reported improved snoring, headaches, restless legs and low concentration 
The simple act of stopping or reducing mouth breathing at night using devices such as chin straps and nasal dilators can significantly improve the size and collapsibility of the airway, reduce snoring and can reduce the need for CPAP [23-25]. Improving the function of the nose might require medication or surgery but these are not necessarily a complete solution [26, 27]
Breathing and nasal rehabilitation exercises can also play an important role in improving the ability to nasal breath in the day and night. Breathing exercises might also help to improve breathing control instability. Breathing control instability is an important factor in some patients with sleep apnea. In these people oversensitivity of the chemical and neural pathways that regulate breathing control leads to disruption of the mechanisms that keep the airways open during the sleep . Case studies of successful resolution of sleep apnea with breathing exercises suggest that these might be particularly helpful for individuals with dysfunctional breathing[21, 29].
Importance of an Individualised and Integrative Approach
Sleep apnea is a complex disorder with many contributing factors. Individuals are likely to get the best results when anatomical and non-anatomical factors are considered. The collapsibility of upper airway muscles is modifiable with simple life style and exercise interventions. Important issues such as improved nasal breathing at night and correction of dysfunctional breathing and poor airway muscle tone are often overlooked. It’s important that these are addressed to improve outcomes for people who are not responsive to or do not tolerate therapies such as CPAP or MAS.
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- Pai, I., et al., The effect of singing on snoring and daytime somnolence. Sleep Breath, 2008. 12(3): p. 265-8.
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