Anatomically based treatments for obstructive sleep apnoea (OSA) may not completely resolve OSA. This has led to interest in exploring ways of addressing physiological risk factors. This review examines the literature for research reporting on the effects of various types of breathing training and breathing activities on sleep apnoea. It also reviews and discusses proposed therapeutic mechanisms.
A search of electronic databases was performed using the search terms related to various breathing therapies or to activities requiring high levels of breath control such as singing and the playing of musical instruments and sleep apnoea.
A total of 14 suitable studies were reviewed. A diverse variety of breathing retraining approaches are reported to improve sleep apnoea, e.g., Buteyko method, inspiratory resistance training, and diaphragmatic breathing. There is also a reduced incidence of sleep apnoea with intensive and regular participation in activities that require high levels of breath control, e.g., singing and playing wind instruments. Improvements in sleep-disordered breathing are thought to be related to improvements in (1) muscle tone of the upper airway; (2) respiratory muscle strength; (3) neuroplasticity of breathing control; (4) oxygen levels; (5) hyperventilation/dysfunctional breathing; and (6) autonomic nervous system, metabolic, and inflammatory status.
Breathing retraining and regular practice of breath control activities such as singing and playing wind instruments are potentially helpful for sleep apnoea, particularly for individuals with minimal anatomical deficit and daytime breathing dysfunction. Research is needed to elucidate mechanisms, to inform patient selection, and to refine clinical protocols.
This is a preview of subscription content, access via your institution.
Buy single article
Instant access to the full article PDF.
Tax calculation will be finalised during checkout.
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
Tax calculation will be finalised during checkout.
Weaver TE, Grunstein RR (2008) Adherence to continuous positive airway pressure therapy: the challenge to effective treatment. Proc Am Thorac Soc 5(2):173–178
Doff MH, Hoekema A, Wijkstra PJ, van der Hoeven J, Huddleston Slater JJ, de Bont LG, Stegenga B (2013) Oral appliance versus continuous positive airway pressure in obstructive sleep apnea syndrome: a 2-year follow-up. Sleep 36(9):1289–1296
Tsuda H, Almeida FR, Tsuda T, Moritsuchi Y, Lowe AA (2010) Craniofacial changes after 2 years of nasal continuous positive airway pressure use in patients with obstructive sleep apnea. Chest 138(4):870–874
Battagel JM, Kotecha B (2005) Dental side-effects of mandibular advancement splint wear in patients who snore. Clin Otolaryngol 30(2):149–156
Eckert DJ (2016) Phenotypic approaches to obstructive sleep apnoea–new pathways for targeted therapy. Sleep Med Rev
Edwards BA, Sands SA, Eckert DJ, White DP, Butler JP, Owens RL, Malhotra A, Wellman A (2012) Acetazolamide improves loop gain but not the other physiological traits causing obstructive sleep apnoea. J Physiol 590(5):1199–1211
Lowe S et al. (2001) Idiopathic hyperventilation (IHV) during wakefulness and sleep Am Rev Respir Crit Care Med
Messineo L et al (2018) Breath-holding as a means to estimate the loop gain contribution to obstructive sleep apnoea. J Physiol 596(17):4043–4056
Jack S et al (1998) Breath hold time in idiopathic hyperventilators. Eur Respir J 12(28):412S
Courtney R, Cohen M (2008) Investigating the claims of Konstantin Buteyko M.D., PhD: the relationship of breath holding time to end tidal CO2 and other proposed measures of dysfunctional breathing. J Altern Complement Med 14(2):115–123
Jack S, Rossiter HB, Pearson MG (2004) Ventilatory responses to inhaled carbon dioxide, hypoxia, and exercise in idiopathic hyperventilation. Am J Respir Crit Care Med 170:118–125
Puhan MA, Suarez A, Lo Cascio C, Zahn A, Heitz M, Braendli O (2006) Didgeridoo playing as alternative treatment for obstructive sleep apnoea syndrome: randomised controlled trial. BMJ (Clinical Research Ed) 332(7536):266–270
Wardrop PJC et al (2011) Do wind and brass players snore less? A cross-sectional study of snoring and daytime fatigue in professional orchestral musicians. Clin Otolaryngol: Official Journal Of ENT-UK ; Official Journal Of Netherlands Society For Oto-Rhino-Laryngology & Cervico-Facial Surgery 36(2):134–138
Ward CP, York KM, McCoy JG (2012) Risk of obstructive sleep apnea lower in double reed wind musicians. J Clin Sleep Med 8(3):251–255
Brown DL, Zahuranec DB, Majersik JJ, Wren PA, Gruis KL, Zupancic M, Lisabeth LD (2009) Risk of sleep apnea in orchestra members. Sleep Med 10(6):657–660
Hilton M et al (2013) Singing exercises improve sleepiness and frequency of snoring among snorers—a randomised controlled trial. Int J Otolaryngol Head Neck Surg 2(03):97
Ojay A, Ernst E (2000) Can singing exercises reduce snoring? A pilot study. Complement Ther Med 8(3):151–156
Pai I, Lo S, Wolf D, Kajieker A (2008) The effect of singing on snoring and daytime somnolence. Sleep Breath 12(3):265–268
Vranish JR, Bailey EF (2016) Inspiratory muscle training improves sleep and mitigates cardiovascular dysfunction in obstructive sleep apnea. Sleep 39(6):1179–1185
Wang TG et al (2002) Resistive inspiratory muscle training in sleep-disordered breathing of traumatic tetraplegia. Arch Phys Med Rehabil 83(9):1325
Sengul Y, Ozalevli S, Oztura I, Itil O, Baklan B (2011) The effect of exercise on obstructive sleep apnea: a randomized and controlled trial. Sleep Breath 15(1):49–56
Khaleghipour S, Masjedi M, Kelishadi R (2013) The effect of breathing exercises on the nocturnal enuresis in the children with the sleep-disordered breathing. Iran Red Crescent Med J 15(11):e8986–e8986
Josephson SC, Rosen RC (1980) The experimental modification of sonorous breathing. J Appl Behav Anal 13(2):373–378
Birch M (2004) Clinical update. Obstructive sleep apnoea and breathing retraining. Aust Nurs J 12(2):27–29
Birch M (2012) Sleep apnoea: a survey of breathing retraining. Aust Nurs J 20(4):40–41
Sengul YS et al (2011) The effect of exercise on obstructive sleep apnea: a randomized and controlled trial. Sleep Breathing = Schlaf & Atmung 15(1):49–56
Ojay A, Ernst E (2000) Can singing exercises reduce snoring? A pilot study. Complem Ther Med 8(3):151–156
Ward CP, York KM, McCoy JG (2012) Risk of obstructive sleep apnea lower in double reed wind musicians. J Clin Sleep Med: JCSM: official publication of the American Academy of Sleep Medicine 8(3):251
Camacho M, Certal V, Abdullatif J, Zaghi S, Ruoff CM, Capasso R, Kushida CA (2015) Myofunctional therapy to treat obstructive sleep apnea: a systematic review and meta-analysis. Sleep 38(5):669–675
Verma RK et al (2016) Oropharyngeal exercises in the treatment of obstructive sleep apnoea: our experience. Sleep Breathing = Schlaf & Atmung 20(4):1193–1201
Lequeux T et al (2005) Physiotherapy in obstructive sleep apnea syndrome: preliminary results. Eur Arch Oto-Rhino-Laryngol: Official Journal Of The European Federation Of Oto-Rhino-Laryngological Societies (EUFOS): Affiliated With The German Society For Oto-Rhino-Laryngology - Head And Neck Surgery 262(6):501–503
Valbuza JS, Oliveira MM, Conti CF, Prado LB, Carvalho LB, Prado GF (2008) Methods to increase muscle tonus of upper airway to treat snoring: systematic review. Arq Neuropsiquiatr 66(3B):773–776
Kreuter M, Kreuter C, Herth F (2008) Pneumological aspects of wind instrument performance--physiological, pathophysiological and therapeutic considerations. Pneumologie (Stuttgart, Germany) 62(2):83–87
Rehling T et al (2017) Reduced inspiratory muscle strength in patients with type 2 diabetes mellitus and obstructive sleep apnoea. J Diabetes Res 2017:4121794–4121794
Younes M et al (2007) Mechanisms of breathing instability in patients with obstructive sleep apnea. J Appl Physiol 103(6):1929–1941
Mateika JH, Syed Z (2013) Intermittent hypoxia, respiratory plasticity and sleep apnea in humans: present knowledge and future investigations. Respir Physiol Neurobiol 188(3):289–300
Brown EC, Cheng S, McKenzie D, Butler JE, Gandevia SC, Bilston LE (2013) Respiratory movement of upper airway tissue in obstructive sleep apnea. Sleep 36(7):1069–1076
Rice A, Fuglevand AJ, Laine CM, Fregosi RF (2011) Synchronization of presynaptic input to motor units of tongue, inspiratory intercostal, and diaphragm muscles. J Neurophysiol 105(5):2330–2336
Cifra A, Nani F, Nistri A (2011) Respiratory motoneurons and pathological conditions: lessons from hypoglossal motoneurons challenged by excitotoxic or oxidative stress. Respir Physiol Neurobiol 179(1):89–96
Edwards BA, Sands SA, Owens RL, White DP, Genta PR, Butler JP, Malhotra A, Wellman A (2014) Effects of hyperoxia and hypoxia on the physiological traits responsible for obstructive sleep apnoea. J Physiol 592(20):4523–4535
Tafil-Klawe M et al (2004) Reflex respiratory responses to progressive hyperoxic hypercapnia and normocapnic hypoxia in normocapnic and hypercapnic obstructive sleep apnea patients. J Physiol Pharmacol 55(Suppl 3):135–138
Hudgel DW, Hendricks C, Dadley A (1988) Alteration in obstrucitvie sleep apnea pattern induced by changes in oxygen and carbon dioxide inspired concentrations. Am Rev Respir Dis 138(1):16–19
Courtney R (2017) Breathing training for dysfunctional breathing in asthma: taking a multidimensional approach. Eur Respir J Open Res 3(4):00065–02017
Meuret A, Ritz T (2010) Hyperventilation in panic disorder and asthma: empirical evidence and clinical strategies. Int J Psychophysiol 78(1):68–79
Lum LC (1975) Hyperventilation: the tip and the iceberg. J Psychomatic Res 19:375–383
Law N, Ruane LE, Low K, Hamza K, Bardin PG (2018) Dysfunctional breathing is more frequent in chronic obstructive pulmonary disease than in asthma and in health. Respir Physiol Neurobiol 247:20–23
Folgering H, Colla P (1978) Some anomalies in the control of PACO2 in patients with a hyperventilation syndrome. Bull Europ Physiopath Resp 14:503–512
Courtney R (2009) Functions and dysfunctions of breathing and their relationship to breathing therapy. Int J Osteopath Med 12:78–85
Hagman C, Janson C, Emtner M (2011) Breathing retraining-a five-year follow-up of patients with dysfunctional breathing. Respir Med 105:1153–1159
Boulding R et al (2016) Dysfunctional breathing: a review of the literature and proposal for classification. Eur Respir Rev 25(141):287–294
Barker N, Everard ML (2015) Getting to grips with ‘dysfunctional breathing’. Paediatr Respir Rev 16(1):53–61
Borel JC et al (2012) Influence of CO(2) on upper airway muscles and chest wall/diaphragm corticomotor responses assessed by transcranial magnetic stimulation in awake healthy subjects. J Appl Physiol (1985) 112(5):798–805
Li Y, Weed JG, Ren R, Sun Y, Zou K, Lu L, Tang X (2016) A case of behavioural hyperventilation associated with severe central sleep apnoea and follow-up management. Thorax 71(6):571–574
Pevernagie D, Mariman A, Vandenbussche N, Tobback E, Overeem S, Delesie L, Janssen H, Vogelaers D (2012) Behavioural hyperventilation as a novel clinical condition associated with central sleep apnoea: a report of three cases. Sleep Med 13(10):1317–1320
Deacon-Diaz NL et al (2018) Daytime loop gain is elevated in obstructive sleep apnea but not reduced by CPAP treatment. J Appl Physiol (1985) 125(5):1490–1497
Wang TG, Grunstein RR, Teichtahl H (2007) Association between ventilatory response to hypercapnia and obstructive sleep apnea-hypopnea index in asymptomatic subjects. Sleep Breath 11(2):103–108
Chamberlin NL (2013) Brain circuitry mediating arousal from obstructive sleep apnea. Curr Opin Neurobiol 23(5):774–779
Yokhana SS, Gerst DG 3rd, Lee DS, Badr MS, Qureshi T, Mateika JH (2012) Impact of repeated daily exposure to intermittent hypoxia and mild sustained hypercapnia on apnea severity. J Appl Physiol 112:367–377
Bowler SD, Green A, Mitchell A (1998) Buteyko breathing technique in asthma: a blinded randomised controlled trial. Med J Aust 169(7):575–578
Ritz T, Meuret AE, Wilhelm FH, Roth WT (2009) Changes in pCO2 symptoms, and lung function of asthma patients during capnometry-assisted breathing training. Appl Psychophysiol Biofeedback 34(1):1–6
Grammatopoulou EP et al (2014) Hyperventilation in asthma: validation study of the Nijmegen Questionnaire–NQ. J Asthma 51(8):839–846
Edwards BA, Andara C, Landry S, Sands SA, Joosten SA, Owens RL, White DP, Hamilton GS, Wellman A (2016) Upper-airway collapsibility and loop gain predict the response to oral appliance therapy in patients with obstructive sleep apnea. Am J Respir Crit Care Med 194(11):1413–1422
Koutsourelakis I, Vagiakis E, Roussos C, Zakynthinos S (2006) Obstructive sleep apnoea and oral breathing in patients free of nasal obstruction. Eur Respir J 28(6):1222–1228
Tafil-Klawe M, Klawe JJ (2003) Role of breathing in genioglosus muscle response to hypoxia in older and younger subjects. J Physiol Pharmacol 54(Suppl 1):48–54
Trimer R, Cabidu R, Sampaio LL, Stirbulov R, Poiares D, Guizilini S, Bianchi AM, Costa FS, Mendes RG, Delfino A Jr, Arena R, Borghi-Silva A (2014) Heart rate variability and cardiorespiratory coupling in obstructive sleep apnea: elderly compared with young. Sleep Med 15(11):1324–1331
Jen R, Grandner MA, Malhotra A (2015) Future of sleep-disordered breathing therapy using a mechanistic approach. Can J Cardiol 31(7):880–888
Conflict of interest
The author declares that she has no conflict of interest.
Human and animal rights and informed consent
This article does not contain any studies with human participants or animals performed by any of the authors.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
About this article
Cite this article
Courtney, R. Breathing retraining in sleep apnoea: a review of approaches and potential mechanisms. Sleep Breath 24, 1315–1325 (2020). https://doi.org/10.1007/s11325-020-02013-4
- Sleep apnoea
- Breathing retraining
- Dysfunctional breathing