O X Y G E N Advantage Theory 1

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O X Y G E N ADVANTAGE THEORY 1

One Technique-Eleven Exercises

• Measurement appraisals: Body Oxygen Level Test

(BOLT) & Maximum Breathlessness Test (MBT)

• Functional breathing pattern training

• Simulation of high altitude training

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Functional Breathing Pattern Training

• Improve blood circulation & oxygen delivery to the cells

• Dilate the upper airways (nose) and lower airways

(lungs)

• Significantly reduce exercise induced bronchoconstriction

• Improve sleep, focus, concentration and calm

Functional Breathing Pattern Training

• Reduce onset and endurance of breathlessness • Posture and spinal stabilization (poor breathing function reduces movement function)

• Reduce risk of injury

• Reduce energy cost associated with breathing

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Simulation of High Altitude Training

• Improve aerobic capacity (some non-responders)

• Improve anaerobic capacity

• Stimulate anaerobic glycolysis without risk of injury

• Increase VO2 max and running economy

• Increase maximum tolerance to breathlessness

Simulation of High Altitude Training

• Improve respiratory muscle strength

• Improve muscle injury repair (New studies)

• Help maintain fitness during rest or injury

• Reduce free radicals and oxidative stress

• Reduce ventilatory response to hypercapnia and hypoxia

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TRAITS OF DYSFUNCTIONAL BREATHING

• Dysfunctional Breathing Patterns: no precise definition

Generally includes any disturbance to breathing including; hyperventilation/over breathing, unexplained breathlessness, breathing pattern disorder, irregularity of breathing.

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NORMAL BREATHING VOLUME

• Normal minute ventilation: 4- 6 litres

• Hyperventilation- breathing in excess of metabolic

requirements of the body at that time.

TRAITS OF DYSFUNCTIONAL BREATHING

• Breathing through mouth • Hearing breathing during rest • Regular sighing • Regular sniffing • Large breaths prior to talking • Yawning with big breaths • Upper chest movement • Paradoxical breathing • Noticeable breathing movement during rest

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Breathing During Stress

• Faster

• Sigh more (irregular)

• Noticeable breathing

• Oral breathing

• Upper chest breathing

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BREATHING TO EVOKE RELAXATION

• Faster • Slow down

• Sigh more (irregular) • Regular

• Noticeable breathing • Soft breathing

• Oral breathing • Nose breathing

• Upper chest breathing • Diaphragm breathing

HOW SHOULD WE BREATHE?

• Breathing is light, quiet, effortless, soft, through the nose,

diaphragmatic, rhythmic and gently paused on the

exhale.

• This is how human beings breathed until the comforts of

modern life changed everything, including our breathing

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HOW SHOULD WE BREATHE?

• If you took a run alongside an elite athlete in good health, would you expect her to be huffing and puffing like a train?

HOW TO HOWMEASURE TO MEASUREBREATHLESSNESS BREATHLESSNESS Demonstration

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BOLT (COMFORTABLE BREATH HOLD TIME) MEASUREMENT • Take a small silent breath in through your nose. • Allow a small silent breath out through your nose. • Hold your nose with your fingers to prevent air from entering your lungs.

• Count the number of seconds until you feel the first distinct desire to breathe in.

BOLT (COMFORTABLE BREATH HOLD TIME) MEASUREMENT

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Body Oxygen Level Test (BOLT)

• Holding of the breath until the first definite desire to breathe is not influenced by training effect or behavioural characteristics, it can be deduced to be a more objective measurement of breathlessness.

• Nishino T. Pathophysiology of dyspnea evaluated by breath-holding test: studies of furosemide treatment. Respiratory Physiology Neurobiology.2009 May 30;(167(1)):20-5

• Voluntary breath holding duration is thought to provide an indirect index of sensitivity to CO2 buildup.

SCREENING TOOL FOR DYSFUNCTIONAL BREATHING • Dysfunctional breathing (DB) has been linked to health conditions including low back pain and neck pain and adversely effects the musculoskeletal system.

• Kiesel K, Rhodes T, Mueller J, Waninger A, Butler R. Development of a screening protocol to identify individuals with dysfunctional breathing. The International Journal of Sports Physical Therapy, Volume 12, Number 5, October 2017, Page 774.

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SCREENING TOOL FOR DYSFUNCTIONAL BREATHING • No single test or screen identifies DB, which is multidimensional, and includes biochemical, biomechanical, and psychophysiological components.

SCREENING TOOL FOR DYSFUNCTIONAL BREATHING • The purpose of this study was to develop a breathing screening procedure that could be utilized by fitness and healthcare providers to screen for the presence of disordered breathing.

• The Kiesel K, Rhodes T, Mueller J, Waninger A, Butler R. Development of a screening protocol to identify individuals with dysfunctional breathing. The International Journal of Sports Physical Therapy, Volume 12, Number 5, October 2017, Page 774. • 774

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SCREENING TOOL FOR DYSFUNCTIONAL BREATHING

• 51 subjects (27 females, 27.0 years, BMI 23.3)

• Biochemical dimension- end-tidal CO2 (ETCO2)

• Biomechanical dimension, the Hi-Lo test

• Psychophysiological dimension, the Self Evaluation of Breathing Symptoms Questionnaire (SEBQ) and Nijmegen questionnaires

SCREENING TOOL FOR DYSFUNCTIONAL BREATHING • No strong correlations between the three measures of DB. Five subjects had normal breathing, 14 failed at least one measure, 20 failed at least two, and 12 failed all three.

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SCREENING TOOL FOR DYSFUNCTIONAL BREATHING • Easily obtained clinical measures of BHT (25 seconds) and four questions (FMS) can be utilized to screen for the presence of DB.

SCREENING TOOL FOR DYSFUNCTIONAL BREATHING • Do you feel tense? • Do you feel cold sensation in your hands or feet? • Do you notice yourself yawning? • Do you notice yourself breathing through your mouth at night?

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SCREENING TOOL FOR DYSFUNCTIONAL BREATHING • If the screen is passed, there is an 89% chance that DB is not present. If the screen is failed, further assessment is recommended.

Maximum Breathlessness Test (MBT)

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Maximum Breathlessness Test (MBT)

• Exhale normally through nose • Walk at a normal pace while holding the breath • Count the maximum number of paces that you can hold your breath

• Goal 80 to 100 paces • Less than 60 paces- significant room for improvement

Maximum Breathlessness Test (MBT)

• Psychological willpower and endurance influence the duration of the breath holding. • The breakpoint of breath holding is preceded by the onset of respiratory movements. • These irregular contractions of the inspiratory muscles reduce the unpleasant sensation in the lower thorax and abdomen that occurs progressively through a breath-holding period. • Discomfort signals are sent from the diaphragm to the brain- terminates the breath hold

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Maximum Breathlessness Test (MBT) • People need to gasp for air long before their brain or body runs out of oxygen (the obvious limitation). • After decades of research, the diaphragm, which contracts to inflate the lungs, plays a key role.

• The best hypothesis is that the diaphragm sends signals to the brain about how long it has been contracted and how it is biochemically reacting to depleted levels of oxygen or rising levels of carbon dioxide. Initially those signals cause mere discomfort, but eventually the brain finds them intolerable and forces breathing to start again.

Parkes 2006

Maximum Breathlessness Test (MBT)

• The duration of breath-holding after deep inspiration is a function of several factors • Chemoreception (chemosensitivity) • Mechanoreception (light stretching receptors) • The impact of descending cortical respiratory drive • Cognitive component The first two are involuntary but the most important (Ilyukhina and Zabolotskikh, 2000; Parkes,2006)

Trembach Nikita, Zabolotskikh Igor. Breath-holding test in evaluation of peripheral chemoreflexsensitivity in healthy subjects. Respiratory Physiology & Neurobiology 235 (2017) 79–82

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Respiratory Physiology

Definitions

• Tidal volume: the normal volume of air entering the lungs during one inhale at rest

• Respiratory rate: The number of breaths per minute

• Minute ventilation: the volume of air which enters the lungs over one minute.

• RR * TV= MV

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Slow Breathing

• Enhances ventilation efficiency and arterial oxygenation via alveolar recruitment, and distension and reduction of alveolar dead space.

• Bilo G, Revera M, Bussotti M, et al. Effects of slow deep breathing at high altitude on oxygen saturation, pulmonary and systemic hemodynamics. PloS one 2012; 7: e49074

Slow Breathing

• Training aimed at a permanently slow breathing rate reduces dyspnoea and improves exercise performance.

• Bernardi L, Spadacini G, Bellwon J, Hajiric R, Roskamm H, Frey AW. Effect of breathing rate on oxygen saturation and exercise performance in chronic heart failure. Lancet 1998; 351:1308±1311.

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Definitions

• PO2 - Partial pressure of oxygen in the blood.

- SpO2

- Percentage of oxygenated hemoglobin versus total

hemoglobin in arterial blood. (allows 70 times more O2 to be carried)

Definitions

• Normoxia: normal levels of oxygen (SpO2 95- 99%) • Hypoxia: deficiency in the amount of oxygen entering the tissues

(SpO2 less than 91%) • Hyperoxia: when cells, tissues and organs are exposed to higher than normal partial pressure of oxygen

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Definitions

• Normocapnia: normal arterial CO2, about 40mmHg

• Hypocapnia: below normal arterial CO2. Less than 37mmHg

• Hypercapnia: abnormally elevated levels of CO2. Greater than 45mmHg

PRIMARY STIMULUS TO BREATHE

• The regulation of breathing is determined by receptors in the brain stem which monitor the concentration of carbon dioxide

(CO2) along with the pH level and to a lesser extent oxygen in your blood.

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PRIMARY STIMULUS TO BREATHE

• Among these, CO2 provides the strongest stimulus to ventilation. For example, a slight increase (e.g., 2–5 mmHg) in arterial blood

pCO2 can more than double the ventilation

Journal of Psychosomatic Research 60 (2006) 291– 298

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 before the brain stimulates breathing.

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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)

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 CO2

• Carotid arteries- underneath the angle of the jaw. Responsive to

CO2 and low levels of O2

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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.

• 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 PCO2 is 40mmHg

• An increase of PCO2 above this level stimulates the medullary inspiratory center neurons to increase their rate of firing. This increases breathing to remove

more CO2 from the blood through the lungs. Timmons B.H., Ley R. Behavioral and Psychological Approaches to Breathing Disorders. 1st ed. . Springer; 1994

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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 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

PCO2 below 40mmHg causes the respiratory center neurons to reduce their rate of firing, to below normal- producing a decrease in rate and

depth of breathing until PCO2 rises to normal.

Timmons B.H., Ley R. Behavioral and Psychological Approaches to Breathing Disorders. 1st ed. . Springer; 1994

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PRIMARY STIMULUS TO BREATH

• However, breathing more than what the body requires over a 24 hour period conditions the body to increased breathing volume.

CARBON DIOXIDE NOT JUST A WASTE GAS!

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pH CO22 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 Authors: Rachel Casiday and Regina Frey

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pH CO22 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 - 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 CO22 Link

• CO2 disassociates into H+ and HCO3- constituting a major alkaline buffer which resists changes in acidity. (reversibly bind H+)

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pH CO22 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 carbon dioxide and normalisation of pH.

pH CO22 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

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pH CO22 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.

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 CO22 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.

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Bohr Effect

• In 1904, Christian Bohr, a Danish biochemist discovered that “the lower the partial pressure of carbon dioxide (CO2) in arterial blood (paCO2), the greater the affinity of hemoglobin for the oxygen it carries”

Bohr Effect

• That is, an increase in blood CO2 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’.

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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 CO22 Link

• There is little difference between CO2 in alveoli and

arterial blood. The level of arterial blood depends entirely

on alveolar CO2.

• Alveolar CO2 depends on breathing volume.

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Bohr Effect

• By nasal breathing, aCO2 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.

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OXYHEMOGLOBIN DISSOCIATION CURVE

• Horizontal axis; PO2

- Partial pressure of O2.

• Vertical axis: SpO2

- Percentage of oxygenated hemoglobin versus total

hemoglobin in arterial blood. (allows 70 times more O2 to be carried)

OXYHEMOGLOBIN DISSOCIATION CURVE

• An exercising muscle is hot and

generates carbon dioxide and it

benefits from increased unloading

of O2 from its capillaries.

West J 1995 Respiratory Physiology: the essentials. Lippincott, Williams and Wilkins.

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CONSTRICTION OF CAROTID ARTERIES

• A primary response to

hyperventilation can reduce

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

CO2 Response to Hyperventilation Arterial carbon dioxide tension and alveolar carbon dioxide are

virtually identical and arterial CO2 is directly proportional to

alveolar CO2.

A decrease in PaCO2 (arterial) can result from hyperventilation. A

decrease in PaCO2 without a change in the bicarbonate increases the blood pH producing respiratory alkalosis.

Lung (1983) 161 : 257-273

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CO2 Response to Hyperventilation

The changes in the arterial CO2 content and tension are greatest during the first 30 to 60 seconds of acute hyperventilation.

PaCO2 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

CO2 Response to Hyperventilation

With a decrease in PaCO2 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

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CO2 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

Carbon Dioxide Anomalies

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Carbon Dioxide Anomalies Widely assumed that HVPT (voluntary overbreathing for 1-3 minutes) reproduce symptoms by inducing hypocapnia. However, in most subjects the mechanism

of symptoms did not require a fall in PCO2.

Howell. The Hyperventilation Syndrome: a syndrome under threat? Thorax. 1997 S2

Carbon Dioxide Anomalies The act of overbreathing itself (stress stimulus) can bring on symptoms.

Howell. The Hyperventilation Syndrome: a syndrome under threat? Thorax. 1997 S2

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Carbon Dioxide Anomalies • Patients with primary alveolar hypoventilation (Ondine’s curse) ventilate normally in response to exercise even though they cannot respond to CO2 even at high concentrations.

Howell. The Hyperventilation Syndrome: a syndrome under threat? Thorax. 1997 S2

Carbon Dioxide Anomalies • On the other hand, some patients are unable to take a deep breath voluntarily following a stroke yet respond normally to increased concentrations of CO2.

Howell. The Hyperventilation Syndrome: a syndrome under threat? Thorax. 1997 S2

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Carbon Dioxide Anomalies • In addition to the “metabolic” pathway via the respiratory

centre, there must also be a motor “behavioural” pathway

involved in the control of breathing. This pathway

presumably mediates increased ventilatory drive associated with muscular exercise when the PCO2 is either unchanged or lower than at rest.

Howell. The Hyperventilation Syndrome: a syndrome under threat? Thorax. 1997 S2

Howell. The Hyperventilati on Syndrome: a syndrome under threat? Thorax. 1997 S2

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Carbon Dioxide Anomalies • The neurophysiology of emotional disturbance is poorly understood, but emotional factors may generate nervous activity which influences that part of the sensorimotor cortex which controls the behavioural pathway

• Howell. The Hyperventilation Syndrome: a syndrome under threat? Thorax. 1997 S2

Voluntary activation of the sympathetic nervous system and attenuation of the innate immune response in humans PNAS | May 20, 2014 | vol. 111 | no. 20 | 7379–7384 IMMUNOLOGY

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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.

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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.

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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.

• These results could have important implications for the treatment of conditions associated with excessive or persistent inflammation, such as autoimmune diseases.

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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 indeed be voluntarily influenced.

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WHM

• This study could have important implications for the treatment of a variety of conditions associated with excessive or persistent inflammation, especially autoimmune diseases in which therapies that antagonize proinflammatory cytokines have shown great benefit.

WHM

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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

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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 42

22.9 171.76

4.8 36

22.6 169.51

3.4 25.50

SNORING ASTHMA

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ASTHMA, 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

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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.

• Dehydration induces inflammation of the airways.

• McConnell Breathe Strong, Perform Better

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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.

• 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.

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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.

• 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 exacerbations.

• Hallani M, Wheatley JR, Amis TC. Enforced mouth breathing decreases lung function in mild asthmatics. Respirology. 2008 Jun;13(4):553-8.

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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 inspired air.

• Morton, King, Papalia 1995 Australian Journal of Science and Medicine in Sport. 27, 51-55

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EXERCISE INDUCED ASTHMA

• Nasal breathing increases the respiratory system's ability to warm and humidity the inspired air 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

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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. • 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

higher BOLT is especially effective at helping to prevent

exercise induced asthma and cyclists cough.

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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.

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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 flow limitation (IFL)

THE NEXT PROGRESSION FROM SNORING IS SLEEP APNEA

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RHINITIS & SLEEP APNEA

• Apnea is a Greek word meaning “without breath.” • Three types: central, obstructive and mixed. • Obstructive sleep apnoea is the most common type of apnoea and is characterised by holding the breath from collapse of the upper airways during sleep.

RHINITIS & SLEEP APNEA

• Can occur five to fifty times per hour. • Each breath hold can range from a few seconds to over one minute, causing one’s blood oxygen saturation to decline to as low as 50%.

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RHINITIS & SLEEP APNEA

• "There are athletes everywhere who have sleep apnea". • "Not only does the apnea affect their athletic performance, but it is extremely hard on their cardiovascular systems as well."

• W. Christopher Winter, M.D., medical director of the Martha Jefferson Hospital sleep medicine center in Charlottesville, Virginia

RHINITIS & SLEEP APNEA

• Though heart-related deaths from untreated sleep apnea usually occur during sleep, chronic stress on the heart can leave victims vulnerable during strenuous athletic events.

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RHINITIS & SLEEP APNEA

• "Athletes' hearts are pushed by their sport during the day and by their apnea at night," says Dr. Winter. "A time for rest and recovery now becomes a time that puts their health in peril.”

RHINITIS & SLEEP APNEA

• The prevalence of sleep-disordered breathing among all professional football players to be 14 percent overall and 34 percent within the high-risk group. (Offensive and defensive linemen)

• N Engl J Med 2003; 348:367-368

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ASTHMA & SLEEP APNEA

• Approximately 74% of asthmatics experience nocturnal symptoms of airflow obstruction secondary to reactive airways disease.

• Bonekat HW, Hardin KA, Severe upperway airway obstruction during sleep. Clin Rev Allergy Immunol. 2003 Oct;25(2):191-210

ASTHMA & SLEEP APNEA

• 88% of patients in the severe asthma group, 58% of patients in the moderate asthma group, and 31% of patients in the controls without asthma group had more than 15 apnoeic events per hour.

• Julien JY, Martin JG, Ernst P, Olivenstein R, Hamid Q, Lemi?re C, Pepe C, Naor N, Olha A, Kimoff RJ.Prevalence of obstructive sleep apnea-hypopnea in severe versus moderate asthma. J Allergy Clin Immunol. 2009 Aug;124(2):371-6. Epub 2009 Jun 26.

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RHINITIS & SLEEP APNEA

• During sleep upper airway resistance was much higher while breathing orally. In addition, obstructive (but not central) apnoeas and hypopnoeas were profoundly more frequent when breathing orally (apnoea-hypopnoea index 43+/-6) than nasally (1.5+/-0.5).

• Fitzpatrick MF1, McLean H, Urton AM, Tan A, O'Donnell D, Driver HS. Effect of nasal or oral breathing route on upper airway resistance during sleep. Eur Respir J. 2003 Nov;22(5):827-32.

RHINITIS & SLEEP APNEA

• Study was to determine the effect of acute nasal obstruction on sleep and breathing in eight normal persons. The subjects were randomized into two groups. One night the subject was studied with the nose open and a second night with the nose obstructed.

• Olsen KD, Kern EB, Westbrook PR. Sleep and breathing disturbance secondary to nasal obstruction. Otolaryngol Head Neck Surg. 1981 Sep-Oct;89(5):804-10.

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RHINITIS & SLEEP APNEA

• The subjects with the nose obstructed awoke more often, had a greater number of changes in sleep stage, and spent a greater amount of time in stage I (light sleep).

• Olsen KD, Kern EB, Westbrook PR. Sleep and breathing disturbance secondary to nasal obstruction. Otolaryngol Head Neck Surg. 1981 Sep-Oct;89(5):804-10.

RHINITIS & SLEEP APNEA

• Acute nasal obstruction increased the number of partial and total obstructive respiratory events (obstructive hypopnea and obstructive apnea). Sleep apnea developed in one subject during this study merely on the basis of acute nasal obstruction.

• Olsen KD, Kern EB, Westbrook PR. Sleep and breathing disturbance secondary to nasal obstruction. Otolaryngol Head Neck Surg. 1981 Sep-Oct;89(5):804-10.

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STUDIES

• 30 Patients with ≥5 events hourly but <15 hourly on the apnea-hypopnea index (AHI) were enrolled. All patients slept with their mouths closed by using the tape.

• Huang TW, Young TH Novel porous oral patches for patients with mild obstructive sleep apnea and mouth breathing: a pilot study. Otolaryngol Head Neck Surg. 2015 Feb;152(2):369-73.

STUDIES

Before POP Using POP • ESS 8.1 ±1.5 5.2 ±1.6 • VAS 7.5 ±2.0 2.4 ±1.4 • The median AHI score was significantly decreased by using a POP from 12.0 per hour before treatment to 7.8 per hour during treatment (P < .01). • (Median AHI reduced by 33% just by closing mouth!) • Huang TW, Young TH Novel porous oral patches for patients with mild obstructive sleep apnea and mouth breathing: a pilot study. Otolaryngol Head Neck Surg. 2015 Feb;152(2):369-73.

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GETTING A BETTER NIGHT’S SLEEP Low BOLT and mouth breathing contribute to the following: • Snoring, Sleep apnoea • Disrupted sleep • Nightmares • Asthma symptoms (3am-5am) • Needing to use the bathroom at about 6am • Fatigue first thing in morning • Dry mouth upon waking • Symptoms upon waking- blocked nose, wheezing, coughing or breathlessness

GETTING A BETTER NIGHT’S SLEEP

• Avoid blue light – smart phone and laptop • Sleep in a cool and airy bedroom • Don’t eat late at night or drink alcohol • Switch to nasal breathing permanently • Practise breathing softly for twenty minutes before sleep- parasympathetic NS

• Sleep on side or tummy (not back)

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GETTING A BETTER NIGHT’S SLEEP

• Nasal dilator MuteSnoring

• Tape mouth closed- LipSealTape.com

• Provide each student with tape

• Demonstrate how to apply it

• Wear tape for twenty minutes during the day to become comfortable with it

• If mouth naturally moist in the morning, no need for tape

O X Y G E N ADVANTAGE MASTERCLASS

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One Technique-Eleven Exercises

• Measurement appraisals: Body Oxygen Level Test

(BOLT) & Maximum Breathlessness Test (MBT)

• Functional breathing pattern training

• Simulation of high altitude training

• Pre-competition preparation

Functional Breathing Pattern Training

• Improve blood circulation & oxygen delivery to the cells

• Dilate the upper airways (nose) and lower airways

(lungs)

• Significantly reduce exercise induced bronchoconstriction

• Improve sleep, focus, concentration and calm

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Functional Breathing Pattern Training

• Reduce onset and endurance of breathlessness • Posture and spinal stabilization (poor breathing function reduces movement function)

• Reduce risk of injury

• Reduce energy cost associated with breathing

Simulation of High Altitude Training

• Improve aerobic capacity. EPO and Spleen contraction (some

non-responders)

• Improve anaerobic capacity

• Stimulate anaerobic glycolysis without risk of injury

• Increase VO2 max and running economy

• Increase maximum tolerance to breathlessness

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Simulation of High Altitude Training

• Improve respiratory muscle strength

• Improve muscle injury repair (New studies)

• Help maintain fitness during rest or injury

• Reduce free radicals and oxidative stress

• Reduce ventilatory response to hypercapnia and hypoxia

THE NOSE

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THE NOSE

• ‘One of the first lessons in the Yogi Science of Breath is to learn how to breathe through the nostrils, and to overcome the common practice of mouth-breathing.’

• Ramacharaka Yogi. Nostril versus mouth breathing. In: (eds.)THE HINDU-YOGI SCIENCE OF BREATH By YOGI RAMACHARAKA Author of "Yogi Philosophy and Oriental Occultism", "Advanced Course in Yogi Philosophy", "Hatha Yogi", "Psychic Healing", etc. Copyright 1903 ( Expired)

THE NOSE

• ‘many of the diseases to which civilized man is subject are undoubtedly caused by this common habit of mouth breathing.’

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BENEFITS OF NOSE BREATHING

•Dr. Maurice Cottle, who founded the American Rhinologic Society in 1954: your nose performs at least 30 functions, all of which are important supplements to the roles played by the lungs, heart, and other organs

•Timmons B.H., Ley R. Behavioral and Psychological Approaches to Breathing Disorders. 1st ed. Springer; 1994

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BENEFITS OF NOSE BREATHING

• The nasal cavity has a fundamental role in the physiology of respiration. It promotes filtering, heating and humidification of the inhaled air, causing it to reach the lungs at the ideal temperature and favoring the adequate oxygenation of the body.

• Rev. CEFAC vol.18 no.1 São Paulo Jan./Feb. 2016

BENEFITS OF NOSE BREATHING

• Nose breathing imposes approximately 50 percent more resistance to the air stream than mouth breathing during wakefulness, resulting in 10-20 percent more O2 uptake;

• Warms and humidifies incoming air; • Removes a significant amount of germs and bacteria;

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BENEFITS OF NOSE BREATHING

• Increased risk of developing forward head posture, and reduced respiratory strength

• A dry mouth also increases acidification of the mouth and results in more dental cavities and gum disease;

BENEFITS OF NOSE BREATHING

• Mouth breathing causes bad breath due to altered bacterial flora.

• Proven to significantly increase the number of occurrences of snoring and obstructive sleep apnoea

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NITRIC OXIDE

• Nitric oxide (NO) is released in the nasal airways in humans. During inspiration through the nose this NO will follow the airstream to the lower airways and the lungs. Nasally derived NO has been shown to increase arterial oxygen tension and reduce pulmonary vascular resistance, thereby acting as an airborne messenger.

•Lundberg JO. Nitric oxide and the paranasal sinuses. Anat Rec (Hoboken).2008 Nov;(291(11)):1479- 84

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NITRIC OXIDE

• Since NO is continuously released into the nasal airways the concentration will be dependent on the flow rate by which the sample is aspirated. Thus, nasal NO concentrations are higher at lower flow rates.

•Lundberg J, Weitzberg E. Nasal nitric oxide in man. Thorax.1999;(54):947-952

THE DIAPHRAGM

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THE DIAPHRAGM

• Breathing is a process that involves neural, chemical and muscular components and has as the main agents the diaphragm, intercostal and abdominal muscles.

• Fisioter Mov. 2014 abr/jun;27(2):211-8

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THE DIAPHRAGM

• Mouth breathing syndrome is characterized by a set of signs and symptoms, which may be present in subjects who replace the adequate and efficient nasal breathing mode by mouth or mixed breathing mode for more than six months.

• Rev. CEFAC vol.18 no.1 São Paulo Jan./Feb. 2016

THE DIAPHRAGM

• The patient with MBS has higher activity of accessory musculature of inspiration and, as a consequence, an increased energetic consumption and improper lung ventilation.

• Rev. CEFAC vol.18 no.1 São Paulo Jan./Feb. 2016

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THE DIAPHRAGM

• The failure in the filtration, humidification and heating of the inhaled air stimulates increased presence of

leukocytes in the blood, increasing the lung

hypersensitivity and decreasing its volumes and capacity.

• Rev. CEFAC vol.18 no.1 São Paulo Jan./Feb. 2016

THE DIAPHRAGM

• Nasal or upper airways obstruction determines disturbances in the afferent nerves with profound effects

on breathing and airway calibre of the lungs, negatively

affecting chest expansion and pulmonary ventilation.

• Rev. CEFAC vol.18 no.1 São Paulo Jan./Feb. 2016

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THE DIAPHRAGM

• Nasal obstruction can lead to decreased olfactory stimuli, increased pulmonary hyperresponsiveness and nasal

congestion.

• Rev. CEFAC vol.18 no.1 São Paulo Jan./Feb. 2016

THE DIAPHRAGM

• Eighteen articles were selected. Few studies refute or do not find any relationship between mouth breathing and

postural changes.

• Rev. CEFAC vol.18 no.1 São Paulo Jan./Feb. 2016

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THE DIAPHRAGM

• The muscle imbalance produced by these changes may contribute to the mechanical disadvantage of the

diaphragm and the increased effort of the accessory

muscles of inspiration.

• Rev. CEFAC vol.18 no.1 São Paulo Jan./Feb. 2016

THE DIAPHRAGM

• Decrease in the diaphragm amplitude caused by mouth breathing. If significant nasal obstruction- an attempt to overcome this obstruction occurs through conscious effort, by increasing the inspiratory effort through the accessory muscles of inspiration.

• The relationship between excursion of the diaphragm and curvatures of the spinal column in mouth breathing children. J Pediatr. 2008;84(2):171-7.

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THE DIAPHRAGM

• Mouth breathers develop hypertrophy in these muscles with impairment in the diaphragm muscle because of its inactivity and lack of synergism with abdominal muscles.

• International Journal of Pediatric Otorhinolaryngology (2008) 72, 1335—1343

THE DIAPHRAGM

• Higher activity of the sternocleidomastoid and upper Trapezius muscles in children with MBS than in children with nasal breathing mode, indicating that the head posture modifies with the nasal obstruction.

• J Electromyogr. Kinesiol.(2002) 302—316.

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THE DIAPHRAGM

• To evaluate diaphragmatic amplitude (DA) in nasal and mouth-breathing adults. The study evaluated 38 mouth- breathing (MB group) and 38 nasal-breathing (NB group) adults, from 18 to 30 years old and both sexes.

•Diaphragmatic amplitude and accessory inspiratory muscle activity in nasal and mouth breathing adults: a cross-sectional study. 2015; Journal of electromyography and kinesiology 25. 463-468

THE DIAPHRAGM

• Mouth breathing reflected on lower recruitment of the accessory inspiratory muscles during fast inspiration and lower diaphragmatic amplitude, compared to nasal breathing.

•Diaphragmatic amplitude and accessory inspiratory muscle activity in nasal and mouth breathing adults: a cross-sectional study. 2015; Journal of electromyography and kinesiology 25. 463-468,

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THE DIAPHRAGM

• Diaphragmatic breathing reduces heart rates, increases insulin, reduces glycemia, and reduces free-radical production as indicated by the higher antioxidants levels.

• Martarelli D1, Cocchioni M, Scuri S, Pompei P. Diaphragmatic breathing reduces exercise-induced oxidative stress.

THE DIAPHRAGM

• The consequence is a lower level of oxidative stress, which suggests that an appropriate diaphragmatic breathing could protect athletes from long-term adverse effects of free radicals.

• Martarelli D1, Cocchioni M, Scuri S, Pompei P. Diaphragmatic breathing reduces exercise-induced oxidative stress.

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HEAT & WATER LOSS

RESPIRATORY WATER LOSS

• To compare the difference in respiratory water loss during expiration through the nose and through the mouth, in healthy subjects.

• The study included 19 healthy volunteers. • Svensson S1, Olin AC, Hellgren J. Increased net water loss by oral compared to nasal expiration in healthy subjects. Rhinology. 2006 Mar;44(1):74-7.

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RESPIRATORY WATER LOSS

• The mean loss of expired water was 42% less by nasal expiration before decongestion than by oral expiration

• Svensson S1, Olin AC, Hellgren J. Increased net water loss by oral compared to nasal expiration in healthy subjects. Rhinology. 2006 Mar;44(1):74-7.

RESPIRATORY WATER LOSS

• Increased water and energy loss by oral breathing could be a contributing factor to the symptoms seen in patients suffering from nasal obstruction.

• Svensson S1, Olin AC, Hellgren J. Increased net water loss by oral compared to nasal expiration in healthy subjects. Rhinology. 2006 Mar;44(1):74-7.

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DENTAL HEALTH

• 35 triathletes who trained almost 10 hours a week • Significant correlation was found between caries prevalence and the cumulative weekly training time

• Athletes produced less saliva and it was acidic. Degree of acidity increased with the length of time exercising. Saliva is considered important to good tooth health.

• (Sports drinks, dry mouth) •Frese C1, Frese F2, Kuhlmann S1, Saure D3, Reljic D2, Staehle HJ1, Wolff D1. Effect of endurance training on dental erosion, caries, and saliva. Scand J Med Sci Sports. 2015 Jun;25(3):e319-26.

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FORWARD HEAD POSTURE

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FORWARD HEAD POSTURE

• Our study confirms that the oral breathing modifies head position. The significant increase of the craniocervical angles in patients with this altered breathing pattern suggests an elevation of the head and a greater extension of the head compared with the cervical spine.

•Breathing pattern and head posture: changes in craniocervical angles. Minerva Stomatol. 2015 Apr; 64(2):59-74.

FORWARD HEAD POSTURE

• Respiratory biomechanics and exercise capacity were negatively affected by Mouth Breathing.

• The presence of moderate forward head position acted as a compensatory mechanism in order to improve respiratory muscle function.

•J Bras Pneumol. 2011 Jul-Aug; 37(4):471-9. Mouth breathing and forward head posture: effects on respiratory biomechanics and exercise capacity in children.

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FORWARD HEAD POSTURE

• Mouth breathing children had cervical spine postural changes and decreased respiratory muscle strength compared with Nose Breathing.

•Braz J Otorhinolaryngol. 2011 Sep-Oct; 77(5):656-62. Exercise capacity, respiratory mechanics and posture in mouth breathers.

FORWARD HEAD POSTURE

• The results indicate that adults with mouth-breathing childhood have postural alterations, mainly in the head and lumbar column, which keeps for the whole life.

•Eur J Pediatric Dent. 2012 Dec; 13(4):321-3. Impact of the mouth breathing occurred during childhood in the adult age: biophotogrammetric postural analysis.

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Oral Breathing in Children video

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WORKLOAD

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WORKLOAD

• During exercise, nasal breathing causes a reduction in

FEO2 (fraction of expired air that is oxygen (O2%)), indicating that on expiration the percentage of oxygen extracted from the air by the lungs is increased.

• Morton, King, Papalia 1995 Australian Journal of Science and Medicine in Sport. 27, 51-55

WORKLOAD

• Maximal exercise intensity that could be achieved by healthy subjects while nasal breathing

• On average subjects could reach 90% of their max workload while nasally breathing (at least for the short period during the test).

Thomas, S. A., Phillips, V., Mock, C., Lock, M., Cox, G. and Baxter, J. (2009) The effects of nasal breathing on exercise tolerance. In: Chartered Society of Physiotherapy Annual Congress 2009

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WORKLOAD • 12 healthy physiotherapy students aged between 21 and 27 (8 male and 4 female) completed both runs. Nasal breathing was continued to 85% of V02 peak achieved indicating that people are capable of nose breathing at much higher intensities than they would normally chose to do.

Thomas, S. A., Phillips, V., Mock, C., Lock, M., Cox, G. and Baxter, J. (2009) The effects of nasal breathing on exercise tolerance. In: Chartered Society of Physiotherapy Annual Congress 2009

NOSE VERSUS MOUTH

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POOR NASAL FUNCTION

• Narrow nostrils - resistance to breathing will be too much during physical exercise

• Wear nasal dilator to reduce resistance • Recommended: TheTurbine Nasal dilator

RECREATIONAL ATHLETES

• Nasal breathing at all times • If you find that your need for air is so great that you need to open your mouth, simply slow down and allow your breathing to calm once more.

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COMPETITIVE ATHLETES

• Competitive athletes • Alternate nasal breathing with mouth breathing. • High-intensity training helps to prevent muscle de- conditioning and will require an athlete to periodically breathe through their mouth.

COMPETITIVE ATHLETES

• For less-than maximum intensity training, and at all other times, nasal breathing should be employed.

• For example, competitive athletes may spend 50 percent of their training with the mouth closed.

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COMPETITIVE ATHLETES

• Also devote training to working at an all-out pace in order to maintain muscle condition, for which brief periods of mouth breathing will be required.

COMPETITIVE ATHLETES

• During competition there is no need to intentionally take bigger breaths.

• Instead, bring a feeling of relaxation to your body and breathe as you feel necessary.

• However, breath-holding exercises during your warm-up can be very advantageous, as can practicing breathing recovery during your warm-down.

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COMPETITIVE ATHLETES

• Competition isn’t the ideal time to focus about how well or poorly you are breathing, as your full concentration should be devoted to the game. The best way to improve breathing for competition is to improve your everyday breathing, and the key to this is obtaining a higher BOLT score.

BREATHING EFFICIENCY

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BREATHING EFFICIENCY

• During hyperpnea (increased depth of breathing), the relative cost of breathing increases exponentially when moving from moderate exercise to heavy and maximal exercise levels.

• Aaron EA, Seow KC, Johnson BD, Dempsey JA. Oxygen cost of exercise hyperpnea: implications

for performance. J Appl Physiol (1985). 1992 May;72(5):1818- 25.

BREATHING EFFICIENCY

• While at moderate exercise, the cost of the respiratory system accounts for 3-6% total VO2max, heavy exercise accounts for a ~10% demand and maximal exercise accounts for anywhere between 13-15%.

• Aaron EA, Seow KC, Johnson BD, Dempsey JA. Oxygen cost of exercise hyperpnea: implications

for performance. J Appl Physiol (1985). 1992 May;72(5):1818- 25.

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BREATHING EFFICIENCY

• Breathing efficiency and physical fitness are both independent and complementary; while physical fitness does not always translate into breathing efficiency, there is no doubt that breathing efficiency is the gateway to attaining physical fitness.

BREATHING EFFICIENCY

• Breathing is light, quiet, effortless, soft, through the nose, diaphragmatic, rhythmic and gently paused on the exhale.

• This is how human beings breathed until the comforts of modern life changed everything, including our breathing.

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How to Measure Breathlessness

O X Y G E N ADVANTAGE MASTERCLASS

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One Technique-Eleven Exercises

• Measurement appraisals: Body Oxygen Level Test

(BOLT) & Maximum Breathlessness Test (MBT)

• Functional breathing pattern training

• Simulation of high altitude training

• Pre-competition preparation

Functional Breathing Pattern Training

• Improve blood circulation & oxygen delivery to the cells

• Dilate the upper airways (nose) and lower airways

(lungs)

• Significantly reduce exercise induced bronchoconstriction

• Improve sleep, focus, concentration and calm

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Functional Breathing Pattern Training

• Reduce onset and endurance of breathlessness • Posture and spinal stabilization (poor breathing function reduces movement function)

• Reduce risk of injury

• Reduce energy cost associated with breathing

Simulation of High Altitude Training

• Improve aerobic capacity. EPO and Spleen contraction (some

non-responders)

• Improve anaerobic capacity

• Stimulate anaerobic glycolysis without risk of injury

• Increase VO2 max and running economy

• Increase maximum tolerance to breathlessness

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Simulation of High Altitude Training

• Improve respiratory muscle strength

• Improve muscle injury repair (New studies)

• Help maintain fitness during rest or injury

• Reduce free radicals and oxidative stress

• Reduce ventilatory response to hypercapnia and hypoxia

HOW TO HOWMEASURE TO MEASUREBREATHLESSNESS BREATHLESSNESS Demonstration

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• Count the number of seconds until you feel the first distinct desire to breathe in.

BOLT (COMFORTABLE BREATH HOLD TIME) MEASUREMENT

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HOW TO MEASURE BREATHLESSNESS • Stanley et al. concluded that, ‘the breath hold time/partial pressure of carbon dioxide relationship provides a useful index of respiratory chemosensitivity’.

• Stanley,N.N.,Cunningham,E.L.,Altose,M.D.,Kelsen,S.G.,Levinson,R.S., and Cherniack, N.S. 7) Evaluation of breath holding in hypercapnia as a simple clinical test of respiratory chemosensitivity. Thorax.1975;30():337-343

• Voluntary breath holding duration is thought to provide an indirect index of sensitivity to CO2 buildup.

HOW TO MEASURE BREATHLESSNESS

• Breath holding as one of the most powerful methods to induce the sensation of breathlessness, and that the breath hold test ‘gives us much information on the onset and endurance of dyspnea.

• Nishino T. Pathophysiology of dyspnea evaluated by breath-holding test: studies of furosemide treatment. Respiratory Physiology Neurobiology.2009 May 30;(167(1)):20-5

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How to Measure Breathlessness

HOW TO MEASURE BREATHLESSNESS

• “If a person breath holds after a normal exhalation, it takes approximately 40 seconds before the urge to breathe increases enough to initiate inspiration.”

• McArdle W, Katch F, Katch V. Exercise Physiology: Nutrition, Energy, and Human Performance. 1st ed. North American Edition. Lippincott Williams & Wilkins; Seventh, (p289) (November 13, 2009)

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Maximum Breathlessness Test (MBT)

• Exhale normally through nose • Walk at a normal pace while holding the breath • Count the maximum number of paces that you can hold your breath

• Goal 80 to 100 paces • Less than 60 paces- significant room for improvement

HOW SHOULD WE BREATHE?

• When your breathing receptors have a strong response to carbon dioxide and reduced pressure of oxygen in the blood, your breathing will be intense and heavy.

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HOW SHOULD WE BREATHE?

• Strong ventilatory response to CO2 – breathing will be intense and heavy. (poor tolerance)

• Reduced ventilatory response to CO2- breathing will be relatively light.

HOW SHOULD WE BREATHE?

• During strenuous physical exercise, the consumption of oxygen increases, leading to a slightly reduced

concentration of O2 in the blood. At the same time, increased muscle activity and metabolic rate produces more carbon dioxide. (normally ventilation increases

proportionately to CO2 production so actual levels of

aCO2 wont change by much)

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HOW SHOULD WE BREATHE?

• The sensitivity of your receptors to carbon dioxide and oxygen will have implications for the way your body copes with physical exercise.

HOW SHOULD WE BREATHE?

• A low hypercapnic drive linked with physiological, biochemical and psychological components to make up an outstanding endurance performer.

McGurk et al. The relationship of hypercapnic ventilatory responses to age, gender and athleticism. Sports Med. 19 (3) 173-183. 1995

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HOW SHOULD WE BREATHE?

• One difference between endurance athletes and non- athletes is decreased ventilatory responsiveness to hypoxia (low oxygen) and hypercapnia (higher carbon dioxide).

• Scoggin CH, Doekel RD, Kryger MH, Zwillich CW, Weil JV. Familial aspects of decreased hypoxic drive in endurance athletes. Journal Applied Physiology1978;(Mar;44(3)):464-8

HOW SHOULD WE BREATHE?

• The lighter breathing of the athlete group may explain the link between “low ventilatory chemosensitivity and outstanding endurance athletic performance.”

• See: Martin BJ, Sparks KE, Zwillich CW, Weil JV. Low exercise ventilation in endurance athletes. Med Sci Sports.1979;(Summer;11(2):):181-5

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HOW SHOULD WE BREATHE?

• The lower ventilation in Trained Men than in Untrained Men, both at sea level and in hypoxia, was probably due to reduced chemoresponsiveness. A weaker hypercapnic ventilatory responsiveness may reduce ventilation in trained men.

• 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

HOW SHOULD WE BREATHE?

• Hypercapnic ventilatory drive might be lowered by severe physical training.

McGurk et al. The relationship of hypercapnic ventilatory responses to age, gender and athleticism. Sports Med. 19 (3) 173-183. 1995

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EFFECTEFFECT ON ON

VOVO2 MAX2 MAX

EFFECT ON VO2 MAX

• The maximum capacity of your body to transport and utilise oxygen in one minute during maximal exercise.

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EFFECT ON VO2 MAX

• Affected by amount of red blood cells, muscle and how much blood your heart can pump.

• If your body can take in more oxygen and deliver it to your working muscles- higher VO2 max.

• (Increase oxygen carrying capacity, and improve tolerance to carbon dioxide (reduced ventilatory response))

EFFECT ON VO2 MAX

• The athletes’ response to increased carbon dioxide was 47% of that recorded by the non-athlete controls. Athletic ability to perform during lower oxygen pressure and higher carbon dioxide pressure, corresponded to

maximal oxygen uptake or VO2 max.

• Byrne-Quinn E, Weil JV, Sodal IE, Filley GF, Grover RF. Ventilatory control in the athlete. J Appl Physiol.1971 ;(Jan;30(1):91-8

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EFFECT ON VO2 MAX

• CO2 responsiveness was found to correlate negatively with maximum oxygen uptake in four out of the five trained subjects.

• Miyamura M, Hiruta S, Sakurai S, Ishida K, Saito M. Effects of prolonged physical training on ventilatory response to hypercapnia. Tohoku J Exp Med.1988;(Dec;156 Suppl:):125-35

INTERMITTENTINTERMITTENT HYPOXIAHYPOXIA TRAININGTRAINING (IHT)(IHT)

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INTERMITTENT HYPOXIA TRAINING (IHT)

• Intermittent hypoxic interval training (IHIT) is defined as a method where during a single training session, there is alternation of hypoxia (inadequate oxygen) and normoxia (normal oxygen).

• J Hum Kinet. 2011 Jun; 28: 91–105.

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INTERMITTENT HYPOXIA TRAINING (IHT)

• Repeatedly using breath holding following exhalation during training would represent an intermittent hypoxic exposure and could therefore be likened to IHT, although hypoventilation also induces hypercapnia.

• Millet GP1, Roels B, Schmitt L, Woorons X, Richalet JP. Combining hypoxic methods for peak performance. Sports Med 2010; 40 (1): 1-25

INTERMITTENT HYPOXIA TRAINING (IHT)

• Craig, Dicker, Holmer reported that reduced frequency breathing would not achieve hypoxemia

• Yamamoto et al. 1987 reported a decrease to 87% SpO2 when breath holding was performed at functional residual capacity. (FRC)

• Respiratory Physiology & Neurobiology 158(1):75-82

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INTERMITTENT HYPOXIA TRAINING (IHT)

• A difference of exercise intensity may have a significant impact on SaO2%

• The harder you exercise, the stronger the effect.

• Respiratory Physiology & Neurobiology 158(1):75-82

INTERMITTENT HYPOXIA TRAINING (IHT)

• Breath-hold training causes lower blood acidity, higher tolerance to anoxia, decelerated metabolism and an increase in Hct value, Hb and EPO concentration as well as the mass and volume of the lungs.

• Schagatay et al., 2000, 2001, 2005, 2007, Bakovic et al., 2005, Prommer et al., 2007, De Bruijn et al., 2008, Richardson et al., 2008) Journal of Human Kinetics volume 32/2012, 197-210

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INTERMITTENT HYPOXIA TRAINING (IHT)

• Not all researchers have reported improvements to aerobic capacity. More research is required.

• No change in Hb after training

Xavier Woorons , Pascal Mollard, Aur´elien Pichon, Alain Duvallet, Jean-Paul Richalet, Christine Lamberto. Effects of a 4-week training with voluntary hypoventilation carried out at low pulmonary volumes. Respiratory Physiology & Neurobiology 160 (2008) 123–130

INTERMITTENT HYPOXIA TRAINING (IHT)

• For most people, after a week or so of practice, a drop of oxygen saturation below 90% can be observed – a level that is comparative to the effects of living at an altitude of 3,000-4,000 metres.

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EFFECT ON RUNNING ECONOMY

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EFFECT ON RUNNING ECONOMY

• The amount of energy or oxygen consumed while running at a speed that is less than maximum pace. Typically, the less energy required to run at a given pace, the better – if your body is able to use oxygen efficiently, it is indicative of a high running economy.

EFFECT ON RUNNING ECONOMY

• Running economy has been linked to success in distance running, such that faster runners are more economical (Morgan et al., 1995; Lavin et al., 2012) and better metabolic efficiency preserves glycogen and delays the onset of fatigue (Rapoport, 2010).

• Scand J Med Sci Sports 2015: 25: 16–24

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EFFECT ON RUNNING ECONOMY

• Eighteen swimmers comprising of ten men and eight women who were assigned to two groups. The first group was required to take only two breaths per length and the second group seven breaths.

• See: Lavin, K. M.; Guenette, J. A.; Smoliga, J. M.; Zavorsky, G. S. Controlled-frequency breath swimming improves swimming performance and running economy. Scandinavian Journal of Medicine & Science in Sports 2013 Oct 24

EFFECT ON RUNNING ECONOMY

• Researchers found that running economy improved by 6% in the group that performed reduced breathing during swimming.

• Lavin, K. M.; Guenette, J. A.; Smoliga, J. M.; Zavorsky, G. S. Controlled-frequency breath swimming improves swimming performance and running economy. Scandinavian Journal of Medicine & Science in Sports

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EPO EPO

EPO

• As a result of decreased blood perfusion, local ischaemia occurs in the kidneys, causing anoxia (absence of O2), which stimulates EPO production (Balestra et al., 2006). EPO stimulates proliferation and maturation of bone marrow’s red blood cells.

• Journal of Human Kinetics volume 32/2012, 197-210

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BREATH HOLDING INCREASES EPO

• The hormone erythropoietin (Epo) is essential for red blood cell (RBC) production.

• First described by the French anatomist Francois-Gilbert Viault in 1890 (Viault, 1890), who observed a rise in RBC numbers on a journey to the highlands of Peru (Morococha, about 4500 m).

• Wolfgang Jelkmann. Regulation of erythropoietin production. J Physiol. 2011 Mar 15; 589(Pt 6): 1251–1258.

BREATH HOLDING INCREASES EPO

• Epo production increases under hypoxic conditions in the kidneys and, in minor amounts, in distinct other organs such as the liver and the brain.

• Wolfgang Jelkmann. Regulation of erythropoietin production. J Physiol. 2011 Mar 15; 589(Pt 6): 1251–1258.

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BREATH HOLDING INCREASES EPO

• Ten healthy volunteers • 15 maximal duration apneas, divided into three sets of five apneas, each set separated by 10 min of rest. • Apneas within sets were separated by 2 min and preceded by 1 min of hyperventilation to increase apnea duration and arterial oxygen desaturation.

• (Three sets of five maximum duration breath holds, with each set separated by ten minutes of rest.) de Bruijn R, Richardson M, Schagatay E. Increased erythropoietin concentration after repeated apneas in humans. Eur J Appl Physiol 2008;102:609–13.

BREATH HOLDING INCREASES EPO

• Apnea started after a full exhalation and a deep, but not maximal inhalation. Subjects were instructed to try to reach below 85% SaO2 during each apnea and received continuous visual feedback on their SaO2 levels.

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BREATH HOLDING INCREASES EPO

• Results showed that EPO concentration increased by 24%, which peaked at three hours after the final breath hold and returned to baseline two hours later.

BREATH HOLDING INCREASES EPO

• Our 24% increase in EPO is comparable to an increase of 24% found by Ge and associates (2002) after 6 h at an altitude of 1,780 m.

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BREATH HOLDING INCREASES EPO

• The erythropoiesis is slow, because it takes a lot of cell division. After an acute rise of EPO in the blood it takes 3- 4 days until a significant higher amount of young red blood cells (reticulocytes) release from the bone marrow into the blood. Different hormones boost the EPO effect.

BREATH HOLDING INCREASES EPO

• Erythropoiesis is a slow-acting process. Following a rise in plasma Epo it takes 3–4 days before reticulocytosis becomes apparent.

• Wolfgang Jelkmann. Regulation of erythropoietin production. J Physiol. 2011 Mar 15; 589(Pt 6): 1251–1258.

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BREATH HOLDING INCREASES EPO

• Erythropoiesis is a slow-acting process. Following a rise in plasma Epo it takes 3–4 days before reticulocytosis becomes apparent.

• Wolfgang Jelkmann. Regulation of erythropoietin production. J Physiol. 2011 Mar 15; 589(Pt 6): 1251–1258.

HYPERCAPNIC- HYPOXIC TRAINING

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HYPERCAPNIC- HYPOXIC TRAINING

• The Voluntary Hypoventilation Low lung volumes (VHL) technique has recently been included in the updated nomenclature of altitude training methods.

• Girard, O., Brocherie, F., & Millet, G. P. (2017). Effects of Altitude/Hypoxia on Single- and Multiple-Sprint Performance: A Comprehensive Review. Sports Medicine (Auckland, N.Z.). https://doi.org/10.1007/s40279-017-0733-z

HYPERCAPNIC- HYPOXIC TRAINING

• 8 week hypercapnic-hypoxic training program in elite male swimmers, 30 to 45 minutes, three times a week.

• Darija Baković, Zoran Valic, Davor Eterović, Ivica Vuković, Ante Obad, Ivana Marinović-Terzić, Zeljko Dujić. Spleen volume and blood flow response to repeated breath-hold apneas. Journal of Applied Physiology.2003;(vol. 95 no. 4):1460-1466

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HYPERCAPNIC- HYPOXIC TRAINING

• Each test subject has withheld breath individually, by a subjective feeling, for as long as possible.

HYPERCAPNIC- HYPOXIC TRAINING

• Each breath hold must be above the minimum values which describe hypercapnia, that is, the values of carbon dioxide in the exhaled breath had to be over 45 mmHg, which was controlled by a capnometer.

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HYPERCAPNIC- HYPOXIC TRAINING

• Besides the swimming training sessions the control group was subjected to additional aerobic training sessions on a treadmill. The program was conducted three times a week for eight weeks.

HYPERCAPNIC- HYPOXIC TRAINING

Experiment Control

Pre: Hb(g/L) 144.63 147.75

Post: Hb (g/L) 152.38 145.38

5.35% higher Hb

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HYPERCAPNIC- HYPOXIC TRAINING

Experiment Control

VO2 Max Pre: 63.80 59.46

VO2 Max Post: 70.38 60.81

10.79% increase to VO2 max

HYPERCAPNIC- HYPOXIC TRAINING

Saunders et al. (2013). 1% Hb increase after altitude training eventually results in .6 - .7% VO2 max increase.

• Zoretić, D., Grčić-Zubčević, N. and Zubčić, K.: THE EFFECTS OF HYPERCAPNIC- HYPOXIC TRAINING.

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HYPERCAPNIC- HYPOXIC TRAINING

• 15 middle distance runners

• (600- 3000m) over six weeks

• Runners participated in official athletics competition before and after

•Fortier E, Nadeau. Peterborough, Canada

HYPERCAPNIC- HYPOXIC TRAINING

•First group- normal breathing +.03% improvement

• Fortier E, Nadeau. Peterborough, Canada

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HYPERCAPNIC- HYPOXIC TRAINING

• Second group- 15 to 20 minutes of breath holding on the exhalation once per week: +1.27% improvement

• Third group- 15 to 20 minutes of breath holding on the exhalation twice per week: +1.33% improvement

•Fortier E, Nadeau. Peterborough, Canada

HYPERCAPNIC- HYPOXIC TRAINING

• Runners trained 3 times per week with VHL over a 4 week period

• 85% of the runners who applied VHL improved their maximum velocity attained at the end of a treadmill test by .5km/h on average.

• Mean improvement of VHL group: + 2.4%

• Normal breathing group- no change

•Woorons X. Effects of 4 week training with voluntary hypoventilation carried out at low pulmonary volumes.

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HYPERCAPNIC- HYPOXIC TRAINING

• Over a 5-week period, sixteen triathletes (12 men, 4 women) were asked to include twice a week into their usual swimming session one with hypoventilation at low lung volume (VHL group) or with normal breathing (CONT group).

• Woorons X, Mucci P, Richalet JP, Pichon A. Hypoventilation Training at Supramaximal Intensity

Improves Swimming Performance. Med Sci Sports Exerc. 2016 Jun;48(6):1119-28

HYPERCAPNIC- HYPOXIC TRAINING

• Before (Pre-) and after (Post-) training, all triathletes performed all-out front crawl trials over 100, 200 and 400m.

• Woorons X, Mucci P, Richalet JP, Pichon A. Hypoventilation Training at Supramaximal Intensity

Improves Swimming Performance. Med Sci Sports Exerc. 2016 Jun;48(6):1119-28

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HYPERCAPNIC- HYPOXIC TRAINING

• Time performance was significantly improved in trials involving breath holding following an exhalation in all trials but did not change in CONTROLS.

• 100m: – 3.7 ± 3.7s • 200m: – 6.9 ± 5.0s • 400m: – 13.6 ± 6.1s

• Woorons X, Mucci P, Richalet JP, Pichon A. Hypoventilation Training at Supramaximal Intensity Improves

Swimming Performance. Med Sci Sports Exerc. 2016 Jun;48(6):1119-28

HYPERCAPNIC- HYPOXIC TRAINING

• To determine the effects of repeated sprint training in hypoxia induced by voluntary hypoventilation at low lung volume (VHL) on running repeated sprint ability (RSA) in team-sport players.

Repeated sprint training in hypoxia induced by voluntary hypoventilation improves running repeated sprint ability in rugby players. European Journal of Sport Science · January 2018

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HYPERCAPNIC- HYPOXIC TRAINING

• Twenty-one highly trained rugby players performed, over a 4-week period, 7 sessions of repeated 40m sprints either with VHL (RSH-VHL, n = 11) or with normal breathing (RSN, n = 10).

Repeated sprint training in hypoxia induced by voluntary hypoventilation improves running repeated sprint ability in rugby players. European Journal of Sport Science · January 2018

HYPERCAPNIC- HYPOXIC TRAINING

• Repeated sprint ability (RSA), which represents the ability to reproduce performance during maximal or near maximal efforts interspersed with brief recovery intervals, is considered a key factor in team sports.

Repeated sprint training in hypoxia induced by voluntary hypoventilation improves running repeated sprint ability in rugby players. European Journal of Sport Science · January 2018

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HYPERCAPNIC- HYPOXIC TRAINING

• First two sessions, subjects performed two sets of 8 x 40m. The number of repetitions was then progressively increased over the course of the training period (two more repetitions per week on average) to reach 3 x 8 sprints at the last session.

• Repeated sprint training in hypoxia induced by voluntary hypoventilation improves running repeated sprint ability in rugby players. European Journal of Sport Science · January 2018

HYPERCAPNIC- HYPOXIC TRAINING

• Each set was separated by three minutes of semiactive recovery (i.e. walking). The RSN group performed the repeated sprint training with normal breathing while RSH-VHL group completed the repetitions with VHL (except the recovery between sets which was performed with normal breathing).

• Repeated sprint training in hypoxia induced by voluntary hypoventilation improves running repeated sprint ability in rugby players. European Journal of Sport Science · January 2018

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HYPERCAPNIC- HYPOXIC TRAINING

• Before (Pre-) and after training (Post-), performance was assessed with a RSA test (40-m all-out sprints with a departure every 30s) until task failure (85% of the peak velocity of an isolated sprint).

Repeated sprint training in hypoxia induced by voluntary hypoventilation improves running repeated sprint ability in rugby players. European Journal of Sport Science · January 2018

HYPERCAPNIC- HYPOXIC TRAINING

Normal exhalation just before the start of each sprint, then to hold their breath until the end of the 40-m sprint and finally to perform the second exhalation to empty the remaining air from the lungs. (8 reps per set)

Repeated sprint training in hypoxia induced by voluntary hypoventilation improves running repeated sprint ability in rugby players. European Journal of Sport Science · January 2018

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HYPERCAPNIC- HYPOXIC TRAINING

• The number of sprints completed during the RSA test was significantly increased after the training period in RSH-VHL (9.1 vs. 14.9) but not in RSN (9.8 vs. 10.4).but not in RSN. • Repeated sprint training in hypoxia induced by voluntary hypoventilation improves running repeated sprint ability in rugby players. European Journal of Sport Science · January 2018

HYPERCAPNIC- HYPOXIC TRAINING

• Maximal velocity was not different between Pre- and Post- in both groups whereas the mean velocity decreased in RSN and remained unchanged in RSH- VHL. • Repeated sprint training in hypoxia induced by voluntary hypoventilation improves running repeated sprint ability in rugby players. European Journal of Sport Science · January 2018

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HYPERCAPNIC- HYPOXIC TRAINING

• The mean SpO2 recorded over an entire training session was lower in RSH-VHL than in RSN (90.1 ± 1.4 vs. 95.5 ± 0.5 %, p<0.01). • RSH-VHL appears to be an effective strategy to produce a hypoxic stress and to improve running RSA in team sport players.

• Repeated sprint training in hypoxia induced by voluntary hypoventilation improves running repeated sprint ability in rugby players. European Journal of Sport Science · January 2018

Acidosis

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REDUCED ACIDOSIS

• Fatigue- physiological- breaking point at which the athlete

cannot continue exercise intensity.

REDUCED ACIDOSIS

• Metabolism produces CO2 - dissociates to H+ and HCO3-

• Sufficient oxygen to the muscles - H+ is oxidised in the

mitochondria to generate water

• Insufficient oxygen- all H+ cannot be oxidised and

associates with pyruvic acid to form lactic acid

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REDUCED ACIDOSIS

• Breath holding after an exhalation causes a decrease to the

concentration of oxygen to trigger increased lactic acid.

• At the same time, carbon dioxide also increases leading to an

increased concentration of hydrogen ions to further acidify the

blood.

REDUCED ACIDOSIS

• Repeated exposure to increased acidosis- forces the

body to adapt to it.

• To neutralise H+, buffering capacity improves.

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REDUCED ACIDOSIS

• Factors participating in the weaker blood acidosis may have an origin within the muscular cell.

• Hydrogen ions may accumulate more slowly and allow the athletes to continue to exercise longer or at a higher

intensity for a given distance.

ANEROBIC TRAINING

• It can be traumatizing to repeatedly perform exercises at high intensities to stimulate an anaerobic state.

• Training at a moderate intensity with breath holding could reduce the risk of injury.

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CENTRAL GOVERNOR

• Central Governor theory- the heart is the most important organ to protect against over exercising.

• Governor in the brain which monitors oxygenation of the heart, and possibly the brain and diaphragm.

• If oxygen levels drop too much, the brain will send messages to slow down the athlete.

CENTRAL GOVERNOR

• The body experiences fatigue, burning or pain. The athlete slows down and thus the heart is protected.

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CENTRAL GOVERNOR

• Acidosis impairs homeostasis. Breath holding conditions the brain to tolerate strong acidosis- teaches the brain that the body can go harder and faster without over doing it.

SIMULATE HIGH LONGALTITUDE TERM EFFECTSTRAINING Demonstration - Walking

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LONG TERM EFFECTS OF BREATH HOLDING

• Resting Hb mass in trained breath hold divers was 5% higher than untrained. In addition breath hold divers showed a larger relative increase to Hb after three apneas.

• Lemaître F, Joulia F, Chollet D. Apnea: a new training method in sport? Med Hypotheses. 2010;(Mar;74(3)):413-5

LONG TERM EFFECTS OF BREATH HOLDING

• Pre-test hemoglobin tended to be higher in the diver group than both skiers and untrained. (divers 150.1g/L; skiers 145.5 g/L; untrained 146.9 g/L)

• Richardson M, de Bruijn R, Holmberg HC, et al. Increase of hemoglobin concentration after maximal apneas in divers, skiers, and untrained humans. Can J Appl Physiol 2005;30:276–81

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BREATH HOLDING IN PRACTISE

• World-renowned Brazilian track coach Luiz De Oliveira used breath hold training with Olympic athletes Joaquim Cruz and Mary Decker, who set six world records in 800

metre to one-mile distance running events.

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BREATH HOLDING IN PRACTISE

• De Oliveira, "The most important thing you can do in the race no matter how exhausted you get is to maintain your form.“

• Tom Piszkin . Interview with Luiz De Oliveira. Email to: Patrick McKeown. ([email protected]) November 2012

BREATH HOLDING IN PRACTISE

• The legendary Eastern European athlete Emil Zatopek, described by the New York Times as perhaps one of the greatest distance runners ever also incorporated breath holding into his regular training.

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BREATH HOLDING IN PRACTISE

• On the first day, he held his breath until he reached the fourth poplar. On the second day he held his breath until he reached the fifth poplar, increasing the distance of his breath hold by one poplar each day until he could hold his breath for the entire line of trees. On one occasion, Emil held his breath until he passed out.

BREATH HOLDING IN PRACTISE

• 1952 Helsinki Olympics brought Emil much fame and adoration after he won the 5,000 metres, the 10,000 metres and the marathon, which he decided to run on a whim, having never completed the distance before.

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BREATH HOLDING IN PRACTISE

• Galen Rupp – the current American record holder of the 10,000 metres, indoor 3,000 metres, and silver medal winner at the 2012 Summer Olympics – had recently collapsed during training. Rupp’s headphones had fallen off and “he was unable to hear his coach reminding him to breathe”.

PRE-COMPETITION PREPARATION

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Sleep

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GETTING A BETTER NIGHT’S SLEEP

• Determine sleeping position

GETTING A BETTER NIGHT’S SLEEP

• Tape mouth closed- • 3M micropore tape/LipSealTape.com • Wear tape for twenty minutes during the day to become comfortable with it

• If mouth naturally moist in the morning, no need for tape

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Pre-Competition Preparation

1. Meditation and reduced breathing 20 minutes (focus the mind)

2. Perform 6 to 10 strong breath holds to create hypoxic hypercapnic response. Complete five to ten minutes prior to the game. (EPO and Splenic contraction)

3. Medium to large breaths for 30 seconds to one minute to lower acidosis (BOLT score > 25 seconds)

4. Bring a feeling of intense energy throughout the body

Pre-Competition Preparation

• Nine well-trained swimmers (5 males and 4 females) performed a 50m front crawl sprint either in normal conditions (NO) or after hyperventilation (HV) (30-second pre-exercise maximal voluntary hyperventilation).

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Pre-Competition Preparation

• Average velocity for the 50 m front crawl was significantly higher after HV. • As a result, performance improves (27.79 s vs. 28.08). • The number of breathing cycles recorded during each race was significantly lower under HV compared to NO • The stroke rate was slightly increased under HV conditions. (strokes per minute)

Science & Sports Volume 30, Issue 3, June 2015.

Pre-Competition Preparation

• A pre-exercise maximal voluntary hyperventilation can significantly increase performance on the 50 m front crawl in well-trained swimmers.

Science & Sports Volume 30, Issue 3, June 2015.

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Pre-Competition Preparation

• Repeated high-intensity sprints incur substantial anaerobic metabolic challenges and create an acidic muscle milieu that is unfavorable for subsequent performance.

• J Strength Cond Res. 2014 Apr;28(4):1119-26.

Pre-Competition Preparation

• This study tested the hypothesis that hyperventilation performed during recovery intervals would attenuate performance decrement in repeated sprint pedalling.

• J Strength Cond Res. 2014 Apr;28(4):1119-26.

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Pre-Competition Preparation

• Thirteen male university athletes performed 10 sets of 10-second maximal pedalling on a cycle ergometer with a 60-second recovery between sets under control (spontaneous breathing) and hyperventilation conditions.

• J Strength Cond Res. 2014 Apr;28(4):1119-26.

Pre-Competition Preparation

• This intervention successfully increased blood pH by

0.03-0.07 but lowered PCO2 by 1.2-8.4 mm Hg throughout exercise.

• J Strength Cond Res. 2014 Apr;28(4):1119-26.

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Pre-Competition Preparation

• In conclusion, hyperventilation implemented during recovery intervals of repeated sprint pedalling attenuated performance decrements in later exercise bouts that was associated with substantial metabolic acidosis. (too much H+ from the cells)

• J Strength Cond Res. 2014 Apr;28(4):1119-26.

Pre-Competition Preparation

• The practical implication is that hyperventilation may have a strategic role for enhancing training effectiveness and may give an edge in performance outcomes.

• J Strength Cond Res. 2014 Apr;28(4):1119-26.

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INCREASEDINCREASED CREATIVITYCREATIVITY

INCREASED CREATIVITY

• During breath holding, due to O2 consumption and a decrease in its partial pressure in the lung alveola, the flowing blood is less and less oxygenated with time. This does not mean that the brain immediately receives less oxygen.

• Journal of Human Kinetics volume 32/2012, 197-210

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INCREASED CREATIVITY

• Oxygen blood saturation is admittedly lower, yet the blood circulation to the brain is higher, which is caused by the dilation of blood vessels in the brain that occurs with increased CO2 concentration.

• Journal of Human Kinetics volume 32/2012, 197-210

INCREASED CREATIVITY

• Yoshiro Nakamats, one of the world's most prolific inventors with over 4,000 patents.

• The floppy disk, the hard disk, and the digital watch.

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INCREASED CREATIVITY • One of his best secrets for coming up with his ideas as: "swim till almost die!"; this technique consists in swimming underwater and “holding your breath as long as possible, therefore forcing more and more oxygen into your brain so that you can think better!”

PROGRAM

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PROGRAM

BOLT Score of Less Than 10 Seconds • Measure your BOLT score each morning after waking;

• Breathe through the nose both day and night (tape);

• Swallow or hold the breath any time you feel a sigh coming;

• Practice the many small breath holds (Ex 1) -10 minutes by 6 times per day;

• Small paces (Ex 3): Exhale through your nose, pinch your nose with your fingers, and walk while holding the breath for 5 to 10 paces. Rest for 1 minute and repeat 10 times. (three sets per day)

PROGRAM

BOLT Score of Less Than 10 Seconds • Engage in 10 to 15 minutes of slow walking each day with mouth closed. If need to breathe through mouth, slow down or stop;

• When BOLT score increases to 15 seconds, Breathe Light (Ex2). 1 hour per day (six by 10-minute sets);

• As your BOLT score increases, it will become a lot easier to engage in physical exercise. Your expected progress is to increase your BOLT score to 25 seconds within 6 to 8 weeks.

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PROGRAM

BOLT Score of Less Than 20 Seconds • Measure your BOLT score each morning after waking;

• Breathe through the nose at all times. Wear paper tape at night;

• Regularly observe your breathing throughout the day;

• Breathe Light (Ex2) for 10 minutes by 2 times daily;

• Warm up (Ex 4 or Ex10) for 10 minutes prior to exercise by walking and breath holding every minute or so;

• Practice Breathe walking (Ex 5) for between 30 and 60 minutes per day.

PROGRAM

Oxygen Advantage Program for a BOLT Score of 20 to 30 seconds • Measure your BOLT score each morning after waking;

• Breathe through the nose both day and at night, including wearing tape;

• Breathe Light (Ex2) for 10 minutes, 2 times per day;

• Warm up (Ex 4 or Ex10) for 10 minutes prior to exercise by walking and breath holding every minute or so;

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PROGRAM

Oxygen Advantage Program for a BOLT Score of 20 to 30 seconds • Breathe Light to Breathe Right during a fast walk or jog for 30 to 60 minutes;

• Simulate High-Altitude Training during walking or jogging by practicing 8 to 10 breath holds;

• After physical exercise, practice the Breathing Recovery exercise.

PROGRAM

BOLT Score of 30 Seconds or More • Measure your BOLT score each morning after waking; • Breathe through the nose both day and at night, including wearing tape during sleep;

• Warm up (Ex 4 or Ex10) for 10 minutes prior to exercise by walking and breath holding every minute or so; • Breathe Light during the run ; • Continue with running and nasal breathing for 20 minutes;

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PROGRAM BOLT Score of 30 Seconds or More • Midway through the run, practice breath holds; • Intersperse breath holds every few minutes throughout the run;

• After physical exercise, Breathing Recovery exercise; • Practice one session of Advanced Simulation of High Altitude every other day;

• Breathe Light (Ex2) for 15 minutes before sleep.

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O X Y G E N ADVANTAGE DAY 3

NUANCES

• Persons with migraine, panic attacks, heart disease (if recent heart attack- relaxation without air shortage), high blood pressure may experience stress from holding the breath. • If heart rate remains higher when measured ten minutes after the final breath hold- stop doing strong breath holds.

• Instead begin with relaxation, many small breath holds (Ex 1), light air shortage (Ex 2), small paces.

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NUANCES

• Strong breath holds are only suitable if the heart rate normalises when measured ten minutes after completion of strong breath hold.

PERSONS WITH ANXIETY

• May find it difficult to focus on breathing.

• Air shortage may generate panic.

• If BOLT increases too quickly, cleansing reaction may occur.

• If necessary practise exercises involving distraction. (breathing through nose, stop sighing, relaxation, small breath holds, walking with mouth closed).

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PREGNANCY

• During first trimester- no reduced breathing exercises • Prevent hyperventilation- avoid overeating, high temperatures, stress, mouth breathing etc

• BOLT should not increase by more than 2 seconds each week

• 2nd trimester- go gently with air shortage

MEDICATION

• When the morning BOLT increases to above 20 seconds, persons taking medication for hypertension, diabetes or thyroid should visit their medical doctor to have their medication evaluated.

• Persons taking asthma and rhinitis medication also need to have their medication evaluated.

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LOW BOLT SCORE, SEVERE ASTHMA & ANXIETY OR PANIC • Limit breath holding while walking to ten paces- see how he or she does, then increase to twelve, see how he does. Continue to increase the paces while observing recovery.

• If child or adult has under twenty paces- breathing is very intense. Higher chance of disrupting breathing and causing symptoms.

• Try to achieve as many paces without causing symptoms.

• In addition, practise breathing recovery exercise ten minutes by six times daily.

IF HAVE SYMPTOMS

• Too difficult to reduce breathing if symptoms are present or BOLT is very low.

• Do breathing recovery exercise until symptoms pass, or BOLT reaches 12/13 seconds.

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IF FEELING SUFFOCATED

• Concentrate on stronger breath holds (if person is suited)

• Do paces exercise to help reset respiratory centre quickly

• Breathing will quieten in about half an hour

MILDLY BLOCKED NOSE AT NIGHT

• First clear nose by completing the nose unblocking exercise and rinse your nose with saline solution (described in Close Your Mouth).

• Wear paper tape over lips.

• While wearing the tape, your nose will never completely block. Your nose will partially block if BOLT is low.

• Nose will continue to block until BOLT is 20 seconds.

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UNCOMFORTABLY BLOCKED NOSE AT NIGHT • Practice half an hour of reduced breathing before bed. (or ten repetitions of Paces exercise)

• Rinse your nose with sea salt and water.

• Wear the tape (LipSealTape) across your mouth.

• Wear MuteSnoring in your nose during sleep.

• This will help overcome the feeling of suffocation during sleep.

KNOW WHEN TO REFER TO DOCTOR

• Practise six repetitions of Paces Exercise (create a strong air shortage)

• If child or adult can breathe through their nose for one minute, they can do so for life

• If child or adult is unable to breathe through their nose for one minute, then refer to Doctor/ENT specialist

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WEEK 1

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WEEK 1

• Who is the client? • Approx age? • State of health? • What would they like to achieve? • Is it a team or an individual? • The sportier the client, the greater the emphasis on physical movement.

WEEK 1

• What form of physical exercise do they partake in?

• OA can be applied during walking, running, cycling, rowing or any sport.

• Are they recreational or competitive?

• How do they warm up?

• Do they meditate?

• Incorporate the OA into their existing routine for best effect. But first teach them the basic program so they understand the exercises.

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WEEK 1

• Paper tape • Pulse oximeter- explain how it works. • Measures peripheral oxygen saturation (Spo2) to give a close approximation of the saturation of arterial blood with oxygen (Sao2). What percentage of Hb is loaded with O2.

• Two lights- red light and infrared light. • Oxygenated hemoglobin absorbs more infrared light and allows more red light to pass through. Deoxygenated hemoglobin allows more infrared light to pass through and absorbs more red light.

WEEK 1

• Client intake form (provided in folder- marketing images and more) • How to recognise poor functional breathing • Benefits of functional breathing • Briefly talk about the Bohr effect, nasal breathing, sleep, asthma, reduced breathlessness, improved focus and concentration.

• Discuss the benefits of strong breath holding. Explain how oxygen is carried in the blood and hypercapnic/hypoxic training.

• Benefits: Delayed lactic acid and fatigue, improved resilience, improved respiratory muscle strength.

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WEEK 1

• Measure BOLT score and give feedback

• Measure MBT score and give feedback

• Ex 2: Breathe Light- 5 minutes

• Ex 3: Preparation of simulation of altitude

• Ex 4: Simulation of altitude training- 5 reps

• Tape mouth at night. Lipsealtape.com

WEEK 1

• In assessing functional breathing, BOLT score although not perfect provides good feedback.

• Also observe athletes breathing during rest:

Fast or slow

Regular or interspersed with sighs

Pause if any at the end of exhalation

Upper chest or diaphragm

Amplitudes of the breath

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WEEK 1 HOMEWORK

• Breathe Light 15 minutes during the day and 15 minutes before sleep. (sets of 5 minutes with rest of one minute between each)

• Incorporate nasal breathing and breath holding during warm up.

• 5 reps of breath holding by two times daily (not after eating)

• Nose breathing during physical exercise as much as possible.

WEEK 2

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WEEK 2

• Check progress. Observe athletes breathe. • Recap on functional breathing and dysfunctional breathing • Measure BOLT score • Measure MBT • Ex 2: Breathe Light- 5 minutes • Ex 3: Preparation of simulation of altitude • Ex 4: Simulation of altitude training- 5 reps • Ex 6: walking, jogging 5 minutes • Ex 10: Shark fit

WEEK 2 HOMEWORK

• Breathe Light 15 minutes during the day and 15 minutes before sleep

• Incorporate nasal breathing and breath holding during warm up

• (Ex 4 or Ex 10) 5 reps of breath holding by two sets daily (not after eating)

• Nose breathing during physical exercise as much as possible.

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WEEK 3

WEEK 3 onwards

• Check progress. Observe athletes breathe • Recap on functional breathing and dysfunctional breathing • Measure BOLT score • Measure MBT • Do entire 11 exercise workout • (main addition is breathe light and simulation altitude training advanced)

• Introduce pre competition preparation (also for presentations)

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WEEK 3 HOMEWORK

• 40- 60 minutes of combination of exercises throughout the day

• Jogging/running with mouth closed • Walking/jogging/running 5 to 10 reps of strong breath holds daily

• Breathe light for 15 minutes before sleep • Be aware of nasal breathing and breathe light • Incorporate into existing training

WEEK 3 HOMEWORK

• People are time poor. Compliance is always an issue. • Convey the benefits • Must enjoy the exercises • Must experience positive effects • Minimum dose for maximum effectiveness • Supports: lipsealtape, The Turbine, Pulse Oximeter, Buteyko Belt, Sports Mask

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BREATHE LIGHT Ex 2

EXERCISE 2

• The objective is to breathe less than what you were breathing before you began the exercise, to create a tolerable need for air and sustain it over three to five minutes. • At first, you might only feel an need for air for a few seconds. • With practise it becomes easier.

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EXERCISE 2

• There is no suggestion of changing the number of breaths per minute, or to vary the length of each breath.

• For example, telling someone to inhale for two seconds and exhale for three seconds does not provide guidance on whether they should take in a very gentle breath or a huge inhalation of air.

EXERCISE 2

Two options:

1) Slow down the speed of the air as it enters and leaves your nostrils.

2) Take a shorter breath in and allow a relaxed breath out.

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EXERCISE 2

Four places where air is felt coming into the body:

1. The nose 2. The back of the throat 3. The chest 4. The diaphragm

EXERCISE 2

If client is unable to follow their breathing, try the following:

• Begin air shortage by holding the breath • Ask client to look at his breathing • Point out to the client his or her breathing

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EXERCISE 2

Possible mistakes:

1) Deliberately interfering with breathing muscles- eg. tensing the stomach to restrict breathing

2) Holding of the breath on the exhalation or inhalation

3) Freezing the breath

4) Having too much of an air hunger

EXERCISE 2

• Sit up straight.

• Place one hand on your chest and one hand on your tummy.

• As you breathe, exert gentle pressure with your hands against your tummy and chest. This should create resistance to your breathing.

• Breathe against your hands, concentrating on making the size of each breath smaller.

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EXERCISE 2

• With each breath, take in less air than you would like to. Make the in-breath smaller or shorter.

• Gently slow down and reduce your breathing movements until you feel a tolerable hunger for air.

• Breathe out with a relaxed exhalation. • When the in-breath becomes smaller and the out-breath is relaxed, visible breathing movements will be reduced. You may be able to notice this in a mirror. (Demonstration)

EXERCISE 2

• Slow breathing down or take a shorter breath in to the point where you feel a tolerable need for air. If the need for air is too much, or if you feel a little panicky or stressed, then take a slightly larger breath or take a rest from the exercise for half a minute or so.

• Continue the exercise for three to five minutes. Take a break for about one minute and repeat again.

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EXERCISE 2

• The need for air should be no greater than at the end of the BOLT.

• Achieve an air shortage where you are on the verge of disrupting your breathing rhythm but try not to go beyond it.

• It is a fine line. With practise, it is easier to maintain a tolerable air shortage.

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EXERCISE 2

• Eyes go glassy • Increased saliva in mouth • Nose may run • Hands get warm • Face gets pink • Some people feel sudden calmness, others may feel slight panic

SIMULATE HIGH- ALTITUDE TRAINING WHILE WALKING

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SIMULATE HIGH-ALTITUDE TRAINING WHILE WALKING • WALK & HOLD: After a minute of continuous walking, gently exhale and pinch your nose to hold your breath.

• Walk while holding the breath until you feel a medium to strong air shortage.

• Release your nose, inhale through it and allow your breathing to return to normal.

SIMULATE HIGH-ALTITUDE TRAINING WHILE WALKING • BREAK FOR 30 SECONDS & REPEAT: Continue walking for half a minute to one minute, then gently exhale and pinch your nose with your fingers. Walk while holding the breath until you feel a medium to strong hunger for air. Release your nose and calm your breathing;

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SIMULATE HIGH-ALTITUDE TRAINING WHILE WALKING • REPEAT BREATH HOLDS 8 TO 10 TIMES: While continuing to walk, perform a breath hold every half minute to one minute in order to create a medium to strong need for air. Repeat for a total of eight to ten breath holds during your walk.

SIMULATE HIGH- ALTITUDE TRAINING WHILE RUNNING

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Simulate High-altitude Training While Running

SIMULATE HIGH-ALTITUDE TRAINING WHILE RUNNING • RUN & HOLD: 10-15 minutes into your run, gently exhale and hold your breath until a strong air shortage is reached.

• The length of the breath hold may range from 10-40 paces and will depend on your running speed and BOLT score.

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SIMULATE HIGH-ALTITUDE TRAINING WHILE RUNNING • BREAK FOR ONE MINUTE AND REPEAT: Following the breath hold, continue to jog with normal breathing for about one minute, until your breathing has partially recovered;

• REPEAT BREATH HOLDS 8 TO 10 TIMES

ADVANCED SIMULATION OF HIGH-ALTITUDE TRAINING

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ADVANCED SIMULATION OF HIGH ALTITUDE TRAINING • Practise on a relatively empty stomach; • First breath hold for ten paces; • Subsequent holds are performed every five to ten paces; • Following each breath hold take either a tiny inhalation or a gentle exhalation or sip of air;

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ADVANCED SIMULATION OF HIGH ALTITUDE TRAINING • A ‘sip of air’ means taking a tiny breath, the purpose of which is to relieve tension rather than take in air. It is about 10% of a normal breath; • With each successive breath hold, oxygen saturation will continue to decrease; • Continue to observe the pulse oximeter, ensuring that you do not go below 80% SaO2 • Challenge but do not stress yourself;

ADVANCED SIMULATION OF HIGH ALTITUDE TRAINING • If the air shortage is too great, take a slightly larger breath and continue to relax;

• Perform this exercise for 1-2 minutes. • Because this exercise can promote bowel movements, it is best practised near a bathroom;

• If you experience any other negative effects, please stop this exercise immediately. (Demonstration)

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ENERGY SYSTEM CONTRIBUTION

Energy System Contribution

• The purpose of the present study was to calculate the aerobic and anaerobic energy system contribution during high-speed treadmill exercise that simulated 200-, 400-, 800-, and 1500-m track running events.

• Med Sci Sports Exerc. 2001 Jan;33(1):157-62. Energy system contribution during 200- to 1500-m running in highly trained athletes. Spencer MR1, Gastin PB.

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Energy System Contribution

• Twenty highly trained athletes (Australian National Standard) participated in the study.

• Med Sci Sports Exerc. 2001 Jan;33(1):157-62. Energy system contribution during 200- to 1500-m running in highly trained athletes. Spencer MR1, Gastin PB.

Energy System Contribution

• The relative contribution of the aerobic energy system

200m 29%

400m 43%

800m 66%

1500m 84%

The crossover to predominantly aerobic energy system supply occurred between 15 and 30 s for the 400-, 800-, and 1500-m events. • Med Sci Sports Exerc. 2001 Jan;33(1):157-62. Energy system contribution during 200- to 1500-m running in highly trained athletes. Spencer MR1, Gastin PB.

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Acidosis

REDUCED ACIDOSIS

• Both the hypoxic and hypercapnic effects are responsible for the rise in H+ during BH.

• CO2 accumulates within muscle - converted into HCO3-, H+ ions are automatically produced

• A proportion of H+ ions are neutralised within the muscle by buffering substances which the most important are proteins and phosphate.

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REDUCED ACIDOSIS

• Increased carbon dioxide: Increased H+ and HCO3-

• Repeated exposure to increased acidosis- forces the body to adapt to it.

• To neutralise H+, buffering capacity improves

REDUCED ACIDOSIS

• Main Buffering: • Blood- Haemoglobin and bicarbonate • Skeletal muscle- proteins, phosphates (60%) and to a

lesser extent bicarbonate (18%)

• Possibly, enhanced buffering capacity in muscle

compartments- lowering diffusion of H+ to the blood.

• Woorons X

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REDUCED ACIDOSIS

Increased H+ ions in the muscle. Increased H+ ions in the blood

A STRONG ACIDITY WITHIN THE MUSCLE TISUE IS A MAJOR CONSEQUENCE OF EXERCISE WITH BH. IT IS THE MAIN CAUSE OF ADAPTATIONS THAT OCCUR AFTER BH TRAINING.

Increased acidosis. When this occurs repeatedly, adaptation mechanisms are triggered to reduce acidosis.

The buffer systems have the fastest action- enhanced blood and or muscle buffering capacity. Woorons

INCREASED LACTATE MAX

• In breath holding following an exhalation, maximal lactate concentration (+ 2.35 ± 1.3 mmol.L-1 on average) and the rate of lactate accumulation in blood (+ 41.7 ± 39.4%) were higher at Post- than at Pre- in the three trials whereas they remained unchanged in CONTROLS.

• Woorons X, Mucci P, Richalet JP, Pichon A. Hypoventilation Training at Supramaximal Intensity

Improves Swimming Performance. Med Sci Sports Exerc. 2016 Jun;48(6):1119-28

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INCREASED LACTATE MAX

• Increased Lactate max reflects an improved anaerobic capacity and may be due to a greater ability to tolerate high concentrations of lactate and high level of acidosis, as reported after high-intensity training.

• Woorons X, Mucci P, Richalet JP, Pichon A. Hypoventilation Training at Supramaximal Intensity Improves Swimming Performance. Med Sci Sports Exerc. 2016 Jun;48(6):1119-28

Weight Lifting

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WEIGHT LIFTING • In general, I would hold my breath ( breathe in, breathe out, hold) execute a set, minimise breathing for 6 breaths before normal breathing. Some sets I had to either break my breath hold or I forgot to minimise breathing. But in general, this was what I did - the breath holds added in another "load", as you said, especially psychologically, even though the urge to breath Is physiological. A challenge I relished.

WEIGHT LIFTING • On smaller body parts, like arms, it is easier to control and push through the "load", although when it comes to bigger body parts like back and legs, it gets very difficult. It is with these bigger muscle groups where I feel the 85% wall, and need to breathe in order to progress through the set

• The readings are from an upper back workout. I would do a set, put on my oximeter, take a snap shot, and then strap on my blood pressure cuff

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FIRST SET WITH BREATH HOLDS

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FIRST SET WITH BREATH HOLDS

SECOND SET WITH BREATH HOLDS

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SECOND SET WITH BREATH HOLDS

THIRD SET WITH BREATH HOLDS (upped weight)

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THIRD SET WITH BREATH HOLDS (upped weight)

TRAINING METHODS

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OXYGEN CARRYING CAPACITY

• Blood is made up of three parts: oxygen-carrying red cells, white blood cells and plasma.

• Hemoglobin is a protein found within the red cells.

OXYGEN CARRYING CAPACITY

• Hematocrit refers to the percentage of red blood cells in the blood. Under normal conditions, hematocrit will relate closely to the concentration of hemoglobin in the blood. Hematocrit is usually found to be 40.7- 50% for males and 36.1- 44.3% for females.

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OXYGEN CARRYING CAPACITY

• Performance improves with an increase in hemoglobin and hematocrit, which increases oxygen carrying capacity of the blood thus improving aerobic ability.

• J Appl Physiol. 1972 Aug;33(2):175-80. Response to exercise after blood loss and reinfusion. Ekblom B, Goldbarg AN, Gullbring B.

THE SPLEEN

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THE SPLEEN

• The Spleen acts as a blood bank by absorbing excess volume and releasing stores during increased oxygen demands or decreased oxygen availability.

• Isbister JP. Physiology and pathophysiology of blood volume regulation. Transfus Sci.1997;(Sep;18(3):):409-423

THE SPLEEN

• The spleen stores blood to a volume that may amount to about 200–300 ml, with 80% of the content consisting of hematocrite (Laub et al., 1993).

• Journal of Human Kinetics volume 32/2012, 197-210

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THE SPLEEN

• During the breath-hold, the spleen contracts to the same extent, regardless of whether the diver is above or under water.

• (Bakovic et al., 2005, Schagatay et al., 2007). Journal of Human Kinetics volume 32/2012, 197-210

THE SPLEEN

• The resultant blood oxygen capacity enables an increase in O2 concentration by 2.8–9.6%.

• (Stewart and McKenzie, 2002, Richardson et al., 2008). Journal of Human Kinetics volume 32/2012, 197-210

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THE SPLEEN

• Spleen contraction develops quickly, as it occurs in the first repetition of the breath-hold, and after the next 3 to 4, it reaches its maximum and is very variable (20–46%) and depends on changes in the hypoxia rate

• (Hurford et al., 1990, Schagatay et al., 2001, 2005, Espersen et al., 2002, Bakovic et al., 2005, Balestra et al., 2006, Prommer et al., 2007). Journal of Human Kinetics volume 32/2012, 197-210

THE SPLEEN

• With every apnea the spleen contracts, releasing successive amounts of blood containing red blood cells.

• Journal of Human Kinetics volume 32/2012, 197-210

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THE SPLEEN

• Repeated, multiple breath hold dives intensify the spleen contraction effect. It shows that hypoxemia enhances spleen and kidney function, increasing Hct and Hb circulating in blood (Schagatay et al., 2007, De Bruijun et al., 2008).

• Journal of Human Kinetics volume 32/2012, 197-210

THE SPLEEN

• During breath holding, large amounts of erythrocytes are excreted from the spleen, which raises Hct and Hb concentration from 2 to 5% (Jelkmann, 1992).

• Journal of Human Kinetics volume 32/2012, 197-210

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APNEIC SPLEEN CONTRACTION

• Five maximum breath holds with their face immersed in cold water, and each breath hold was separated by a two-minute rest- Spleen size decreased by 20%.

APNEIC SPLEEN CONTRACTION

• Researchers concluded that the "results show rapid, probably active contraction of the spleen in response to breath hold in humans.”

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APNEIC SPLEEN CONTRACTION

• Results showed a 6.4% increase in hematocrit (Hct) and a 3.3% increase in hemoglobin concentration (Hb) following five breath holds.

• Schagatay E, Andersson JP, Hallén M, Pålsson B.. Selected contribution: role of spleen emptying in prolonging apneas in humans. Journal of Applied Physiology.2001;(Apr;90(4)):1623-9

APNEIC SPLEEN CONTRACTION

• Significant splenic contraction has been found to take place with even very short breath holds of 30 seconds

• However, the strongest contractions of the spleen are shown following maximum breath holds

• Kurt Espersen, Hans Frandsen, Torben Lorentzen, Inge-Lis Kanstrup,Niels J. Christensen. The human spleen as an erythrocyte reservoir in diving-related interventions . Journal of Applied Physiology.2002;(May;92(5)):2071-9

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APNEIC SPLEEN CONTRACTION

• Five maximal breath holdings with cold face immersion spleen contracts 20% after the first apnea and only partially recovers following 60min of recovery from the last apnea.

• doi:10.1152/japplphysiol.00182.2007.

APNEIC SPLEEN CONTRACTION

• For a single maximal breath holding it took 8 min for the full recovery of the splenic volume, an observation that was later confirmed by Schagatay et al.

• This slow recovery of spleen volume may contribute to the prolongation of successive apneas by increasing the pool of available red blood cells.

• doi:10.1152/japplphysiol.00182.2007.

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APNEIC SPLEEN CONTRACTION

• Apnoea should be used directly before a race because its

effects (i.e. increased Hct) disappear in 10 minutes after

the last apnoea.

• J Hum Kinet. 2011 Jun; 28: 91–105.

RESPIRATORY MUSCLE FATIGUE

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RESPIRATORY MUSCLE TRAINING

• During heavy exercise, breathing frequency rises to 40 to 50 breaths per minute. Tidal volume is 3 to 4 litres. This gives a minute volume of 120 to 160 litres.

• For Olympic class male endurance athletes, tidal volume can be as high as 5 litres resulting in a minute ventilation of 200 to 250 litres.

• McConnell. A. Breathe Strong. Perform Better.

RESPIRATORY MUSCLE TRAINING

• During intense exercise, the demands on proper functioning of the respiratory system are markedly increased. Research has shown that the respiratory system often “lags behind,” while cardiovascular function and skeletal muscle improve with aerobic training (Bye et al., 1983; Wagner, 2005).

• Scand J Med Sci Sports 2015: 25: 16–24

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RESPIRATORY MUSCLE TRAINING

• There are several lines of evidence suggesting that the diaphragm should be the most important muscle to target during IMT.

• Studies suggest that more than 50% of healthy humans with varying fitness levels develop diaphragmatic fatigue after bouts of high-intensity constant work rate

• Diaphragm Recruitment Increases during a Bout of Targeted Inspiratory Muscle Training. Medicine & Science in Sports & Exercise · 2016 Jun;48(6):1179-86

RESPIRATORY MUSCLE TRAINING

• The lungs do not respond to physical training. Training does not increase lung volumes, improve lung function or enhance the ability of the lungs to transfer oxygen to the blood. (Wagner 2005)

• McConnell. A. Breathe Strong. Perform Better.

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RESPIRATORY MUSCLE TRAINING

• There is strong evidence that the diaphragm and other respiratory muscles may become exhausted during both short term, high intensity exercise (Bye et al) and more prolonged exercise such as marathon running (Loke et al)

• Tim Noakes .The Lore of Running.

RESPIRATORY MUSCLE TRAINING

• The ventilatory response during heavy exercise requires substantial increases in both inspiratory and expiratory muscle work, often leading to respiratory muscle fatigue.

• Markus Amann, Pulmonary System Limitations to Endurance Exercise Performance in Humans. Exp Physiol. 2012 March ; 97(3): 311–318

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RESPIRATORY MUSCLE TRAINING

• As the respiratory muscles fatigue they require an increasing amount of blood flow and oxygen in order to continue. As fatigue sets in, the respiratory muscles are thought to potentially monopolize the blood flow needed for the locomotor muscles.

• The Effects of Inspiratory Muscle Training on Anaerobic Power in Trained Cyclists By Courtenay McFadden Accepted in Partial Completion of the Requirements for the Degree Master of Science

RESPIRATORY MUSCLE TRAINING

• To stimulate any muscle to undergo adaptation, the muscle must be overloaded. This means forcing it to do something that it is not accustomed to. Most aerobic training is within the comfort of working muscles. High intensity training would be best- but cannot be sustained long enough to provide an effective overload.

• McConnell A. Breathe Strong, Perform Better.

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BREATH HOLD TRAINING

• The "extradiaphragmatic" shift in inspiratory muscle recruitment may reflect an extreme loading response

to breathing against a heavy elastance (i.e., closed

glottis). • Med Sci Sports Exerc. 2013 Jan;45(1):93-101

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BREATH HOLD TRAINING

• In addition, the relative intensity of diaphragmatic and inspiratory rib cage muscle contractions

approaches potentially "fatiguing" levels by the break

point of maximal breath holding. • Med Sci Sports Exerc. 2013 Jan;45(1):93-101

BREATH HOLD TRAINING

• Limiting breath frequency during swimming further stresses the respiratory system through hypercapnia and mechanical loading and may lead to appreciable improvements in respiratory muscle strength.

• Scand J Med Sci Sports 2015: 25: 16–24

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BREATH HOLD TRAINING

• 20 competitive college swimmers were randomly divided into either the CFB group that breathed

every 7 to 10 strokes, or a control group that

breathed every 3-4 strokes.

• Burtch AR1, Ogle BT, Sims PA, Harms CA, Symons TB, Folz RJ, Zavorsky GS. Controlled Frequency Breathing reduces Inspiratory Muscle Fatigue. J Strength Cond Res. 2016 Aug 16.

BREATH HOLD TRAINING

• After four weeks of training, only the CFB group prevented a decline in MIP values. CFB training

appears to prevent inspiratory muscle fatigue.

• Burtch AR1, Ogle BT, Sims PA, Harms CA, Symons TB, Folz RJ, Zavorsky GS. Controlled Frequency Breathing reduces Inspiratory Muscle Fatigue. J Strength Cond Res. 2016 Aug 16.

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BREATH HOLD TRAINING

• Swimmers, who were subjected to the hypercapnic- hypoxic regimen, had significantly improved strength of their inspiratory muscles in comparison to swimmers in the control group.

• Dajana KARAULA 1, Jan HOMOLAK 2, Goran LEKO. Effects of hypercapnic-hypoxic training on respiratory muscle strength and front crawl stroke performance among elite swimmers. Turkish Journal of Sport and Exercise. Year: 2016 - Volume: 18 - Issue: 1 - Pages: 17-24

BREATH HOLD TRAINING

• Experimental group have improved the inspiratory muscle strength values (MIP) for 14.9% and the expiratory muscle strength values (MEP) for 1.9% in relation to the control group.

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BREATH HOLD TRAINING

• Voluntary holding of breath may have resulted in involuntary contractions of intercostal muscles during the hypercapnic-hypoxic practice. It is also assumed that above mentioned contraction occurrence has resulted in hypertrophy of intercostal muscles.

BPD & INJURY

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• BPDs known as hyperventilation syndrome and rapid breathing alters the body’s pH producing respiratory alkalosis; which results in an array of symptoms including headache, dizziness, chest pain, trouble sleeping, breathlessness, light sensitivities, exhaustion, and cramps.

Chapman E et al. A clinical guide to the assessment and treatment of breathing pattern disorders in the physically active: part 1. The International Journal of Sports Physical Therapy, Volume 11, Number 5, October 2016, Page 803.

• An athlete with an abnormal breathing pattern during physical activity may experience premature breathlessness or muscle fatigue, resulting in decreased performance.

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• Normal breathing mechanics play a key role in posture and spinal stabilization. Breathing Pattern Disorders (BPD) have been shown to contribute to pain and motor control deficits, which can result in dysfunctional movement patterns.

Bradley H, Esformes J. Breathing pattern disorders and functional Movement. The International Journal of Sports Physical Therapy, Volume 9, Number 1, February 2014.

• Correction or re-education of BPDs can result in new neural connections and restoration of normal motor control patterns in the CNS.

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• “If breathing is not normalized, no other movement pattern can be.”

BPD ARE MULTIDIMENSIONAL

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• Thoracic breathing can have an acute effect on respiratory chemistry, specifically a decrease in the level of carbon dioxide (CO ) in the bloodstream. This causes

the pH of the blood to₂ increase, and a state of respiratory alkalosis results. Respiratory alkalosis can trigger changes in physiological, psychological, and neuronal states within the body that may negatively affect health, performance, and the musculoskeletal system.

Bradley H, Esformes J. Breathing pattern disorders and functional Movement. The International Journal of Sports Physical Therapy, Volume 9, Number 1, February 2014.

• Method to assess this biochemical aspect of respiratory function is capnography. Capnography measures average CO partial pressure at the end of exhalation, known as end

tidal₂ CO (etCO ) and has good concurrent validity when compared₂ to arterial₂ CO2 measures. • Normal ranges are between 35-40 mmHg, while values of <35mmHg were suggestive of a BPD.

Bradley H, Esformes J. Breathing pattern disorders and functional Movement. The International Journal of Sports Physical Therapy, Volume 9, Number 1, February 2014.

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• Breath-holding ability is an aspect of breathing functionality that is commonly disturbed in individuals with dysfunctional breathing. Times of <20 seconds are proposed to indicate the presence of BPD and to correlate with resting CO2 levels.

Bradley H, Esformes J. Breathing pattern disorders and functional Movement. The International Journal of Sports Physical Therapy, Volume 9, Number 1, February 2014.

THE STUDY

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• 34 healthy men and women

• Resting etCO and resting RR were the most sensitive measures of₂ BPD with over 70% of subjects having disordered results.

• Between 50 to 60% of participants had abnormal scores

Bradley H, Esformes J. Breathing pattern disorders and functional Movement. The International Journal of Sports Physical Therapy, Volume 9, Number 1, February 2014.

• Functional movement is defined as the ability to produce and maintain an adequate balance of mobility and stability along the kinetic chain while integrating fundamental movement patterns with accuracy and efficiency.

Bradley H, Esformes J. Breathing pattern disorders and functional Movement. The International Journal of Sports Physical Therapy, Volume 9, Number 1, February 2014.

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Variables Mean ± SD MIN MAX

FMSTM Score 14.71 ±1.84 12.00 19.00

Rest etCO (mmHg) 33.70±2.74 27.70 39.33

Active etCO₂ (mmHg) 34.28 ±2.44 29.37 40.17

Rest RR (breaths/min)₂ 18.39 ±3.41 12.25 25.2 Active RR (breaths/min) 24.30 ±3.06 17.65 30.64

BHT (sec) 19.22 ±5.05 10.57 34.13

NQ 9.24 ±6.43 0.00 27.00

FMS™, Functional Movement Screen™ ; etCO , end-tidal carbon dioxide; RR, respiratory rate; BHT, breath-hold time; NQ, Nijmegen Questionnaire ₂ The International Journal of Sports Physical Therapy | Volume 9, Number 1 | February 2014

• The Functional Movement Screen (FMS) has been shown to accurately predict injury in individuals who demonstrate poor movement patterns.

Bradley H, Esformes J. Breathing pattern disorders and functional Movement. The International Journal of Sports Physical Therapy, Volume 9, Number 1, February 2014.

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• Subjects who scored higher on the Nijmegen Questionnaire, had a lower etCO during the FMS™ test

and a higher RR. ₂

Bradley H, Esformes J. Breathing pattern disorders and functional Movement. The International Journal of Sports Physical Therapy, Volume 9, Number 1, February 2014.

The International Journal of Sports Physical Therapy | Volume 9, Number 1 | February 2014

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• Individuals with a high RR during the FMS™ had lower etCO measurements.

₂ • Resting etCO measurements were significantly different between diaphragmatic₂ (mean=35.47 mmHg) and thoracic breathers (mean=32.14 mmHg)

Bradley H, Esformes J. Breathing pattern disorders and functional Movement. The International Journal of Sports Physical Therapy, Volume 9, Number 1, February 2014.

• Individuals with a less efficient breathing pattern scored worse on the FMS™ compared to those subjects who had normal breathing patterns. Resting etCO was

positively correlated with FMS™ scores. ₂

Bradley H, Esformes J. Breathing pattern disorders and functional Movement. The International Journal of Sports Physical Therapy, Volume 9, Number 1, February 2014.

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• The results from this study show that a relationship exists between elements of BPD and functional movement.

• Both biomechanical and biochemical measures of BPD had a significant association with FMS™ scores.

Bradley H, Esformes J. Breathing pattern disorders and functional Movement. The International Journal of Sports Physical Therapy, Volume 9, Number 1, February 2014.

• Furthermore, 87.5% of individuals who were in the Pass group on the FMS™ were classified as diaphragmatic breathers. These results demonstrate the importance of diaphragmatic breathing on functional movement.

Bradley H, Esformes J. Breathing pattern disorders and functional Movement. The International Journal of Sports Physical Therapy, Volume 9, Number 1, February 2014.

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• A higher etCO level, indicating efficient respiratory function, was positively₂ correlated with a higher FMS™ score.

Bradley H, Esformes J. Breathing pattern disorders and functional Movement. The International Journal of Sports Physical Therapy, Volume 9, Number 1, February 2014.

CO & INJURY

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• Skeletal muscle injuries are commonly observed in sports and traumatology medicine.

• We investigate whether transcutaneous CO2 application could enhance recovery from muscle injury.

Int Orthop. 2017 May;41(5):1007-1015

• Tibialis anterior muscle damage was induced in 27 Sprague Dawley rats.

• After muscle injury, rats were randomly assigned to

transcutaneous CO2-treated or -untreated groups. From each group, three rats were sacrificed at weeks one, two, four and six.

Int Orthop. 2017 May;41(5):1007-1015

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• Injured muscle fibres were completely repaired at week

six in the CO2 - treated group but only partially repaired in the untreated group.

Int Orthop. 2017 May;41(5):1007-1015

• Endurance exercise generates CO2 via aerobic metabolism; however, its role remains unclear.

Ueha T Increase in carbon dioxide accelerates the performance of endurance exercise in rats. J Physiol Sci. 2017 Jun 10

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• Exogenous CO2 by transcutaneous delivery promotes muscle fibre-type switching to increase endurance power in skeletal muscles.

Ueha T Increase in carbon dioxide accelerates the performance of endurance exercise in rats. J Physiol Sci. 2017 Jun 10

• Here we determined the performance of rats running in activity wheels with/without transcutaneous

CO2 exposure to clarify its effect on endurance exercise and recovery from muscle fatigue.

Ueha T Increase in carbon dioxide accelerates the performance of endurance exercise in rats. J Physiol Sci. 2017 Jun 10

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• Running performance improved over the treatment period

in the CO2 group, with a concomitant switch in muscle fibres to slow-type.

Ueha T Increase in carbon dioxide accelerates the performance of endurance exercise in rats. J Physiol Sci. 2017 Jun 10

• The mitochondrial DNA content and capillary density in

the CO2 group increased. CO2 was beneficial for performance and muscle development during endurance exercise: it may enhance recovery from fatigue and support anabolic metabolism in skeletal muscles.

Ueha T Increase in carbon dioxide accelerates the performance of endurance exercise in rats. J Physiol Sci. 2017 Jun 10

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• Carbon dioxide (CO(2)) therapy refers to the transcutaneous administration of CO(2) for therapeutic purposes. This effect has been explained by an increase in the pressure of O(2) in tissues known as the Bohr effect.

PLoS One. 2011;6(9):e24137 A Novel System for Transcutaneous Application of Carbon Dioxide Causing an “Artificial Bohr Effect” in the Human Body

• In this study, we investigate whether the Bohr effect is caused by transcutaneous application of CO2 in human living body.

PLoS One. 2011;6(9):e24137 A Novel System for Transcutaneous Application of Carbon Dioxide Causing an “Artificial Bohr Effect” in the Human Body

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• Application of CO(2) using pure CO(2) gas.

• The intracellular pH of the triceps surae muscle decreased significantly 10 min. after transcutaneous application of CO(2).

• The NIRS data show the oxy-Hb concentration decreased significantly 4 min. after CO(2) application, and deoxy-Hb concentration increased significantly 2 min. after CO(2) application in the CO(2)-applied group compared to the control group. PLoS One. 2011;6(9):e24137 A Novel System for Transcutaneous Application of Carbon Dioxide Causing an “Artificial Bohr Effect” in the Human Body

• Our novel transcutaneous CO(2) application facilitated an O(2) dissociation from Hb in the human body, thus providing evidence of the Bohr effect in vivo.

PLoS One. 2011;6(9):e24137 A Novel System for Transcutaneous Application of Carbon Dioxide Causing an “Artificial Bohr Effect” in the Human Body

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END OF THREE DAY TRAINING

AcidosisADDITIONAL MATERIAL

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REDUCED ACIDOSIS

• Breath holding after an exhalation causes a decrease to the concentration of oxygen to trigger increased lactic acid, therefore increased H+.

• At the same time, carbon dioxide also increases leading to an increased concentration of hydrogen ions to further acidify the blood.

• During breath holding CO2 increases to 50mmHg in the lungs.

REDUCED ACIDOSIS

• Fall of O2 and increase to CO2 greatly disturb the blood acid base balance.

• Causes a combined acidosis: metabolic and respiratory • (metabolic acidosis decrease in pH associated with a fall in HCO3-)

• Due to a drop on pH and increase in H+

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REDUCED ACIDOSIS

• Increase to CO2 increases HCO3- (as CO2 dissociate into H+ and HCO3-)

• However, the increased lactic acid causes a large accumulation of H+, therefore HCO3- tends to decrease.

• HCO3 - decreases as it buffers the excess of H+ generated by lactic acid.

REDUCED ACIDOSIS

• Near infrared spectroscopy measures oxygen saturation within the muscle (SmO2)

• Amount of O2 lower in the muscle

• Tissue hypoxia increases blood lactate concentrations

• CO2 also increases in the muscle. However, because of elevated aCO2, diffusion gradient between the tissues and blood is reduced, therefore CO2 release is slowed down and the gas accumulates in the muscle.

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ANEROBIC TRAINING

• Both the hypoxic and hypercapnic effects are responsible for the rise in H+ during breath holding.

• CO2 accumulates within muscle - converted into HCO3-, H+ ions are automatically produced

• A proportion of H+ ions are neutralised within the muscle by buffering substances which the most important are proteins and phosphate.

ANEROBIC TRAINING

Increased H+ ions in the muscle. Increased H+ ions in the blood

A STRONG ACIDITY WITHIN THE MUSCLE TISUE IS A MAJOR CONSEQUENCE OF EXERCISE WITH BH. IT IS THE MAIN CAUSE OF ADAPTATIONS THAT OCCUR AFTER BH TRAINING.

Increased acidosis. When this occurs repeatedly, adaptation mechanisms are triggered to reduce acidosis.

The buffer systems have the fastest action- enhanced blood and or muscle buffering capacity. Woorons

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ANEROBIC TRAINING

• Main Buffering: • Blood- Haemoglobin and bicarbonate • Skeletal muscle- proteins, phosphates (60%) and to a

lesser extent bicarbonate (18%)

• Possibly, enhanced buffering capacity in muscle

compartments- lowering diffusion of H+ to the blood.

• Woorons X

ANEROBIC TRAINING

• Woorons X, Mucci P, Richalet JP, Pichon A. Hypoventilation Training at Supramaximal Intensity

Improves Swimming Performance. Med Sci Sports Exerc. 2016 Jun;48(6):1119-28

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ANEROBIC TRAINING

• Woorons X, Mucci P, Richalet JP, Pichon A. Hypoventilation Training at Supramaximal Intensity Improves Swimming Performance. Med Sci Sports Exerc. 2016 Jun;48(6):1119-28

BREATH BREATHHOLDING HOLDINGBREAKPOINT BREAK POINT

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HOW TO MEASURE UPPER LIMIT OF BREATHLESSNESS-

• Inspiratory muscle activity was the final common pathway determining the breakpoint.

• The onset of electrical activity during a breath holding period is closely related to the alveolar Pc02.

• Agostoni E. Diaphragm activity during breath holding: factors related to its onset. J Appl Physiol 1963; 18:30-6

WHAT DETERMINES HOW LONG WE CAN HOLD OUR BREATH?

• Edward Schneider, a pioneer of breath-holding research described a subject lasting for 15 minutes and 13 seconds under comparable conditions in the 1930s.

• Parkes, Scientific American, April 2012

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WHAT DETERMINES HOW LONG WE CAN HOLD OUR BREATH?

• 1959 physiologist Hermann Rahn used a combination of unusual methods—slowing his metabolism, hyperventilating, filling his lungs with pure oxygen, and more to hold his breath for almost 14 minutes.

• Parkes, Scientific American, April 2012

WHAT DETERMINES HOW LONG WE CAN HOLD OUR BREATH?

• The lungs alone should contain enough oxygen to sustain us for about four minutes. In the same vein, carbon dioxide does not accumulate to toxic levels in the blood quickly enough to explain the one-minute limit.

• Parkes, Scientific American, April 2012

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WHAT DETERMINES HOW LONG WE CAN HOLD OUR BREATH?

• Breath-holding divers feel compelled to draw a breath well before they actually run out of oxygen. As Schneider observed, “it is practically impossible for a man at sea level to voluntarily hold his breath until he becomes

unconscious.”

• Parkes, Scientific American, April 2012

WHAT DETERMINES HOW LONG WE CAN HOLD OUR BREATH?

• The break point may depend very much on stimuli that reach the brain from the diaphragm. During such a lengthy contraction, the brain might subconsciously perceive the unusual signals from the diaphragm as vaguely uncomfortable at first but eventually as intolerable, causing the break point. The automatic rhythm then regains control.

• Parkes, Scientific American, April 2012

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BREATH HOLDING BREAKPOINT

• The precise mechanisms explaining breath-holding and causing the breath at breakpoint are unknown. There are several useful reviews (Mithoefer, 1965; Godfrey & Campbell, 1968, 1969; Porter, 1970; Campbell & Guz, 1981; Lin, 1982; Nunn, 1987).

• Parkes MJ. Breath-holding and its breakpoint. Exp Physiol. 2006 Jan;91(1):1-15.

BREATH HOLDING BREAKPOINT

• During breath-holding, the arterial or end tidal partial pressure of oxygen falls below its normal level of 100

mmHg and that of carbon dioxide rises above its normal∼ level of 40 mmHg.

∼

• Parkes MJ. Breath-holding and its breakpoint. Exp Physiol. 2006 Jan;91(1):1-15.

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BREATH HOLDING BREAKPOINT

• At breakpoint from maximum inflation in air, the PetO2 is typically 62 ± 4 mmHg and the PetCO2 is typically 54 ± 2 mmHg, and the longer the breath-hold the more they change.

• Parkes MJ. Breath-holding and its breakpoint. Exp Physiol. 2006 Jan;91(1):1-15.

BREATH HOLDING BREAKPOINT

• It is remarkable that adults normally cannot breath-hold consistently to unconsciousness, even under laboratory supervision. Nunn (1987) estimates that consciousness in normal adults is lost at PO2 levels below 27 mmHg

and PCO2 levels between 90 and 120 mmHg.∼

• Parkes MJ. Breath-holding and its breakpoint. Exp Physiol. 2006 Jan;91(1):1-15.

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BREATH HOLDING BREAKPOINT

• Breakpoint levels close to these have been reported, e.g. PetO2 levels as low as 24 mmHg, PetCO2 levels as high as 91 mmHg and breath-hold durations of 14 min or more (Schneider 1930, Ferris et al 1946, Klocke and Rahn 1959)

• Parkes MJ. Breath-holding and its breakpoint. Exp Physiol. 2006 Jan;91(1):1-15.

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