ST. JOHN HOSPITAL

’’SLEEP”

JULY 2015

DR. RICHARD E. KLEIN

THE VARYING

ROLES OF THE

NOSE AND MOUTH

IN BREATHING

OBJECTIVES

1. REVIEW ANATOMY AND PHYSIOLOGY

OF NOSE

1. EXPLAIN NASAL FUNCTION

2. RELATIONSHIP OF MOUTH BREATHING

TO OBSTRUCTIVE SLEEP APNEA AND

SNORING

3. FUNCTIONAL CONSEQUENCES OF

MOUTH BREATHING

4. PHYSIOLOGICAL CONSEQUENCES OF

MOUTH BREATHING

HUMAN BEINGS ARE

DESIGNED TO BE

NASAL BREATHERS

THE IMPULSE TO NASAL BREATHE IS

INSTINCTIVE

GEORGE

CATLIN, 1870

THE UNION OF THE

FOODWAY AND THE AIRWAY

IN HUMANS HAS CAUSED

MANY ADAPTIVE PROBLEMS

THE USE OF THE MOUTH AS

AN EMERGENCY AIRWAY

OUTWEIGHS THE POSSIBLE

DANGERS OF CHOKING AND

INFECTION

WHAT IS THE ROLE OF THE

NOSE?

ITS FUNCTIONS ARE VITAL:

WARMING

HUMIDIFICATION

FILTERING

CLEANING OF AMBIENT

AIR INHALED INTO THE LUNGS

WHAT IS THE ROLE OF THE

NOSE?

THE NOSE IS A HIGHLY COMPLEX ORGAN,

INITIATING REFLEXES AFFECTING IT AND

THE REST OF THE BODY, SUCH AS:

• SNIFF REFLEX

• SNEEZE REFLEX

• AUTONOMIC AIRWAY/LUNG REFLEXES

• CARDIOVASCULAR REFLEXES

VASCULATURE OF THE NOSE IS

COMPLEX

SINUSOIDAL CAPACITANCE VESSELS

DISTENSIBLE VENULE CAPACITANCE VESSELS

ARTERIOVENOUS ANASTOMOSES

ARTERIOLES

CAPILLARIES

VENULESCELLS

SECRETORY TISSUE OF THE NOSE

• EPITHELIAL

• SUBMUCOSAL GLANDS

• SEROUS GLANDS

NASAL LINING

PSEUDOSTRATIFIED EPITHELIUM

•SEROUS, MUCOUS, SEROMUCOUS

GLANDS

•CAPACITANCE VESSELS

•SUBMUCOSAL LAYERS

•ARTERIOLES

ARTERIAL SYSTEM

DETERMINES BLOOD

FLOW

VENOUS SYSTEM

(CAPACITANCE

VESSELS)

DETERMINES NASAL

PATENCY

CAPACITANCE VESSELS

CONSTRICTION AND RELAXATION OF

VEINS DETERMINE NASAL PATENCY

CONTAIN SMOOTH MUSCLE

REGULATED BY AUTONOMIC

(SYMPATHETIC) NERVOUS SYSTEM

MOST DENSE IN THE INFERIOR AND

MIDDLE TURBINATES

LOSS OF SYMPATHETIC

TONE

& CHOLERGENIC

STIMULATION

CAUSE ARTERIAL DILATION AND ACTIVE SECRETION OF MUCOUS

…….RESULTING IN RUNNY

NOSE

SYMPATHETIC AND PARASYMPATHETIC

NERVES PLAY CRITICAL ROLES IN

REGULATING GLANDULAR, VASCULAR AND

OTHER PROCESSES IN AIRWAY MUCOSA

SYMPATHETIC NERVE STIMULATION CAUSES

CONSTRICTION OF THE RESISTANCE CELLS

PARASYMPATHETIC NERVE STIMULATION OF

THE NASAL VASCULATURE CAUSES DILATION

NASAL CONGESTION IS MORE A WITHDRAWAL OF

SYMPATHETIC DISCHARGE, THAN OVER

ACTIVITY OF THE PARASYMPATHETIC SYSTEM

ALLERGY – A HISTAMINIC

REACTION

CHARACTERIZED BY:

VASOMOTOR RHINITIS

MUCOSAL HYPEREMIA

ENGORGEMENT

HYPERRHINORHEA

OBSTRUCTED NASAL BREATHING

NASAL PATENCY IS

AFFECTED BY:

EXERCISE

DECREASES NASAL AIRFLOW RESISTANCE,

↑SYMPATHETIC DISCHARGE CONSTRICTS CAPACITANCE VESSELS

POSTURE

↑ NASAL RESISTANCE WHEN SUPINE

↑ NASAL RESISTANCE IN DEPENDENT NASAL PASSAGE IN LATERAL RECUMBENT

THE KEY TO

SUCCESSFUL NASAL

BREATHING IS

MAINTAINING A

CRITICAL BALANCE

NASAL CYCLE

80% – 20% SWITCH IN

NASAL PATENCY FROM ONE

NASAL CAVITY TO THE

OTHER EVERY 2 - 4 HOURS

OCCURS IN 60% - 70% OF ALL

HEALTHY INDIVIDUALS

Positional OSA

Unilateral blockage of right or left nasal

airway will have documentation of

apnic event difference during the nasal

cycle since more air can traverse the

side that is larger.

UPPER AIRWAY

RESISTANCE

2/3 NASAL RESISTANCE

1/3 PHARYNGEAL

RESISTANCE

NASAL VALVE

NARROWEST PART OF THE NASAL AIRWAY SYSTEM

CONTRIBUTES THE MOST

(OVER 50%) TO NASAL RESISTANCE

COTTLE’S

MANEUVER

COTTLE MANEUVER

NASAL VALVE IS THE NARROWEST SEGMENT OF NASAL CAVITY

CHEEK IS GENTLY PULLED LATERALLY WITH ONE TO TWO FINGERS

PATIENT ASKED IF INHALATION IS EASIER

IF AIRFLOW IS EASIER RESTRICTION, MAY BE AT NASAL VALVE

DONE IN SUCCESSION BY USE OF A NASAL DECONGESTANT, LOCALIZATION TO ORIGIN OF CONSTRICTION IS POSSIBLE

SNIFF TEST

SEAL YOUR LIPS, TAKE A DEEP

BREATH THROUGH YOUR NOSE

AS DEEP AND AS FAST AS YOU

CAN

NOSE BREATHER – THE NARES

FLARE

NASAL OBSTRUCTION – NARES

CONSTRICT

NARES

CONSTRICT

NARES FLARE

SNIFF TEST

TYPES OF AIRFLOW

FUNCTIONS OF NASAL

AIRWAY PASSAGES

1. TRANSPORT AIR TO & FROM LUNGS

2. OPTIMAL CONDITIONING INSPIRED AIR

a) HEATING

b) HUMIDIFICATION

c) FILTRATION

3. OLFACTION

4. RECAPTURE HEAT AND MOISTURE ON EXHALATION

THE LARGE, VASCULAR SURFACE AREA LINED WITH CILIATED

MUCOSA MAXIMIZES OLFACTION AND CONDITIONING

Humidification and

Dehumidification

During the intake of air it is humidified

to increase lung oxygen facilitation.

Upon exhalation the air is

dehumidified to keep water in our

cells. If this were not the case we

would dehydrate unless we

continually drank water.

TURBULENT AIRFLOW

BRINGS ABOUT:

1. BETTER WARMING

2. FILTRATION

3. HUMIDIFICATION

4. IRREGULAR FLOW

5. DIFFERING VELOCITIES

6. INCREASES WORK OF BREATHING

TURBULENT AIRFLOW

INCREASED BY:

1. PROJECTION OF INFERIOR

TUBINATES*

2. DOWNTURNED NOSTRILS

TWO DISTINCT

TYPES OF NOSES

LEPTORHINE PLATYRHINE

LEPTORRHINE NOSES, tall

& narrow

•DOWNWARD & INFERIOR DIRECTION OF NARES

•MAXIMIZE MUCOSAL SURFACE TO VOLUME

•FACILITATE HEAT AND MOISTURE EXCHANGE IN COLD, DRY ENVIRONMENTS

•AIRFLOW MUST NEGOTIATE 90⁰ BEND FROM EXTERNAL NARES TO HORIZONTAL CHAMBER

• WELL DEVELOPED NASAL VALVE

•GREATER PROJECTION OF THE NOSE, HIGH NASAL SILL AND PROJECTING TURBINATES ENHANCE TURBULENT AIRFLOW

PLATYRHINE NOSES, short

& broad

LOWER SURFACE AREA TO VOLUME RATIO

LESS EFFICIENT HEAT RECAPTURE

NARES MORE ANTERIORLY DIRECCTED

POOR OR NO DEVELOPMENT OF NASAL VALVE

NO OR POORLY DEVELOPED NASAL SILL

LITTLE OR SMALL PROJECTION OF TURBINATES

ECOGEOGRAPHICALLY WARM WEATHER SETTLER

LAMINAR AIRFLOW

IN HUMAN

NOSES THERE

IS LESS

LAMINAR

AIRFLOW IN

PLATYRHINES

THAN

LEPTORHINES

Cosmetic Surgery

He couldn’t breath through his small nose, became hypercapnic and died

THE AIRFLOW IN THE BEFORE AND AFTER NOSES CANNOT BE THE SAME

90⁰90⁰

• TWO 90⁰ TURNS IN

AIR FLOW

•NARROWEST OPENING

AT NARES

•VARYING CROSS-

SECTIONAL AREA

THROUGHOUT AIRWAY

•VARYING

OBSTRUCTIONS IN

AIRWAY

•VARYING THICKNESS

OF MUCOSAL WALLS

LAMINAR AIRFLOW

CANNOT OCCUR IN

BOTH THE BEFORE

AND AFTER

SURGICALLY ALTERED

NOSES

BERNOULLI’S

PRINCIPAL

DECREASE IN SIZE OF THE

LUMEN CAUSES AN

INCREASE IN VELOCITY OF

AIR, RESULTING IN A

DECREASE IN PRESSURE,

SUCKING IN THE

COMPLIANT WALLS AND

POTENTIATING CLOSURE

The more obstructions, the

more turbulence and

greater suction on the walls

POISSEUILLE’S LAW

IN AN AIRWAY WITH A DIMINUTIVE LUMEN,

INCREASES IN RADIUS SIZE CAUSE EXPONENTIAL

CHANGES IN AIRFLOW

BERNOULLI &

POISSEUILLE

INCREASE THE SIZE OF THE

AIRWAY

REDUCE THE TURBULENCE

ENHANCES AIRFLOW

AND

PREVENTS COLLAPSE OF AIRWAY

THE CONTRIBUTION OF THE

NOSE TO AIR FLOW IS BASED

ON THE

BERNOULLI & POISSEUILE

EFFECTS

NASAL AIRFLOW AFFECTS

COLLAPSIBILITY OF THE ORAL AIRWAY

Sleep complaints portend worse

outcomes among those with chronic

pain. Compared with patients who have

no sleep complaints, patients with

chronic pain and insomnia report poorer

quality of life indices and have

increased health care utilization

Association of Obstructive Sleep Apnea

and Chronic Pain May 2013

The End

Thank you for not falling asleep during

my lecture.

Dr. Richard Klein