Breathing Re-Education & Sleep Apnea Phenotypes

Patrick McKeown

It’s a pleasure. Dr. Well, it’s great to be here. Thanks very much.

Audrey Wells, MD

I’m excited to talk to you because one of your primary messages to people who are looking for help with breathing is the importance of breathing through the nose. I want you to just take it from the ground up. Why is this critical for health?

Patrick McKeown

Breathing anatomically, the mouth doesn’t do anything when it comes to breathing. it’s not rocket science. One has to look into your mouth and just ask what parts of the motors are devoted in terms of moistness, regulating volume, warming the incoming air, filtering the air, and nitric oxide. There are so many benefits that stem from nasal breathing. Those same benefits don’t apply to my breathing. Even in sleep, we know that the mouth is open. The tongue is interesting. Up on the roof is the mouth. The tongue is then in a lower resting position. It’s more likely to encroach on the airway. We also know that the lower jaw falls back at the hinges downward, and it can narrow the airway as well. then mouth breathing is causing drying and cooling of the airway, which in turn has moisture sucked out of the throat, which can contribute to inflammation and further narrowing of the airway. My breathing also activates the upper chest. If we look down at our chest and take a breath to the mount, we typically see that when we breach the mouth, we engage more of the upper chest, and we have reduced recruitment of the diaphragm.

The problem with that, with sleep, is that the airway is one airway. Whether we are talking about the nose or the throat, the bronchi, the bronchioles, or the diaphragm, it’s all one area. When we breathe through the nose, we get better recruitment of the diaphragm, which in turn increases lung volume because, quite simply, we’re using a greater area of our lungs, and the throat is stiffer and less likely to collapse. So it’s interesting that the whole relationship between the upper airway and obstructive sleep apnea would be considered, and that’s where most of it is taking place. But we forget about the lower airway because if there is a problem in the lower airway, it’s going to affect the upper airway. So, Dr. Wells knows breathing is crucial. We’re not just talking about noise or breathing during sleep. We’re talking about noise, breathing during wakefulness and rest, and also during physical exercise.

Audrey Wells, MD

I couldn’t agree with you more. in my line of work, where breathing factors contribute fundamentally to not only problems with sleep apnea but also to relaxing the brain and the body into sleep during insomnia treatment. Oftentimes, I run up against some resistance from people who characterize themselves as mouth-breathers, as if it’s part of their identity. I’ve always been a mouth breather, and it seems rather inaccessible for them to change into nasal breathing. I wonder if you could give a few tips about how they might start taking those first steps.

Patrick McKeown

Well, I suppose, do people feel comfortable breathing through the nose in the first instance? Because I was my operator for 25 years, and I remember when I first switched from out to nose breathing, during the day, the nose opposes a resistance to your breathing, which is very good in terms of slowing down the breath. But that same resistance during wakefulness can generate a slight feeling of restlessness. Sometimes, when people feel that sensation of breathlessness, they will unconsciously switch to my breathing to alleviate that feeling of air hunger. But what I would say is to continue breathing through your nose, because the more you use your nose, the better your breathing pattern.

Your breathing improves, but your nasal breathing improves, and you’re less likely to be in this fight or flight response. Earlier today, I was working with a female with obstructive sleep apnea. She’s not just feeling obstructive sleep apnea. She’s also stressed. She’s breathing fast in her upper chest. She’s got cold hands, charcoal features, and brain fog. She’s not productive, you know, and if our quest is to have good concentration, good memory, a good attention span, feel calm and resilient, and be able to make the right decisions, sleep quality is vital. I suppose there are a couple of things here. One is that we need sleep, and we need slow-wave sleep. We don’t need to have sleep fragmentation and disruptions to our sleep. It has been well written about for hundreds of years. The importance of nose breathing. There was a book written back in the 1870s called Shut Your Mouth and Save Your Life. Not a part of the title, I suppose, is the title, but it was written by an American painter called George Caitlin, and he went to live with the North Native American Indian mothers and, of course, with the tribes. But his observation was that when the native Indian babies had their mouths open, the Native American mothers went over and gently brought the lips together to help ensure nasal breathing.

We also know from our ancestors, from the work of anthropologists when they unearthed skulls, that our ancestors were innate nasal breeders. They knew that by the shape of the face and, of course, the maxilla, it was white, it was U-shaped, and it was well directed. The growth of the face was forward, and there was plenty of room in terms of there being no overcrowding of teeth. There was plenty of room in terms of the teeth, which was, in the mouth for the teeth. The one thing about this is that when the face grows and develops correctly, there’s plenty of room for the tongue. It’s more about awareness of what you’re talking about—the importance of nasal breathing. But I have to confess, no health care professional told me in 25 years about breathing through my nose. I was a chronic operator, and I had undiagnosed obstructive sleep apnea. 50% of the adult population wakes up with a dry mouth in the morning. Very few studies on us, but let’s even look at the work of Dr. Christian Guilleminault. In the latter years of his life, he was talking about the critical importance of restoring nasal breathing, not just during wakefulness and sleep.

This same doctor coined the phrase obstructive sleep apnea, which we all use. He developed the apnea-hypopnea index. He’s considered to be one of the founding fathers of sleep medicine. He’s talking about the importance of nose breathing. If there was greater awareness of this information and if people were hearing about it from different directions, then they would start to get on board. Nobody should be waking up with a dry mouth in the morning. That’s one short indicator that at least the mouth has been opened and breathing is true for at least part of the nation.

Audrey Wells, MD

Agree. It’s such a big problem that can not only disrupt sleep but also cause discomfort and increase arousal during sleep. Those brief awakening things that disrupt sleep quality. I want people to hear this quite plainly. Mouth breathing in and of itself is a sleep disruptor and can lead to problems with energy and wakefulness during the day. I want to circle back to something that you said, too, which is that when we have an open mouth for breathing, our breaths are rather shallow, at the top of our chest. This can exacerbate or drive forward anxiety measures, just feeling anxious and on edge, which is incompatible with sleep and also reduces our feeling of well-being during the day. I’d like you to describe more of the benefits of taking a diaphragmatic breath and how that’s different from shallow breathing from the mouth.

Patrick McKeown

We have the vagus nerve, which interfaces with the major organs, and 80 to 90% of the communication of the vagus nerve is from the body up to the brain. We have all of this bottom-up communication. To fall asleep, we need to tell the brain that the body is safe, the brain is doing its job, and the brain is here to protect us and ensure that we survive. But if we are breathing fast and shallow in the upper chest, the brain interprets that the body is trash, and the brain won’t allow us to fall asleep. In terms of activating the relaxation response, it’s very much in the speed of the exhalation. even by just breathing in an area of the nose, but by consciously taking a softer breath in through the nose and a relaxed, slow, and gentler breath out.

Because when we slow down the speed of the exhalation, we stimulate the vagus nerve. This, in turn, secretes a neurotransmitter called Acetylcholine. The heart rate slows down. The brain interprets that the body is safe. But there’s another cluster of neurons—brain cells—that are spying on our breathing. This was identified at Stanford Medical School in 2017. We have parts of the brain; we have this bottom-up communication, but we also have this top-down observation. This part of the brain is spying on our breathing. If we breathe faster and harder, not only does it trigger anxiety, but it can also awaken us from sleep. The speed at which we breathe during sleep also has some importance. You can imagine, say, somebody with asthma. I was always intrigued. Why do people with asthma have sleep problems so much more than the normal population? Asthma is characterized by inflammation of the lower airways. Why, too, are they sleepy? They tend to breathe faster and harder because of the narrowing of the airways. They’re harder and faster. Breathing increases resistance and turbulence, but they’re also more likely to wake up from sleep.

You know, one very simple way to talk about circling back to your question about my breathing is to make the sound of a snore through the mouth. Anyone can do this, and it goes like this. then close the mount and try to snore through your match with your mouth closed. My snoring stopped straight away once we got the mouth closed, and then we had nasal snoring. That’s vendas turbulence inside the nose, and forward to the nose meets the chosen nasopharynx. But if we were to breathe softly, taking a soft, gentle breath in through the nose and a relaxed and slow general breath out, we could automatically reduce the turbulence because we’re reducing the flow of air. It’s not just about the airway; it’s also about how hard and how fast we breathe. Coming back to the diaphragm, it is very important to breathe with a good recruitment of the diaphragm because of the connection between the diaphragm and the mind. The connection is via the phrenic nerve. When people talk about a mental health condition, such as schizophrenia, we can see the connection there. But this is coming back, and to know is breathing.

Sometimes the best observation would be to look at young infants’ brains, look at animals, and breathe. The dog will have its mouth open for periods, but next time your dog is nice and comfortable and the dog has no time, The dog has no problem falling asleep, by the way, and the dog doesn’t feel guilty about relaxing and resting. When you see that the dog has its mouth closed and breathing in the neck through its nose, you’ll see the nice recruitment of the diaphragm, they tend to breathe slowly. They’re not taking these full, big breaths. the belief that it’s good to be taking big breaths, they’re not purposely bringing more air into their body. They’re just breathing in two ways, as nature has intended. We need to go back to that. We need to go back to the basics. I use the acronym LSD. It mightn’t be ideal, but people get it like L for life. We don’t want to have turbulence and heavy breathing. S is for slow. We just want to have a normal respiratory rate, especially when we want to activate the body’s relaxation response. And D is for deep. But when I talk about deep breathing, it’s not about taking big breaths.

Audrey Wells, MD

I like that. It’s such good common sense, light, slow, and deep, recruiting your diaphragm, and you can feel your stomach move outward as we’re talking. What occurs to me is that for people who want to discover the power of this new way of breathing, a great way to do so is through the practice of mindfulness. It’s being deliberate about taking some time out during the day to practice this technique and become more comfortable with it, and then using that skill at night, at bedtime, to relax, communicate that message of safety to the brain, and then drift into sleep peacefully, like we all want to do.

Patrick McKeown

I agree with you. I suppose when we talk about mindfulness, we’re just taking our attention out of our minds and into the body and onto the breath. There’s nothing left to filter through about this. Education has trained us to think and to break information into tiny pieces. We have been trained how to think, but we haven’t been trained how to stop thinking. I’m not talking about the practical thinking that we all need—cognition. We need to be able to plan, organize, and make decisions. All of that thinking is pretty useful. That’s good. But it’s the rumination; it’s the critical thinking. It’s the stuff that goes on in our minds—the worries and the anxiety. The thing about the human mind is that the body doesn’t know the difference between a real event and an emergent event.

If I’m there just before sleep, I would also say to people, don’t watch the news. If you want to watch the news, watch it maybe at 1:00 pm today because the more we are overstimulated before sleep, there’s a risk of overstimulation because we have so much information going on us. Instead of giving all of our attention outwards and taking all of this information in, we’re not able to process so much information coming, forget about all of the information, bring our attention into our practice, and answer the body. Even for a short time, it can be one to two minutes, and observe your breath so you feel the airflow coming into your nose. Just slow down the speed of the air coming into your nose and then take a relaxed, slow, and gentle breath out. When you have that very soft and slow, gentle breath in and a relaxed and slow, gentle breath out, you’re telling the brain that your body is safe.

If you do it to the point that you’re soft and you’re breathing to the point that you feel air hunger, you feel asleep and breathless, which signifies that carbon dioxide has increased just a little in the blood. However, the increase in carbon dioxide can also stimulate the vagus nerve. As you’re doing this, pay attention to the slide in the match when you underbreathe. In other words, when you’re gently softening the speed of your breathing and then have a relaxed, slow, gentle breath out and you’re underbreathing to the point of air hunger, it can activate the rest and digest response. The woman this morning, after three to four minutes, was feeling sleepy. We know we’re activating the rest response when we feel sleepy. that digest responds when we have this increased watery saliva, and then we can fall asleep. But there’s another thing to this. Dr. Wells, one of the characteristics of obstructive sleep apnea is high loop gain. High loop gain is when breathing is quite unstable during sleep, and that can be recognized by the breath of time. What I look at is when our breath or time as measured during wakefulness is low. For example, this morning, the person’s breath total time was 12 seconds, which would indicate that she has high loop gain because of her strong chemosensitivity to carbon dioxide. Excuse me. There was a rugby match on Saturday, and I was shouting. It’s my voice. My voice on Monday morning isn’t so good, but high loop gain be recognized, as I said, by my low breath all the time. When we have a stronger sensitivity to the accumulation of carbon dioxide, the problem is that during sleep.

Audrey Wells, MD

This is the season for throat clearing and post-nasal drip.

Patrick McKeown

It certainly is fun. There’s a rugby match on, and you’re shouting and roaring. But. In terms of, say, somebody with high loop gain they have it? They will have a strong chemical sensitivity to carbon dioxide. When they stop breathing during sleep, carbon dioxide can’t leave the body so quickly because, of course, one has to stop breathing. As carbon dioxide accumulates, people with high loop gain when they resume breathing, they resume breathing with such exaggerated ventilation. Now that carbon dioxide has gone from being too high during the stopping of the breath to be too low, there is carbon dioxide in the blood is going to be low, and the brain doesn’t send a signal to breathe.

It could be central apnea. But when the brain doesn’t send a signal to breathe the output from the brain to the upper airway, dilator muscles are also reduced. 30% of people with obstructive sleep apnea have high loop gain. How do you reduce the chemosensitivity to carbon dioxide? Because high loop gain is a non-anatomical phenotype, one way to help reduce the chemosensitivity to carbon dioxide is to practice breathing lightly. Under breath. Do your physical exercise. Picture me closed. It’s not about doing physical exercise to the point that it’s excruciating; it’s about doing physical exercise with your mind closed to the point that you can sustain this live breathing and that you’re feeling that sensation of breathlessness. The more we do our physical exercise with the mouth closed and the more we gently soften and then slow down our breathing patterns during the day, we have to reduce our chemosensitivity to carbon dioxide. Our breath total time during wakefulness increases, and now our breathing during sleep is better because we can’t just think about the airway without having a flow.

The other thing about somebody with strong chemosensitivity to carbon dioxide is that they often feel air hunger, and it’s the sensation of air hunger that can drive their breathing into the chest. Now we have another problem: a reduction in lung volume. One of the phenotypes, aside from anatomical compromise, is a very important characteristic of sleep apnea to help address is high loop gain, and the breathing exercise that we just did there a little while ago, just like the person sitting down, will offer us two potentials. One is to activate the rest and digest responses. But number two is that, in the long term, it’s helping to reduce cytokines. the last ten, or 15 minutes at night, you’re sitting in a nice, comfortable environment. You’re not being exposed to overstimulation. Maybe to have blue light touch your glasses on and you’re just sitting there and you’re feeling comfortable. For the 15 minutes, you’re telling your brain that your body is safe, but you’re also bringing your attention out of your mind and onto your breath during that time. It’s almost as if you’re taking a holiday from the mind and reducing the rumination and excessive thinking habits of the brain. There’s also something very important.

We’re training our brains to hold attention because, very often, we’re so stuck in our minds that it’s almost like we are frazzled. We can’t endure wakefulness to hold our attention. With this, you’re happy; interactive is the relaxation response. You’re helping to improve your concentration and attention span. You’re helping to reduce chemosensitivity to carbon dioxide. How much reduced is chemosensitivity to carbon dioxide? Your breathing is naturally lighter and slower, which in turn helps to reduce the turbulence and the negative pressure created during inspiration. A lot is going on for such a simple exercise. Yes, this does boil down to what you talked about at the start. Nosebleed, tongue resting up on the roof of the mount, and just gently softening and slowing down or breathing.

Audrey Wells, MD

I love it. There’s so much good common sense here, and I want to circle back to a little bit of what you said about people who have high loop gain and just reinforce this idea that it interferes with breathing and sleep. I see this in sleep studies all the time. People will have central apnea at the onset of sleep, then overbreathe, and then arousal from sleep. This is especially true for women. I’m always trying to help women who perceive that they skate on the surface of sleep, partially because of this breathing instability that’s present with central sleep apnea at sleep onset. But what you’re talking about is so powerful because it helps us be aware that all of this can be under our conscious control. In other words, we can do something about it. We can practice, get better at breathing, and solve the sleep problem naturally. Thank you so much for that.

Patrick McKeown

You’re very welcome. It’s a pleasure. In terms of the phenotypes, this has opened a door to the recognition that obstructive sleep apnea isn’t just anatomical but that you have three non-anatomical interventions. 70% of people have at least one or more of these non-anatomical phenotypes. That’s where breathing can play a role because we can influence all four of the phenotypes. Getting the mouth closed with the tongue resting up on the roof of the mouth helps reduce high peaks because we can help open up the airway. Improving breathing patterns during wakefulness. Breathing, whether light, slow, or deep, will also help to reduce the high pre-crash arousal threshold, which, in layman’s terms, will be insomnia. Being a light sleeper. If we breathe through our nose, we typically have deeper sleep.

Also, if we have lighter and slower breathing during sleep, we’re less likely to be aroused. We have deeper sleep, and we can stay longer in slow-wave sleep. then, as high loop gain as we spoke about, and then as for muscle recruitment, there is a connection. By breathing through the nose, we harness nasal nitric oxide, and it’s thought that nitric oxide is in there too in messenger, that it has some communication to the upper airway to later muscles. But we also spoke about carbon dioxide. If we are hyperventilating during our sleep, breathing hard and breathing fast, and we’re blowing off too much carbon dioxide from the blood through the lungs, the brain doesn’t send a signal to the upper airway to later muscles. breathing reeducation. However, my functional therapy would be a tremendous adjunct. Even when we look at people using CPAP, compliance with CPAP is reduced with mouth breathing versus nose breathing, which is very understudied. But in 2004, there was a study that showed that, at 12 months, 70% of individuals who were breathing through their noses were compliant. But of the individuals who are breathing through their mouths during sleep, only 30% are compliant. We do need to look at breathing in our everyday lives.

Audrey Wells, MD

The study that you referenced was a landmark for people who were recommending CPAP. One of the problems is that when a person is picking out a CPAP mask, one of the very first questions they’re asked is, Can you breathe through your nose during sleep? If there’s any question about whether that’s true, they’re automatically given a full face mask or an oral nasal mask. The root problem isn’t solved. I wonder, Patrick if you can maybe give some techniques or some insight as to how a person who experiences nasal congestion, either just at night when they lay down or even intermittently during the day, might maneuver to solve that so that they can start breathing better through their nose.

Patrick McKeown

The nose is the organ that, the more we use it, the better it works. We’re not going to expect to be able to breathe through our nose during the day if we spend half or more of the time or any amount of time with our motor open during the day. We need to think about how we are breathing during wakefulness. Go for a walk with your mouth close to your yoga, breathing in air through your nose, gear, gardening, and anything else that you’re doing, especially involving physical exercise. Because the way I look at it, if you can breathe through your nose during gentle or physical exercise, you’ll have no problem breathing through your nose during rest. Now, to decongest the nose, there are three ways to do it. One is by doing physical exercise, which is my clothes, that naturally helps to decongest the nose. The second is to do breath tolling, and the third is when humans have sex. One way then is to decongest the nose by doing breath holding as you take a normal breath in through your nose and your nose and you hold your nose and you just gently nod your head up and down even doing it about ten times. By doing that ten times to nodding your head up and down, ten times on a libretto, it’s very light. Most people will tolerate it pretty easily and then let go of a pretend through their nose and then wait maybe a half minute and be rapacious. To do it again, you take a normal breath in through your nose and out through your nose.

You pinch your nose and hold your nose to stop breathing, and then you just gently nod your head up and down, and you could do ten nods. Then you let go and breathe in through your nose, and you’ll start to feel that your nose is opening up. We’ve been using tape on the mouth now, and I’ll explain in a little bit more detail. I started doing this in 1998 because it was one way for me to, you know, wake up feeling refreshed. At the time, I had a lot of nasal congestion. I have a deviated septum as well. Even though I had an operation on my nose in 1994, the thing about the operation was that it didn’t change my behavior. Even though the surgeon worked and I treated my nose, I kept breathing afterward. I read a newspaper article then about the importance of nose breathing. I got pre-written strips based on the coscoastalneuver just to gently open up my nose, and then I used medical tape. The thing about taping is that, even though it can help a lot of people, one-third of people with obstructive sleep apnea, especially moderate to severe, can worsen their SA if they take them out.

The reason is that mouth tape is put right across the lip because it prevents mouth puffing. The individual needs to be able to mouth puff. Now, it was by chance that we developed our tape a few years ago, and it surrounds the mouth to bring the lips together. It’s an elastic tension, but it doesn’t cover the lips. The individual can mouth puff. I was trying to figure out, like, what is mouth puffing? We all know it, you know? I got onto my treadmill, and I was doing those breathing exercises on the treadmill, and I kept on ramping up to speed until I couldn’t sustain nasal breathing because the air hunger was too much. When you can sustain nasal breathing at a certain point, you automatically mouth puff. That’s what’s happening as well. A combination of the flow and detectors with which people are breathing. Of course, when you combine resistance to breathing and stopping the breathing during sleep the individual has to be able to mouth puff, and if they’re taped right across the lips, it’s not ideal.

It will make their sleep apnea worse. What would I say to people with sleep apnea? I would say to do the things that you’ve been talking about nose breathing at all times; it’s vital. Your mouth is simply not for breathing. Your children will notice. You ask a five-year-old, What’s your father saying? It’s for saying, What are your ears farts for listening? What is your mouth for? It’s for eating, for drinking, and for speaking. What’s on your nose first? For smelling and breathing. It is not just the obvious things, you know, that we have overlooked, but also practicing gently softening and slowing down the breaths. That’s crucial, especially ten or 15 minutes before sleep, but even during the day to do that. It’s so wonderful to be able to bring your attention out of your mind and onto your breathing and to tell your body for your body to tell your brain that you are safe. Another benefit of this is that the more you have your attention, that little pocket stroke today, and you bring your attention to the breath, you have to bring quietness and stillness to the mind.

That will improve your concentration and your ability to hold your attention on whatever task you want. We’re happier because we’re not as happy as individuals. Humans are not happy when we worry a lot. That makes sense. How then do we reduce the worrying mind? Well, that’s bringing our attention out of the mind and onto the road. But there’s also another aspect to this. If we have a habit of mouth breathing, we are breathing faster, we are breathing harder, and we can be hyperventilating chronically. Now, I’m not saying that everybody with breathing control disorders hyperventilates, but chronic hyperventilation can happen when our breathing is just a little bit too fast and too hard. There’s a pirate paradigm that came from a psychiatrist, Dr. Michael Bender and he spoke about neuronal excitability. We have a billion brain cells, and each brain cell communicates with 15,000 other brain cells. The signal coming from each brain cell must be strong enough to reach other brain cells. But of course, the brain cell itself, which is receiving the signal, must be able to cope with the signal that’s coming in. But if we are breathing hard and fast, it lowers carbon dioxide, increases blood pressure, and increases neuronal excitability.

That’s another aspect of it because when the mind is agitated, we can’t sleep. But also when we cannot sleep when we have poor sleep, the mind is agitated. I often feel, Dr. Wells, that this is something that’s forgotten about. There are so many people with depression who have undiagnosed obstructive sleep apnea, and nobody seems to talk about not so many people. At least in my observations, clients with depression go to their psychiatrist to go to their medical doctor; they go to their psychologist. Very often, sleep quality is forgotten about. You cannot just address depression from a pharmacological point of view if that same person is having obstructive sleep apnea. Now, I know that the symptoms are common—you know, feeling irritable, poor concentration, and fatigue. Those symptoms are common in both obstructive sleep apnea and depression. probably that’s why it gets watered down a little bit. But at the same time, we cannot properly address mental health issues unless we look at breathing. We look at sleep, and our everyday breathing pattern as very important because it’s how we breathe during wakefulness that is going to influence how we breathe during sleep. if we make a concerted effort to breathe through the nose and, where possible, during the day, just gently soften our breathing to the point of tolerable air hunger and also breathing low. That can be simply having your hands on either side of your lower ribs. As you breathe in, you feel your ribs gently moving out. As you breathe out, you feel your ribs gently moving in because of the connection between the diaphragm and the upper airway dilator muscles. I don’t think we can avoid breathing and functional breathing.

Audrey Wells, MD

There’s so much good information here. I want to take a stab at summarizing the highlights of what we talked about for everybody. First off, I want to say that breathing is a great way to help the mind-body connection, which is crucial not just to getting to sleep when you want to but also to staying asleep and having good well-being and alertness during the day. You’ve given us some accessible techniques to improve our nasal breathing, eliminate congestion, and also do what I like to call a U-turn. Why? You turn at night to go inside and be mindful of what you’re experiencing. Take control of how you’re breathing and start to relax and shed the stressors of the day. Your tip for low, slow, and deep LSD was great. It’s not only the breath rate; it’s also the flow and the depth at which we breathe. All of this is central to achieving the type of breathing that’s going to help you stay healthy. Thank you so much, Patrick McKeown. we learned a lot, and I wonder, as we wrap up, can you tell people how they may learn more about you or might work with you?

Patrick McKeown

Sure, of course. You mentioned a couple of books. I’ve got ten books. The most recent one is Breathing For Yoga. There’s also The Breathing Cure. That tape may be something that your listeners may be interested in. It’s called Myo Tape. Myo stands for muscle, and it’s gentle. It’s an elasticated tape that surrounds the lips to bring them together. In terms of mouth puffing, it allows my puffing, and it’s fairly inexpensive. It’s $25 for a three-month supply, and it can be used for the CPAP machine, for example. We have a resource; we have a free-up oxygen advantage, and it contains everything in terms of breathing exercises. It’s everything inside, and it’s just free. There’s no subscription. If anybody wants to program a daily program for sleep issues and sleep apnea, it’s all in the app. That may be another hub for resources for people.

Audrey Wells, MD

I love that it’s so helpful to have these resources that people can access today and start the path to good nasal breathing. Thank you so much, Patrick McKeown. It’s been a pleasure.

Patrick McKeown

Thank you very much, Dr. Wells.