Nasal Breathing: How Good Is Your Flow?
Screening for perceived nasal patency, tips to improve it and when to seek further medical care.
Progress in the fields of health and performance can be a funny thing. We evolve with the assumption that progressive betterment comes by doing things differently. Yet, occasionally if you take a step back you can see that the best way has been right under our noses all along.
Such is the case for nasal breathing.
Nasal breathing is like the new kid on the block, except you realize they've actually lived there for years. Moving past the attention of yogis and those in the know, nasal breathing is now advocated by many health and wellness practitioners. Performance, Sleep, Asthma management, Stress Reduction, Attention and more seem to benefit from better breathing.
Gosh! that new kid has iconic mouth breathing skills
Proposed benefits of nasal breathing include filtration, humidification and warming of the air. Breathing through your nose promotes a better oral rest posture, thereby positively affecting several things including sleep and occlusion.
Many of the benefits linked to nasal breathing are tied to nitric oxide (NO) which is produced in the paranasal sinuses and released into the nasal cavity upon nasal inspiration. Humming adds an additional boost to this release. (1)
Nitric oxide plays an important role in vasoregulation, immunity and neurotransmission. It also assists in the activation of ciliary movement and mucous secretion, thereby impacting nasal patency.
With so many benefits it seems prudent to not turn your nose up toward this trend but…
If nasal breathing is “THE ANSWER”, then what is the question?
Seems like an appropriate question to ask if you plan on incorporating any type of nasal breathing into your rehab, fitness or heck, sleep routine.
You might think this is a silly question but consider the fact that 1 in 6 adults in the Unites States are diagnosed with nasal allergies and at least 60% of those individuals complain of nasal congestion. The economic burden has been estimated at 6 billion dollars a year. (2) This clearly can impact quality of life too.
You might wonder “Well wouldn’t I know if I had trouble nasal breathing?”
HOW TO SCREEN FOR (PERECEIVED) NASAL PATENCY
Nasal patency is a term that describes a measure of how open the nose is. Congestion is the term most commonly used to describe the symptom of obstructed nasal airflow.
Symptoms of nasal congestion can be caused by a laundry list of things. A thorough subjective history can highlight the possible contributors and comorbidities.
Symptoms: congestion/stuffiness/runny nose/post nasal drip, sleep disturbance, snoring, anosmia (loss of smell), bloody noses, dry mouth, frequent sneezing.
Environment: allergens, relative humidity, high altitude
Facial trauma: history of any type of cranial trauma, especially a broken nose but also including birth trauma
Known structural issues: deviated septums, turbinate and/or adenoid hypertrophy, nasal polyps, malocclusion and high arched palates, history of previous facial surgery especially rhinoplasty
Associated conditions: ADHD and other learning disabilities, Asthma, Sleep Disorders, Headaches, Anxiety, Dental/gum disease, frequent sinus/ear infections
Behaviors: frequent sighing, sniffing, or yawning, taking a large breath before speaking
In addition to a subjective history, testing someone’s perceived ability to nasal breathe can happen with the following simple tests.
Simple Tests To Screen For
Nasal Breathing Competence
As simple as it sounds, you need to close your mouth effectively to be able to breathe through your nose and master the resting tongue posture. Nasal breathing guru Patrick McKeown even has a book appropriately titled “Close Your Mouth.”
What if you can’t close your mouth; or more commonly what if it requires such effort that subconsciously you assume a resting mouth posture that is slightly open?
might look like this situation (3)
This is an important first step because if one’s lip seal is compromised, nasal breathing and proper oral rest posture will be as well. (3)
Checking for a lip seal occurs through observation. Are there creases around the mouth? Is there visible strain of the muscles around the mouth? This is often seen in the Mentalis muscle.
Certain issues of craniofacial structure, including occlusion, how your maxillary and mandibular teeth contact, may also affect lip seal. For example, an overjet bite may be severe enough to cause difficulty.
With this test the individual will block one side of their nose with the index finger of the same side hand and breathe through the opposite side. Then repeat on the opposite side.
Look for possible alar collapse on the side they are breathing through. A collapse might indicate a restriction of airflow. (4)
In addition to looking for alar collapse I will have my patients maintain the
block on one side and breathe a few breaths. This is a quick and simple way to check for perceived patency of each side individually.
As they do this listen to potential differences in the breath sounds produced by each side with both inhalation and exhalation. Ask the individual if they perceive any difficulty and if they sense a difference side to side.
To make this subjective test more objective you can document a measurement on a visual analog scale (VAS) with one end of the scale representing perception of completely blocked nose and the other end a completely clear nose.
completely blocked nose_____________________________________completely clear nose
Alternatively use a numerical scale much like the rate of perceived exertion (RPE). On a scale of 0-10 how difficult or effortful did that feel?
I first learned about the Rosenthal test in AOMT’s Myofunctional Therapy course. (4) It is a bit elusive in the literature but I still use it, albeit aware of its potential limitations.
To test for the subjective experience of nasal patency you instruct the client to close their mouth and breathe exclusively through your nose for one minute (or 20 times). The test is positive for potential patency issues if you feel nasal breathing is difficult, uncomfortable or causes feelings of anxiety.
In the Buteyko Method Instructor course Patrick McKewon states “If you can breathe through your nose for a minute, you can breathe through your nose for life” I’m not usually a fan of catchy marketing phrases but this one holds some truth.
We tend to think of respiratory patency in terms of how easy it is to get a breath in but the exhalation definitely matters and the two (inhalation and exhalation) aren’t necessarily equal.
The Modified Glatzel Mirror test is a screen for one’s ability to achieve a nasal exhale. In the nasal breathing literature this test is frequently used to monitor nasal patency after a surgery to remedy nasal obstruction. (5)
A mirror (or a metal surface) is held just under the nose and a comparison of condensation of exhaled air is compared left to right. To make this test more objective the contour of the condensation can be measured. While the Glatzel Mirror test is often described as an objective test there are no known norms for this test.
I don't use this often but it can provide valuable insight and is more objective than the other tests mentioned.
The Nasal Obstruction Symptom Evaluation (NOSE) is a simple subjective questionnaire that is commonly used to identify individuals who are at risk for obstructive sleep apnea as well widely used for the subjective assessment in studies on nasal breathing.
The NOSE measures 5 items of obstruction related symptoms on a 5 point Likert scale with a higher total score noting a greater sense of obstructed nasal breathing.
The items include:
1. Nasal congestion or stuffiness
2. Nasal blockage or obstruction
3. Trouble breathing through the nose
4. Trouble sleeping
5. Difficulty nasal breathing during exercise or exertion
In addition to the NOSE questionnaire, the SNOT-20 (Sino-Nasal Outcome Test) is another reliable and validated patient reported outcome measure assessing the effect of impaired nasal breathing.
All of the tests mentioned in this blog should be considered as part of an initial screen. They are a good place to start because of their simplicity and ease.
One important thing to consider is that they are mostly looking at the PERCEPTION of patency/obstruction.
In a perfect world, objective and subjective measurements of nasal patency would have strong correlations but this doesn’t seem to be the case. (6) Several studies show weak association between an individual's sensation of nasal airflow and objective measures of the same. Therefore we can’t assume that if one senses restricted flow they indeed have it and vice versa.
Acknowledging this discrepancy we should wonder ‘Why might this be?’ What other factors might influence one’s perception of patency?
Potential factors to consider
The Nasal Cycle is the normal biorhythm of alternating partial congestion and decongestion in the nasal cavities from side to side. (7) During this cycle unilateral nasal dominance lasts on average for 1-4 hours, and up to 7 hours. Due to the nasal cycle it is “normal” to have greater airflow on one side at any given time.
The nasal cycle thus makes research on a larger scale, difficult due to the dynamic nature of flow. It also suggests that it would be beneficial to educate folks on this normal asymmetry if they do perceive nasal flow restriction when we do some of the tests described earlier.
Nasal congestion can be affected by posture. Studies have demonstrated that in the sidelying position the cycle of nasal dominance will shift to the opposite side. For example if lying on your left side the nostril dominance will shift to the right and your left side will be relatively more congested.
Also going from a sitting position to supine has shown to influence hydrostatic pressure with an increase in central venous pressure by up to 8 mm Hg. This causes vascular engorgement of the mucosa and a subsequent increase in nasal resistance. (8)
When testing the relationship between objective and subjective patency we need to standardize postures and explore postures other than sitting.
In addition, we should consider how body posture can impact nasal patency when prescribing rehab exercises and helping individuals improve their sleep.
Another potential reason for lack of correlation between objective and subjective tests is not measuring the right variable.
Recent studies have shown through Computational Fluid Dynamics (CFD) that heat flux, heat loss from the nasal mucosa to inhaled air, correlates with the subjective sensation of patency. (9) This cooling effect may be related to how we experience the decongesting effect of menthol.
Does Subjective Nasal Patency have value?
Short answer: Absolutely
In addition to measuring the perception of patency the tests above can be used as pre and post measures for interventions.
Whatever the cause of potential patency restrictions, an individual may become desensitized to decreased nasal airflow over time. Ultimately, like many experiences, bringing awareness to the sensory experience will help facilitate change. We want to influence someone’s perceived threshold of comfort and change the point they want to switch from nasal to mouth breathing.
A lot of people sense a stuffy nose and reach for the “easy fix” of a nasal decongestant or worse have surgery that isn't needed. Here are some alternative interventions you can try that are more holistic.
find a provider @ https://www.myofunctionaltherapists.com/
Initially the two main goals in Orofacial Myofunctional Therapy are establishing nasal breathing and optimizing the oral rest posture.
Use a humidifier and/or air filter
If you live in Colorado, trying to add a little extra moisture into your air is almost a given!
Daily saline nasal rinse
Breathe right strips
Buteyko Nose Unblocking exercise
Keep your mouth closed, breathe in and out through your nose
Pinch your nose, hold your breath while gently nodding your head up and down until you feel a strong sense of air huger
Release your nose and resume breathing
Calm breath and wait 30-60 sec before repeating
Repeat 6 times
Buteyko Finger Blocking Nostril exercise
The purpose of this exercise is to is to focus airflow on the side that feels more restricted. Occlude the freer side and nasal breathe through the side you perceive to be more congested.
Menthol creates an improved perception of patency via a cooling effect on the nasal cold receptors in the mucosa
If these conservative interventions don’t help…
Who should you refer to if patency perception remains unchanged?
If myofunctional therapy is not appropriate or there was no progress then consider a referral to
an airway-focused an ENT (ears, nose and throat) specialist
an airway focused dentist
Causes of nasal obstruction typically fall into 4 broad categories: anatomical abnormalities, inflammatory conditions (rhinitis), nasal valve incompetence and “other” (eg, pregnancy or drug induced)
The common objective tests to assess nasal airflow and patency are: (10)
rhinomanometry (measuring pressure and airflow resistance)
acoustic rhinometry (measuring nasal cross sectional area and length)
peak nasal inspiratory flow (a measure of nasal airflow during maximal inspiration).
Keep in mind that we can’t assume that when present; structural obstruction is always the the main influencer in perception of patency.
For the most part, we all are born with the ability to nasal breath. In fact, mouth breathing is often a habit that develops for reasons other than structural causes of nasal obstruction.
Like any behavior or habit change we pursue, establishing a connection to ourselves is important. Interoceptive awareness varies among individuals, so as practitioners we need to encourage attention to the sensation. Along these lines we also need to realize the sensation of nasal obstruction can be influenced by emotional states and past experiences just as much as internal structure and external influences.
Perception of congestion can be “felt” in many ways:
fatigue due to energy expenditure
effort in cognitive focus
feeling of discomfort
threathening in terms of air hunger
Beyond its effect on breathing the sensation of nasal obstruction can impede our ability to sense our environment. I wonder, could this subconsciously drive us toward a sympathetic shift because one of our threat detectors (smell) is not working?
This post may make you feel that nasal breathing is more complicated than you thought. What is simple though is that if you aren’t nasal breathing, you are mouth breathing.
The numerous negative consequences from mouth breathing are translating into epidemics of their own in the name of sleep disorders like sleep apnea, allergies, asthma, attention deficit disorder and anxiety. We need to realize that the problem of mouth breathing is more than just a health issue and behavioral issue, it’s a socioeconomic and environmental one as well.
While people don’t usually ask for help for congestion from their physical therapists or personal trainers, we are often the best vehicles to promote a better way. Our unique ability to appreciate the nose within the context of the rest of the body and within the greater context of breathing and human movement can help make the improvement that is needed.
1. Weitzberg E, Lundberg JO. Humming greatly increases nasal nitric oxide. Am J Respir Crit Care Med. 2002 Jul 15;166(2):144-5
2. Stewart M, Ferguson B, Fromer L. Epidemiology and burden of nasal congestion. Int J Gen Med. 2010 Apr 8;3:37-45.
3. Iida J, Kaneko T, Nakanishi M, Yoshizawa S, Yamamoto T, Sato Y. Lip incompetence and myofunctional therapy Hokkaido. J Dent Sci 2017;38:130-5.
4. Academy of Orofacial Myofunctional Therapy: Intro to Myofunctional therapy course manual
5. Brescovici S, Roithmann R. Modified Glatzel mirror test reproducibility in the evaluation of nasal patency. Braz J Otorhinolaryngol. 2008 Mar-Apr;74(2):215-22
6. André RF, Vuyk HD, Ahmed A, Graamans K, Nolst Trenité GJ. Correlation between subjective and objective evaluation of the nasal airway. A systematic review of the highest level of evidence. Clin Otolaryngol. 2009 Dec;34(6):518-25
7. Pendolino A. et al, The nasal cycle: a comprehensive review. Rhinology Online. Vol 1: 67-76, 2018.
8. Pevernagie DA, De Meyer MM, Claeys S. Sleep, breathing and the nose. Sleep Med Rev. 2005 Dec;9(6):437-51.
9. Sullivan CD, Garcia GJM, Frank-Ito DO, Kimbell JS, Rhee JS. Perception of Better Nasal Patency Correlates with Increased Mucosal Cooling after Surgery for Nasal Obstruction. Otolaryngology–Head and Neck Surgery. 2014;150(1):139-147
10. Lam DJ, James KT, Weaver EM. Comparison of anatomic, physiological, and subjective measures of the nasal airway. Am J Rhinol. 2006 Sep-Oct;20(5):463-70
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