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By Dr. Artour Rakhimov, Buteyko breathing teacher and educator

Click on the picture to watch the video clip where I explain the problem. Video clip "How we breathe in the morning" (it will open in a new window).

For most people, even healthy ones, breathing is heaviest during the early morning hours. A group of Italian scientists from Centro di Medicina Subacquea e Iperbarica (CEMSI) in Salerno investigated, according to the title of their article Voluntary breath-holding in the morning and in the evening. They revealed that, “During the evening sessions, most of the BHT/Delta P ACO2 ratios… were higher than the corresponding morning values…” (Bosco et al, 2004).

In sick people the effect is even stronger. Let us first consider asthma.
American pediatricians from the Washington University School of Medicine in St. Louis in their publication note, “BACKGROUND: Symptoms from asthma are often prominent at night. In adults significant circadian variation has been shown with reduced peak expiratory flow rates and increased bronchial reactivity to methacholine in the early morning hours” (Porter et al, 1999).

A group of Brasilian medical scientists investigated, according to their title Morning-to-evening variation in exercise-induced bronchospasm (Vianna et al, 2002). Their objective was “to compare morning and evening EIB [exercise-induced bronchospasm] and minute ventilation during exercise (VE)” (Vianna et al, 2002). Indeed, baseline FEV1 was significantly lower during early morning hours, while minute ventilation higher.

Over 30 years ago the Thorax published a study Physiological patterns in early morning asthma (Hetzel, et al, 1977). The goal of the study was also to explain “the sudden nature of some asthma deaths as these often occur in the early morning” (Hetzel, et al, 1977).
Several other publications were devoted to effects of sleep on patients with COPD (chronic obstructive pulmonary disease). American scientists from the Yale Center for Sleep Medicine (Yale University School of Medicine, New Haven) wrote, “Symptoms related to sleep disturbances are common in individuals with moderate to severe COPD, particularly in the elderly, which is commonly manifested as morning fatigue and early awakenings. One major cause of morbidity in this population is abnormalities in gas exchange and resultant hypoxemia as they can lead to elevated pulmonary pressures, dyspnea and in severe cases right ventricular overload and failure. Sleep has profound adverse effects on respiration and gas exchange in patients with COPD…” (Urbano & Mohsenin, 2006).

Moreover, Sheppard and colleagues in the publication from the Chest magazine noted, “Epidemiologic investigation has revealed that patients with pulmonary disease are at increased risk of dying during the early morning hours” (Sheppard et al, 1984). The load on the heart muscle during the episodes of hypoxemia during sleep can be, according to their conclusion, “can be transiently as great as during maximal exercise”.
If patients with pulmonary conditions can die due to heart problems at night, what about heart patients themselves? “Coronary spasm occurs most often from midnight to early morning when the patient is at rest”, (Yasue & Kugiyama, 1997) says the Japanese study Coronary spasm: clinical features and pathogenesis published in the Internal Medicine magazine.

Intensive care professionals from Department of Anaesthesia and Intensive Care Medicine of the Hadassah Medical Centre in Jerusalem, Israel also decided to investigate, according to their title, In-hospital cardiac arrest: is outcome related to the time of arrest? They wrote,
“BACKGROUND: Whether outcome from in-hospital cardiopulmonary resuscitation (CPR) is poorer when it occurs during the night remains controversial. This study examined the relationship between CPR during the various hospital shifts and survival to discharge…CONCLUSIONS: Although unwitnessed arrest is more prevalent during night shift, resuscitation during this shift is associated with poorer outcomes independently of witnessed status” (Matot et al, 2006)

Trying to explain the cause of deaths, Turkish cardiologists from Ankara published a study Circadian variations of QTc dispersion: is it a clue to morning increase of sudden cardiac death? They explained, “BACKGROUND: Several studies related to cardiac events including sudden death have shown a peak incidence in the early morning hours. Our data suggest that QTcD has a circadian variation with an increase in the morning hours, especially in patients with coronary artery disease. This finding was thought to be an explanation for the role played by sympathetic nervous system in the occurrence of acute cardiac events and sudden death during these hours” (Batur et al, 1999).

A group of American cardiologists from the Georgetown University Medical Center in Washington, D.C. was also interested in the most likely time of death, “The time of death was available in… 96 of the 139 patients who died suddenly. There was a circadian variation of all SCDs [sudden cardiac deaths] compared with other deaths with a distinct peak during the morning (p = 0.04)” (Behrens et al, 1997).

Swiss medical doctors explained in their abstract, “Prinzmetal's angina is a variant of the classic exertion dependent angina pectoris. Typical is the appearance of the symptoms at rest during early morning hours. It is due to spasms in the coronary arteries. Various provocation tests may be used to trigger spasms, among others hyperventilation which leads to vasoconstriction of coronary arteries” (Jacob et al, 1994).

Even healthy people have heavier breathing and lowered oxygenation of the brain during early morning hours, as Australian scientists from Latrobe University in Melbourne revealed. After testing health subjects, these scientists concluded, “These data indicate that normal diurnal changes in the cerebrovascular response to CO(2) influence the hypercapnic ventilatory response as well as the level of cerebral oxygenation during changes in arterial Pco(2); this may be a contributing factor for diurnal changes in breathing stability and the high incidence of stroke in the morning” (Cummings et al, 2007).

It is not a surprise then that British researchers from the National Heart and Lung Institute (Imperial College, London) also noted, “The reduction in hypercapnic cerebral vascular reactivity that occurs in the morning after sleep is associated with an increased risk of cerebral ischemia and stroke” (Meadows et al, 2005).

Similarly, Californian neurologists wrote, “This reduced morning response to hypercapnia suggests diminished vasodilator reserve during this period, and may be related to the increased stroke risk during the morning hours” (Ameriso et al, 1994).

Patients with diabetes also suffer from lower oxygenation in tissues during nights: “Circadian rhythms of tissue oxygen balance and blood rheological properties were investigated in 40 patients with insulin dependent diabetes mellitus... Preserved blood hyperviscosity and increasing tissue hypoxia at night indicated stable disturbance of hemorheological properties and tissue oxygen balance” (Galenok et al, 1988)

Japanese doctors from the Department of Pathology for the Handicapped in Ehime University warn that those who care about people with epilepsy should know about higher chances of seizures during nights, “…S-w paroxysms combined with clinical symptoms and continuing for more than four seconds were fewer during the afternoon than the morning and, moreover, during sleep. …Therefore, the observation of typical absence seizures during the morning should be regarded as important” (Nagao et al, 1990)

A marker of inflammation, C-reactive protein, was measured during different parts of the day in obese patients (Punjabi & Beamer, 2007). The conclusion of these medical scientists from the Johns Hopkins University in Baltimore was in the title of the study, C-reactive protein is associated with sleep disordered breathing independent of adiposity. Hence, it is not just obesity, but disordered breathing at night that can lead to inflammation: “…the results of this study suggest that mechanisms other than adiposity per se could contribute to the inflammatory state seen in adults with SDB [sleep disordered breathing]” (Punjabi & Beamer, 2007).

Since inflammation can get worse during nights in many patients, is it possible that cortisol production (cortisol is one of the key hormones to fight inflammation) also decreases at nights? German researchers suggested, “Some studies found patterns of enhanced or blunted waking cortisol responses observed under chronic stress, burnout, or post traumatic stress disorder… The morning cortisol increase typically observed in healthy subjects and also observed in the control group was absent in the amnesic patients… Further studies are needed to understand the neurological or psychological mechanisms leading to a missing morning cortisol response in amnesic patients”(Wolf et al, 2005).

“Approximately two-thirds of women experience nausea or vomiting during the first trimester of pregnancy. These symptoms are commonly known as morning sickness” (Flaxman & Sherman, 2000). It is known that pregnancy of modern women means chronic hyperventilation (see below). Many of these women have even heavier breathing in comparison with their usual daily chronic hyperventilation.

What are the causes of morning hyperventilation? They are numerous. Some of them are discussed below.

Presence of disease and existing damage in the body
Dr. Buteyko, during his public lecture at the Moscow State University, said, “The horizontal position, lying intensifies breathing. Patients with asthma, heart disease, hypertension, and stenocardia often have acute states at night. If they lie down during the day time, or lie for 2-3 hours – the breathing gets heavier, the attacks come. Many severely sick patients sit, afraid to lie down. This is sensible. We should lie down only for sleeping. Our patients cannot control their breathing at night, and hence, sleep is poison for them” (Buteyko , 1977).

Sleeping too long
Sleeping too long, according to Buteyko, intensifies breathing causing prolonged periods of gradually increasing hyperventilation (p.177, Khoroscho, 1982)

Sleeping on the back
Among body positions, sleeping on the back (supine position) is worst (some people start snoring in this position). Sleeping on the right side also causes increased ventilation in comparison with sleeping on the left side or on the chest. Children's ventilation is minimum when they are sleeping on their tummies (Buteyko, 1977).

There are no physiological studies known to me in which such parameters of breathing, as minute ventilation and aCO2, are monitored in different sleeping body positions. Meanwhile, there are at least 8 studies devoted to the physiological effects of different body night positions on the stomach. All these investigations, trials included, advocate the left position due to the least night-time recumbent reflux (e.g., Khoury et al, 1999). That means that the liquid content of the stomach, for the left position cannot escape or leak due to the absence of physical contact with any of the stomach valves. This position is also the most favourable for general peristaltic waves in the large intestine due to the gravitational effect in the transverse colon. There are, possibly, some other reasons to explain the advantages of the left position (e.g., the influence of the heart position). Some people, due to congenital reasons, have their hearts on the right side. In such cases the effects of sleeping positions are also in reverse.

A simple "sleeping positions" self-test. By measuring stress-free breath holding time in different sleeping positions, one can find out what is the optimum position for breathing and health. Note that one needs to spend about 10-15 minutes in a certain position in order to achieve a stable metabolism correspondent to this position. A ticking mechanical clock can be used for that purpose. Generally, sleeping on the left side will produce the highest BHT, followed by sleeping on the tummy. Sleeping on the back is worst and causes lowest BHT.

For the list of the quoted references click here

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