Mouth Breathing Syndrome: cervical muscles recruitment during nasal inspiration before and after respiratory and postural exercises on Swiss Ball

Association Between Mouth Breathing and Asthma: a Systematic Review and Meta-analysis

PURPOSE OF REVIEW

This systematic review and meta-analysis evaluated the association between asthma and mouth breathing. We performed a systematic search in the PubMed, SCOPUS, Lilacs, Web of Science, Google Scholar and OpenThesis databases.

RECENT FINDINGS

Asthma is defined as a heterogeneous disease characterized by variable symptoms of wheezing, shortness of breath, chest oppression and/or cough, and limitation of expiratory airflow. Although several studies have examined the association between asthma and mouth breathing, there are no systematic reviews or meta-analyses that synthesize the available bodies of evidence. We used the odds ratio as a measure of the association between asthma and mouth breathing. Summary estimates were calculated using random-effects models, and the risk of bias was estimated using the Newcastle-Ottawa Scale for case-control studies and the National Institutes of Health tool for cross-sectional studies. Nine studies were included in the present systematic review. Data from 12,147 subjects were analyzed, of which 2083 were children and adolescents and 10,064 were adults. We found an association between mouth breathing and asthma in children and adolescents (OR 2.46, 95% CI 1.78-3.39) and in adults (OR 4.60, 95% CI 1.49-14.20). However, limitations were found in the methodological description of the included studies, as well as high heterogeneity among studies evaluating adult populations. This meta-analysis showed an association between mouth breathing and asthma in children, adolescents and adults, but the results should be interpreted with caution. Further studies with standardized criteria for the investigation of mouth breathing are needed.

Surface electromyography in orofacial and cervical musculature in mouth breathing children: an integrative literature review

ABSTRACT Purpose: to review, in an integrative manner, studies using surface electromyography in the orofacial and cervical musculature in mouth breathing children aged from three to 11 years and 11 months old. Methods: the survey was conducted in national and international databases, from 1998 to 2018, in Portuguese, English and Spanish. Review articles, dissertations, book chapters, case studies and editorials were excluded. Results: 86 articles were found, 14 of which met the inclusion criteria. Most of these studies used surface electromyography to assess and describe the muscle condition of the mouth breathing population. Only one study addressed the influence of myofunctional speech therapy and two studies included physical therapy treatment, using electromyographic evaluation before and after the intervention. Given the main categories of analysis, the discussion was based on the year, state of publication and journal, sample size, scientific methodology, muscles assessed, assessment protocols used and the results of the publications. Conclusions: surface electromyography has been used mainly in the initial assessment of orofacial and postural myofunctional changes caused by mouth breathing and not as a therapeutic biofeedback, thus, it is important to conduct longitudinal studies using this instrument in mouth breathers.

Muscles of Breathing: Development, Function, and Patterns of Activation

This review is a comprehensive description of all muscles that assist lung inflation or deflation in any way. The developmental origin, anatomical orientation, mechanical action, innervation, and pattern of activation are described for each respiratory muscle fulfilling this broad definition. In addition, the circumstances in which each muscle is called upon to assist ventilation are discussed. The number of "respiratory" muscles is large, and the coordination of respiratory muscles with "nonrespiratory" muscles and in nonrespiratory activities is complex-commensurate with the diversity of activities that humans pursue, including sleep (8.27). The capacity for speech and adoption of the bipedal posture in human evolution has resulted in patterns of respiratory muscle activation that differ significantly from most other animals. A disproportionate number of respiratory muscles affect the nose, mouth, pharynx, and larynx, reflecting the vital importance of coordinated muscle activity to control upper airway patency during both wakefulness and sleep. The upright posture has freed the hands from locomotor functions, but the evolutionary history and ontogeny of forelimb muscles pervades the patterns of activation and the forces generated by these muscles during breathing. The distinction between respiratory and nonrespiratory muscles is artificial, as many "nonrespiratory" muscles can augment breathing under conditions of high ventilator demand. Understanding the ontogeny, innervation, activation patterns, and functions of respiratory muscles is clinically useful, particularly in sleep medicine. Detailed explorations of how the nervous system controls the multiple muscles required for successful completion of respiratory behaviors will continue to be a fruitful area of investigation. © 2019 American Physiological Society. Compr Physiol 9:1025-1080, 2019.

Nasal patency and craniocervical posture in scholar children

ABSTRACT Changes in head posture have been observed as a compensatory mechanism for the nasal airflow impairment. This study aimed to compare the craniocervical posture between children with normal and decreased nasal patency and correlate nasal patency with craniocervical posture. Children aging from six to twelve years went through nasal patency and craniocervical assessments. The biophotogrammetric measures of craniocervical posture used were Cervical Distance (CD), Head Horizontal Alignment (HHA) and Flexion-Extension Head Position (FE), evaluated by SAPO software (v.0.68). Nasal patency was measured using Peak Nasal Inspiratory Flow meter (PNIF) and Nasal Obstruction Symptom Evaluation (NOSE) scale. One hundred thirty-three children were distributed into two groups: G1 (normal nasal patency - PNIF higher than 80% of predicted value) with 90 children; G2 (decreased nasal patency - PNIF lower than 80% of predicted value) with 43 children. Differences between groups were not found in CD and HHA measures. FE was significantly higher in G2 than G1 (p=0.023). Negative weak correlation between FE and %PNIF (r=-0.266; p=0.002) and positive weak correlation between CD and PNIF (r=0.209; p=0.016) were found. NOSE scores negatively correlated with PNIF (r=-0.179; p=0.039). Children with decreased nasal patency presented greater head extension. This postural deviation is prone to increase as nasal airflow decreases, thus indicating the relationship between craniocervical posture and nasal patency. Lower values of PNIF reflected on additional problems caused by nasal obstruction symptoms.

Body posture and pulmonary function in mouth and nose breathing children: cross-sectional study

Abstract Introduction: Mouth breathing can lead to changes in body posture and pulmonary function. However, the consequences are still inconclusive and a number of studies are controversial. Objective: Evaluate and correlate spirometric parameters and postural measures in mouth breathing children, and compare them to nose breathers. Methods: two groups of 6 to 12 year-old children were evaluated: mouth breathers (MB, n = 55) and nose breathers (NB, n = 45). Spirometry and body posture analysis using photogrammetry (SAPo 0.68® v) were carried out. The following spirometric measures were evaluated: peak expiratory flow (PEF), forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), FEV1/FVC ratio (%) and forced expiratory flow between 25% and 75% of FVC (FEF 25-75%). Biophotogrammetric measures analyzed were: horizontal alignment of acromions (HAA) and anterior superior iliac spine (HAASIS), Charpy angle, horizontal alignment of the head (HAH), cervical lordosis (CL), thoracic kyphosis (TK), lumbar lordosis (LL), cervical distance (CD) and lumbar distance (LD). Results: There were no intergroup differences in spirometric and postural variables. Positive and moderate correlations were found between CL and CD measures with PEF, FEV1, FVC and FEF 25-75%, while weak correlations were observed between lumbar lordosis and PEF, FEV1 and FVC. Conclusion: The breathing mode had no influence on postural and respiratory measures. However, greater forward head posture, with smaller cervical lordosis, was related to higher lung volumes and flows in both groups.

The effect of mouth breathing on exercise induced fall in lung function in children with allergic asthma and rhinitis

OBJECTIVES

Exercise induced bronchospasm (EIB) represents a common feature of childhood asthma which is most commonly revealed during free running. On the other hand aerobic exercise shows significant beneficial effects in asthmatics especially on the reduction of the level of systemic inflammation and is recommended as part of its treatment. The aim of this study was to test how mandatory mouth breathing influences the exercise induced level of decrease in lung function according to the level of severity of allergic rhinitis (AR).

METHODS

Free 6-minute running test preceded and followed by spirometry done with and without a nose clip a day apart was conducted in 55 children with moderate persistent asthma and AR. Children were divided into two groups according to the severity of nasal symptoms.

RESULTS

There was a greater fall in forced expiratory volume in one second after exercise with a nose clip in children with less nasal symptoms than in children with more nasal symptoms (mean ± SD; -5.28 (7.91) vs. -0.08 (4.58), p = 0.0228) compared to testing without the nose clip (mean ± SD; LNS, -1.31 ± 3.89%, p = 0.2408; MNS, -1.47 ± 3.68%, p = 0.2883).

CONCLUSION

Our results show that regular mouth breathing due to nasal congestion may lessen the degree of EIB in patients with persistent AR and allergic asthma.

How has our interest in the airway changed over 100 years?

Since the beginning of our specialty, our understanding of the link between function and facial growth and development has progressively improved. Today, we know that children with sleep-related breathing problems will often develop distinctive facial characteristics. In adults, sleep apnea can result in serious morbidity and mortality. Orthodontists can ask sleep-related questions in the health history to help identify sleep breathing disorders. Treating these patients presents unique opportunities for orthodontists to collaborate with other medical specialties to improve a patient's health and treatment outcome. Research presented in our Journal in the next century may shed new light that will help us better identify the problem and aid the specialty in developing more effective evidence-based treatment. Additional efforts are needed to understand the physiology, neurology, and genetics of sleep breathing disorders.

Implicações da respiração oral na função pulmonar e músculos respiratórios

RESUMO A Síndrome do Respirador Oral é caracterizada por um conjunto de sinais e sintomas que podem estar presentes em indivíduos que substituem o modo adequado e eficiente da respiração nasal pelo modo respiratório oral ou misto, por um período igual ou superior a seis meses. O modo respiratório oral ou misto pode estar associado a mudanças na função e mecânica ventilatória. Esta revisão tem como objetivo investigar mais profundamente as consequências da respiração oral na função pulmonar e músculos respiratórios, ressaltando o desenvolvimento de tais alterações desde a infância até a idade adulta. Foram selecionados 18 artigos por meio das bases de dados Pubmed e Web of Science e foram agrupados no texto, compreendendo os seguintes tópicos: 1) Implicações da respiração oral sobre a função pulmonar e 2) Implicações da respiração oral sobre os músculos respiratórios. A partir das informações oriundas dos resultados dos artigos analisados, percebe-se que poucos estudos refutam ou não encontram alguma relação entre as alterações pulmonares e a respiração oral. Sugere-se que, o desequilíbrio muscular produzido por estas alterações pode contribuir para a desvantagem mecânica do músculo diafragma e aumento do trabalho dos músculos acessórios da inspiração. Entretanto, são necessários estudos com métodos mais criteriosos, incluindo avaliações objetivas e reprodutíveis dos músculos respiratórios.

Deficits in working memory, reading comprehension and arithmetic skills in children with mouth breathing syndrome: analytical cross-sectional study

CONTEXT AND OBJECTIVE

Mouth breathing syndrome is very common among school-age children, and it is possibly related to learning difficulties and low academic achievement. In this study, we investigated working memory, reading comprehension and arithmetic skills in children with nasal and mouth breathing.

DESIGN AND SETTING

Analytical cross-sectional study with control group conducted in a public university hospital.

METHODS

42 children (mean age = 8.7 years) who had been identified as mouth breathers were compared with a control group (mean age = 8.4 years) matched for age and schooling. All the participants underwent a clinical interview, tone audiometry, otorhinolaryngological evaluation and cognitive assessment of phonological working memory (numbers and pseudowords), reading comprehension and arithmetic skills.

RESULTS

Children with mouth breathing had poorer performance than controls, regarding reading comprehension (P = 0.006), arithmetic (P = 0.025) and working memory for pseudowords (P = 0.002), but not for numbers (P = 0.76).

CONCLUSION

Children with mouth breathing have low academic achievement and poorer phonological working memory than controls. Teachers and healthcare professionals should be aware of the association of mouth breathing with children's physical and cognitive health.

Combined functional pelvic floor muscle exercises with Swiss ball and urotherapy for management of dysfunctional voiding in children: a randomized clinical trial

We report the clinical results of two types of urotherapy programs in children with dysfunctional voiding (DV). Sixty children with a median age of 8 (range, 5-14) diagnosed with DV were randomly allocated to one of two groups, each made up of 30 patients. Patients in group A underwent behavioral urotherapy (hydration, scheduled voiding, toilet training, and high-fiber diet) combined with pelvic floor muscle (PFM) exercises, whereas group B only received behavioral urotherapy. All parents completed a voiding and bowel habit diary chart. Uroflowmetry with pelvic floor surface electromyography (EMG) and bladder ultrasound were performed on all patients at the beginning and the end of the 1-year study. Abnormal voiding pattern normalized to a bell shape in 21/30 of patients in group A and 8/30 of patients in group B (P < 0.000). EMG activity during voiding disappeared significantly in 23/30 patients in group A compared to 15/30 patients in group B (P < 0.02). Episodes of urgency resolved in 12/14 of patients in group A and 3/11 of patients in group B (P < 0.01). Daytime wetting improved in 15/17 and 4/11 of patients in groups A and B, respectively. In addition, reduction in post-void residue (PVR) was significant in group A (P < 0.003).

CONCLUSION

Functional PFM exercises with Swiss ball combined with behavioral urotherapy proved as a safe and effective therapeutic modality, reducing the frequency of urinary incontinence, PVR, and the severity of constipation in children with DV.

Childhood mouth-breathing consequences at adult age: ventilatory function and quality of life

Introduction Mouth breathing can affect the functions of the respiratory systems and quality of life. For this reason, children who grow up with this stimulus may have implications on physical and psychological aspects at adult age.Objective To evaluate childhood mouth-breathing consequences for the ventilatory function and quality of life at adult age.Materials and methods Prospective, observational and cross-sectional study with 24 adults, between 18 and 30 years old, mouth breathers during childhood, comprised the childhood mouth-breathing group (CMB). The childhood nasal-breathing (CNB) group was composed of 20 adults of the same age, without history of respiratory disease during all their lives. Measurements of maximal respiratory pressures, peak expiratory flow and 6-minute walk test were assessed. In addition, all the volunteers answered the Short Form-36 questionnaire (SF-36).Results The maximal inspiratory (p = 0.001) and expiratory (p = 0.000) pressures as well as the distance in the walk test (p = 0.003) were lower in the COB. The COB also presented lower score in the General Health domain of the SF-36 Questionnaire (p = 0.002).Conclusion Childhood mouth-breathing yields consequences for the ventilatory function at adult age, with lower respiratory muscle strength and functional exercise capacity. Conversely, the quality of life was little affected by the mouth breathing in this study.

Mouth breathing and forward head posture: effects on respiratory biomechanics and exercise capacity in children

OBJECTIVE

To evaluate submaximal exercise tolerance and respiratory muscle strength in relation to forward head posture (FHP) and respiratory mode in children, comparing mouth-breathing (MB) children with nasal-breathing (NB) children.

METHODS

This was a controlled, analytical cross-sectional study involving children in the 8-12 year age bracket with a clinical otorhinolaryngology diagnosis of MB, recruited between October of 2010 and January of 2011 from the Mouth Breather Clinic at the State University of Campinas Hospital de Clínicas, located in the city of Campinas, Brazil. The exclusion criteria were obesity, asthma, chronic respiratory diseases, heart disease, and neurological or orthopedic disorders. All of the participants underwent postural assessment and the six-minute walk test (6MWT), together with determination of MIP and MEP.

RESULTS

Of the 92 children in the study, 30 presented with MB and 62 presented with NB. In the MB group, the differences between those with moderate or severe FHP and those with normal head posture, in terms of the mean MIP, MEP and six-minute walk distance (6MWD), were not significant (p = 0.079, p = 0.622, and p = 0.957, respectively). In the NB group, the mean values of MIP and MEP were higher in the children with moderate FHP than in those with normal head posture (p = 0.003 and p = 0.004, respectively). The mean MIP, MEP, and 6MWD were lower in the MB group than in the NB group. Values of MIP and MEP were highest in the children with moderate FHP.

CONCLUSIONS

Respiratory biomechanics and exercise capacity were negatively affected by MB. The presence of moderate FHP acted as a compensatory mechanism in order to improve respiratory muscle function.

Análise da postura craniocervical de crianças respiradoras bucais após tratamento postural em bola suíça

O estudo teve como objetivo avaliar a postura craniocervical de crianças respiradoras bucais após tratamento postural em bola suíça. Doze crianças respiradoras bucais foram submetidas a um protocolo de reeducação postural constituído por exercícios de alongamento e fortalecimento muscular sobre a bola suíça, estimulação diafragmática e alongamento dos músculos acessórios da inspiração. A postura craniocervical foi avaliada através da análise biofotogramétrica. A posição da anteriorização da cabeça foi aferida por meio do ângulo formado pelos pontos localizados no tragus direito e no processo espinhoso da sétima vértebra cervical com a linha horizontal. A curvatura cervical foi avaliada pela distância horizontal de uma linha vertical tangenciando o ápice da cifose torácica e o ponto de maior concavidade da curvatura cervical. As fotografias foram obtidas antes e após dez atendimentos. A normalidade das variáveis foi verificada a partir do teste Shapiro-Wilk. Para as comparações entre as médias foi utilizado o teste t de Student para amostras dependentes admitindo-se nível de significância de 5% (p<0,05). Verificou-se uma melhora na postura craniocervical, através da diminuição da anteriorização da cabeça (p=0,00) e do restabelecimento da curvatura fisiológica da coluna cervical (p=0,01). O tratamento postural em bola suíça proporcionou um melhor alinhamento da postura craniocervical, provavelmente pelo equilíbrio dos músculos cervicais e maior ação diafragmática.

Efeito da fisioterapia sobre os parâmetros ventilatórios e a dinâmica tóraco-abdominal de crianças respiradoras bucais

Este estudo objetivou avaliar o efeito da fisioterapia nos parâmetros ventilatórios e na dinâmica tóraco-abdominal de crianças respiradoras bucais. Dez crianças respiradoras bucais foram submetidas a um programa de reeducação respiratória e correção postural durante 20 sessões de exercícios de alongamento e fortalecimento muscular sobre a bola suíça, estimulação diafragmática e alongamento dos músculos acessórios da inspiração. Os dados coletados foram as medidas de pressões inspiratórias e expiratórias máximas (PIM e PEM), capacidade inspiratória (CI), pico de fluxo expiratório (PFE), mobilidade torácica por meio do coeficiente respiratório (Cr) nos níveis axilar (CrA), xifoide (CrX) e umbilical (CrU) e análise biofotogramétrica do ângulo de Charpy. Estes foram verificados antes e após 10 e 20 atendimentos. Os dados foram submetidos a uma análise de variância (ANOVA) e, nas diferenças encontradas entre as médias, aplicou-se o Teste de Tukey com nível de significância de 5% (p<0,05). Houve melhora para as medidas referentes ao ângulo de Charpy (p=0,048), CI (p=0,037), PFE (0,002), PIM (0,007), CrA (p=0,008) e CrX (p=0,041). A PEM e o CrU, apesar da melhora nos valores absolutos, não apresentaram resultados estatisticamente significativos. O programa de fisioterapia respiratória e postural produziu efeitos positivos sobre a função ventilatória de crianças respiradoras bucais.

Three-dimensional assessment of pharyngeal airway in nasal- and mouth-breathing children

OBJECTIVES

The aim of this study was to assess the pharyngeal airway space (PAS) in nasal and mouth-breathing children using cone beam computed tomography (CBCT).

METHODS

Volume, area, minimum axial area and linear measurements (PAS-NL, PAS-UP, PAS-OccL, PAS-UT, PAS-Bgo, PAS-ML, PAS-TP) of the pharyngeal airway of 50 children (mean age 9.16 years) were obtained from the CBCT images. The means and standard deviations were compared according to sexes (28 male and 22 female) and breathers patterns (25 nasal breathers and 25 mouth breathers).

RESULTS

There were no statistically significant differences (p>0.05) between all variables when compared by sexes. Comparisons between nasal and mouth breathers showed significant differences only in two linear measurements: PAS-OccL (p<0.001) and PAS-UP (P<0.05). Airway volume (p<0.001), area (p<0.001) and minimum axial area (p<0.01) had significant differences between the groups.

CONCLUSIONS

The CBCT evaluation showed that pharyngeal airway dimensions were significantly greater in nasal-breathers than in mouth-breathers.

Impact of the mouth breathing occurred during childhood in the adult age: biophotogrammetric postural analysis

OBJECTIVE

This study aims to evaluate the impact of the mouth breathing occurred during childhood on the body posture in the adult age.

METHODS

24 adults, of both genders, aged from 18 to 30 years old with report of clinical manifestations of mouth breathing during the childhood composed the study group (SG). The control group (CG) was composed by 20 adults in the same age, without any respiratory problem since the childhood up to the present time. All the volunteers underwent a physiotherapeutic evaluation consisted of anamnesis and postural biophotogrammetry (SAPo v 0.68(®)). The comparison between the data of the SG and CG was accomplished by Student's t-test.

RESULTS

The biophotogrammetric analysis demonstrated that the SG showed more forward head posture confirmed by the angles A9 (p = 0.0000) and CL (p = 0.0414) and also by the cervical distance (p = 0.0079). Additionally, this group presented a larger angular measure of the lumbar lordosis (p = 0.0141) compared to the CG.

CONCLUSION

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.

Aspectos respiratorios, posturais e vocais da Doença de Parkinson: considerações teóricas

TEMA: manifestações respiratórias, posturais e vocais, associadas aos estágios da Doença de Parkinson (DP) e suas possíveis inter-relações. OBJETIVO: revisar a literatura, a fim de descrever as características respiratórias, posturais e vocais associadas aos estágios na DP e suas possíveis inter-relações. CONCLUSÃO: Na DP, a etiologia das manifestações respiratórias é multifatorial, sendo obstrutivas; restritivas; relacionadas à bradicinesia, à rigidez e às alterações posturais; fraqueza da musculatura; anormalidades na musculatura laríngea; interferência da medicação antiparkisoniana. A postura em flexão altera a dinâmica corporal, interferindo nas funções estomatognáticas e na relação tóraco-abdominal. As alterações vocais podem estar presentes desde os estágios iniciais com diminuição dos tempos máximos de fonação e da intensidade vocal; adução glótica incompleta; fendas glóticas; tremor e instabilidade fonatória; perturbações de frequência e de intensidade; e qualidade vocal alterada. Os déficits na força muscular respiratória se refletem no menor suporte respiratório à emissão vocal e, por consequência, na diminuição da intensidade vocal e dos tempos máximos de fonação. Do mesmo modo, a postura em flexão gera desvantagem biomecânica à atividade respiratória, com menor expansão e redução dos volumes pulmonares, e déficit na excursão diafragmática. Os distúrbios respiratórios, posturais e/ou vocais, à medida que a DP evolui, de acordo com os seus estágios, tendem ao maior comprometimento, apresentando efeitos na comunicação verbal e não-verbal.

Parâmetros espectrais da voz em crianças respiradoras orais

OBJETIVO: investigar parâmetros espectrais (f0 e formantes) descritivos da voz de crianças respiradoras orais, visando contribuir na caracterização desta população e, consequentemente, na efetividade do diagnóstico. MÉTODOS: foram selecionadas 50 crianças respiradoras orais e 101 crianças com respiração nasal de ambos os gêneros entre cinco e dez anos. Os sinais de fala foram obtidos a partir das gravações de sentenças-veículo e os segmentos das vogais orais [a], [i] e [u] do português falado no Brasil em posição tônica foram selecionados para a estimação da frequência fundamental (f0) e da frequência dos três primeiros formantes (F1, F2 e F3). O software Praat foi utilizado para gravar, recortar e processar os sinais. RESULTADOS: a frequência fundamental das vogais [i] e [u] apresentou-se menor nos respiradores orais, enquanto que a frequência de F1 da vogal [u] foi mais elevada no mesmo grupo. CONCLUSÃO: a partir dos resultados expostos, concluiu-se que a frequência fundamental consiste em um parâmetro vocal que auxilia na diferenciação de crianças respiradores orais e respiradoras nasais, contribuindo, desta forma para uma caracterização mais efetiva do respirador oral.