Overview

Sleep apnoea is a common sleep disorder characterised by reduced oxygen blood saturation, which disrupts normal sleep cycles. The reduction in oxygen delivery to the brain triggers frequent awakenings, fragments sleep patterns, and causes daytime sleepiness and fatigue.¹

This condition has been associated with a myriad of diseases, from problems with memory, focus, and learning to heart disease. Therefore, addressing it is of great importance in the prevention and improvement of quality of life.¹

Different breathing techniques may help improve breathing quality and efficiency, with pursed-lip breathing (PLB) being one of the most commonly used techniques in respiratory therapy. PLB consists of exhaling while pursing the lips to reduce and slow the airflow. PLB has been studied for the treatment of COVID-19 and other pulmonary conditions. Here, we will explore its potential role in the management of sleep apnoea.²

What is sleep apnoea?

Sleep apnoea is a common sleep disorder in which reduced blood oxygen saturation disrupts the normal sleep cycles. The reduction in oxygen delivery to the brain can result in frequent awakenings and fragmented sleep, which leads to symptoms such as:¹

• Morning headaches
• Daytime sleepiness
• Fatigue
• Difficulties with memory
• Mood disturbances

Sleep apnoea is estimated to affect 2–4% of the middle-aged population.^3,7 Individuals often seek medical attention and diagnosis after concerns related to loud snoring, gasping for air or choking during sleep, frequent toilet visits during the night, and awakenings.¹ If left untreated, this condition is associated with an increased risk of several diseases, including:^1,3

• Heart disease
• High blood pressure
• Stroke
• Memory impairment

Sleep apnoea is typically classified into the following subtypes:¹

Obstructive sleep apnoea

Obstructive sleep apnoea (OSA) is the most common form of sleep apnoea. Up to 25-30% of American men and 9-17% of American women meet the criteria for OSA diagnosis, while prevalence may be even higher among Hispanic, Black, and Asian people.³

As the name suggests, OSA arises from the obstruction of the upper airway during sleep. This can result in structural abnormalities that reduce the upper airway's intrinsic ability to transport air from the external environment to the lungs in an efficient manner. Examples of structural issues affecting the upper airway include:^4,5

• Retrognathic lower jaw
• Excess soft/fatty tissue in the airway
• Increased size of upper airway organs, e.g., big tonsils, tongue, or airway lateral walls

Central sleep apnoea

Central sleep apnoea is a more complex disorder where the brain's respiratory centre has a reduced ability to command the respiratory muscles to perform the necessary movements to guarantee timely and proper inhalation and exhalation.⁶

Complex sleep apnoea

Complex sleep apnoea is the result of a combination of factors that hinder the classification of the patient's apnoea into one of the types described above.¹

What is pursed-lip breathing?

Pursed-lip breathing (PLB) is a breathing technique that consists of two steps: 

• Regular inhalation through the nose
• Slow and controlled exhalation through pursed lips

Pursing the lips during exhalation reduces the airflow leaving the body and, thereby, prolongs the exhalation process.² By extending exhalation, a greater volume of air remains in the lungs for a longer time than usual. This creates a positive pressure on the lower and smaller regions of the lungs, where the alveoli are located. Due to increased pressure, the alveoli are forced to remain open for a longer time, which facilitates gas (air, oxygen and blood carbon dioxide) exchange. This results in lower carbon dioxide and higher oxygen levels in blood.²

PLB is used in respiratory therapy for several diseases, including:^2,7,8

• Chronic obstructive pulmonary disease (COPD)
• Asthma
• COVID-19
• Breathing rehabilitation

How PLB might help with sleep apnoea?

A study investigated the effect of breathing exercises on daytime sleepiness and fatigue in individuals with OSA. Participants were taught breathing exercises, including diaphragmatic and PLB, and applied them every morning/evening for 10-15 minutes and a total of 20-30 minutes for 8 weeks. In comparison with the participants who did not perform breathing exercises (control group), those who did them experienced lower fatigue and daytime sleepiness.⁹ Another study also found that physiotherapy sessions for respiratory muscle training, which included PLB along with diaphragmatic and thoracic expansion exercises, improved OSA symptoms in an 80-year-old woman.¹⁰

Despite these reported benefits, to date, there is not enough evidence supporting the benefits of PLB in individuals with sleep apnoea. Furthermore, because PLB is often practised in combination with diaphragmatic breathing and other therapeutic approaches, it is difficult to isolate the specific contribution of PLB to any observed benefits. Additional research is needed to determine the effects of PLB on this condition, establish optimal practice frequency, and clarify its potential role in improving sleep apnoea symptoms and related complications.

Benefits and limitations of PLB

Potential benefits:

• PLB is a low-cost, non-invasive, and relatively easy to learn technique
• PLB may help with daytime breathing control and efficiency

Limitations:

• Lack of sufficient evidence supporting its benefits for sleep apnoea
• It may not be helpful as a stand-alone treatment
• Adherence to PLB and technique consistency may affect results

How to do PLB

Ideally, individuals should receive professional guidance when learning and performing PLB for the first time. Proper PLB execution ensures adequate timing and effort to prevent counterproductive outcomes. When performed incorrectly, PLB may lead to air trapping and increased carbon dioxide levels in the blood.²

Self-guided PLB includes the following steps:

• Find a relaxed position to sit or lie down comfortably
• Put one of your hands on your belly and one on your chest. This will help monitor your breathing
• Take a regular breath and focus on it to get used to the sensation
• Regularly inhale through your nose
• Purse your lips without applying excessive tension on them
• Exhale slowly until you empty your lungs
• Inhale again as your body demands it

Repeat this process 3-5 times. You can practice PLB before bed or whenever you need to relax. Performing PLB at the same time every day will help you adhere to it and establish a consistent routine.

Keep in mind: The benefits from PLB are believed to be transitory, which may encourage individuals to practice it more often. However, PLB requires involvement of the respiratory muscles to achieve proper control of respiration, which, if done excessively, may cause muscle fatigue. Moreover, overuse of the technique may cause an abnormal reduction in carbon dioxide blood levels, resulting in fainting.²

When to see a doctor

Sleep apnoea is a condition that requires appropriate management to prevent long-term complications. Therefore, you should talk to your doctor if you have some of the sleep apnoea symptoms to get a proper diagnosis and target its cause.

Your doctor may recommend an evaluation of your upper airway and a sleep study to determine the most appropriate treatment for your sleep apnoea. Since sleep apnoea can have multiple underlying causes, treatment should be individualised and tailored to the severity of the condition.

FAQs

Can breathing exercises cure sleep apnoea?
There is no evidence that indicates that PLB or any other breathing exercise helps treat or cure sleep apnoea.

How often should I do PLB?

PLB should be performed with moderation to prevent overuse. Experts recommend 3-5 PLB repeats each session. 

Summary

• Sleep apnoea is a serious condition that affects nighttime breathing, causing fragmented sleep and worsening quality of life
• PLB may offer support by improving relaxation and airway openness during practice time
• More research is needed to determine the PLB benefits on sleep apnoea. To date, not enough evidence is available to recommend PLB for the management of this condition