The Nose and Sleep

Written by Dr Louis Chan on August 28, 2021

In this blog, I am going to discuss in detail regarding the relationship between sleep and nasal breathing, as well as treatment modalities from Western and Chinese medicine.

Breathing is an essential function to keep us alive; most of us would not be able to not breathe for 2 minutes. The nose is designed for breathing; its function is to filter, warming and humidify the air. Nasal obstructions can lead to chronic health issues such as sleep apnoea, impaired cognitive function, and poor posture due to mouth breathing (Lee, Guilleminault, Chiu, & Sullivan, 2015). The comorbidities associated with nasal obstruction can also have a negative effect on the patient’s mental health and quality of life. (Dykewicz & Hamilos, 2010; Silva, Silva, Morales, Fernandes, & Pinto, 2009).

In the previous Blog “Introduction to common Sleep Disorders”, I mentioned Guilleminaulta et al. (2005) found that “nasal disuse” is commonly overlooked in the treatment of sleep-disordered breathing (SDB).

There are two common types of SDB; obstructive sleep (OSA) and upper airway resistance syndrome (UARS). OSA is caused by obstructions in the upper airway, while UARS is caused by the resistance of airflow in the upper airway, and they affect sleep differently. Both OSA and UARS patients have daytime sleepiness and nasal obstructions; OSA sufferers complain less about pain and onset of sleep, while UARS sufferers complain more about insomnia and pain. Patients with sleep apnoea are often unable to get enough air in the lungs to maintain their blood oxygen saturation from 10 seconds to over 3 minutes, causing their blood oxygen saturation (SPO2) down to a dangerous level of below 80%. When we are awake, our SPO2 is 98% to 100%; during sleep, the average SPO2 is 95% or above, the lowest SPO2 during sleep should be 90% or above. Patients suffering from UARS often have normal SPO2 during sleep, but they have pain and insomnia (Guilleminault et al., 2001; Pépin, Guillot, Tamisier, & Lévy, 2012).

Obstructions of the nose can be caused by collapsed nasal valves, a deviated nasal septum, enlarged turbinates, and a swell body on the septum. The most common obstruction is caused by inflammation of the nasal mucosa due to allergic rhinitis; common symptoms are sneezing, itching and runny nose. The prevalence of allergic rhinitis is increasing, and estimated up to 40% of the population is affected (Dykewicz & Hamilos, 2010; Singh, Axelrod, & Bielory, 2010).

The Western medical treatments for Allergic rhinitis can have unwanted side effects (Cheng et al., 2018; Sohn, 2018).

1: Pharmaceuticals: (antihistamine tablets and nasal sprays, nasal steroid sprays and decongestants)

Side effects: drowsiness, nausea, restlessness, dry mouth, nasal irritation, blood bleeds and headaches

2: Immunotherapy

Expensive and require a long-term commitment

3: Trigger avoidance

Can be difficult and limits activities

4: Surgical management

Limited long-term results

Acupuncture treatment for allergic rhinitis has shown to not only be effective short term as well as long term (Chen et al., 2020). For evidence-based treatment, we would like to examine the quality of the scientific evidence on treatment modalities in the peer-reviewed scientific literature.

“System review of randomised controlled trials” is considered to have the highest level of evidence. Liang, Lenon, and Yang (2017) published an article on “Acupressure for Respiratory Allergic Diseases: A Systematic Review of Randomised Controlled Trials”, they found using acupressure points to relieve allergic rhinitis is more effective than 1% ephedrine nasal drop with thermal therapy. They also found that combination therapy of acupressure points with either Western medicine or Chinese herbal medicine can dramatically improve the efficacy of treatment. However, many studies did not have enough patients to be considered a good quality clinical trial. Most randomised clinical trials for acupuncture treatment also found having a high risk of treatment bias due to the nature of acupuncture treatment; because it is difficult to blind participants for control treatments to test for placebo effects.

A well designed “Randomised controlled trial” is considered to have the second-highest level of evidence. In recent years there are more combination therapies emerging in the literature:

Yung et al. (2019) in Hong Kong combined acupuncture and moxibustion therapy and found that it helps to decrease nasal symptoms, as well as improvement in the quality of life for patients with allergic rhinitis. They also found a lower level of IgE, which elevates in patients with allergies comparing to the no treatment group.

Another local study using ear acupressure for perennial allergic rhinitis has found great results (Zhang et al., 2014). This clinical trial was conducted as a multicentre clinical trial to help to increase the evidence of acupuncture treatment for allergic rhinitis, and it was run at Royal Melbourne Institute of Technology University (Melbourne, Australia) Clinical Trial Clinic and Guangdong Provincial Hospital of Chinese Medicine in Guangzhou China, there were 124 patients in the treatment trial group and 121 in the control group. They found ear acupressure help in reducing nasal symptoms as well as the quality of life.

From the recent literature, we can see Chinese Medicine therapies can be beneficial for treating nasal obstructions and respiratory allergic diseases. Patients with nasal airway related sleep issues can consider Chinese Medicine therapies to assist their sleep therapies.

Chen, S., Guo, S.-N., Marmori, F., Wang, J., Bai, P., Zhang, J.-J., . . . Zhao, J.-P. (2020). Clinical Practice Guideline for Allergic Rhinitis Treatment with Acupuncture. Chinese Journal of Integrative Medicine. doi:10.1007/s11655-020-3161-0

Cheng, L., Chen, J., Fu, Q., He, S., Li, H., Liu, Z., . . . Zhang, L. (2018). Chinese Society of Allergy Guidelines for Diagnosis and Treatment of Allergic Rhinitis. Allergy, Asthma & Immunology Research, 10(4), 300-353. doi:10.4168/aair.2018.10.4.300

Dykewicz, M. S., & Hamilos, D. L. (2010). Rhinitis and sinusitis. J Allergy Clin Immunol, 125(2 Suppl 2), S103-115. doi:10.1016/j.jaci.2009.12.989

Guilleminault, C., Do Kim, Y., Chowdhuri, S., Horita, M., Ohayon, M., & Kushida, C. (2001). Sleep and daytime sleepiness in upper airway resistance syndrome compared to obstructive sleep apnoea syndrome. The European respiratory journal, 17(5), 838-847. doi:10.1183/09031936.01.17508380

Lee, S. Y., Guilleminault, C., Chiu, H. Y., & Sullivan, S. S. (2015). Mouth breathing, “nasal disuse,” and pediatric sleep-disordered breathing. Sleep Breath, 19(4), 1257-1264. doi:10.1007/s11325-015-1154-6

Liang, Y., Lenon, G. B., & Yang, A. W. H. (2017). Acupressure for Respiratory Allergic Diseases: A Systematic Review of Randomised Controlled Trials. Acupuncture in Medicine, 35(6), 413-420. doi:10.1136/acupmed-2016-011354

Pépin, J. L., Guillot, M., Tamisier, R., & Lévy, P. (2012). The Upper Airway Resistance Syndrome. Respiration, 83(6), 559-566. doi:10.1159/000335839

Silva, C. H. M. D., Silva, T. E. D., Morales, N. M. O., Fernandes, K. P., & Pinto, R. M. C. (2009). Quality of life in children and adolescents with allergic rhinitis. Brazilian Journal of Otorhinolaryngology, 75(5), 642-649. doi:10.1590/s1808-86942009000500005

Singh, K., Axelrod, S., & Bielory, L. (2010). The epidemiology of ocular and nasal allergy in the United States, 1988-1994. J Allergy Clin Immunol, 126(4), 778-783.e776. doi:10.1016/j.jaci.2010.06.050

Sohn, M. H. (2018). Efficacy and Safety of Subcutaneous Allergen Immunotherapy for Allergic Rhinitis. Allergy, Asthma & Immunology Research, 10(1), 1. doi:10.4168/aair.2018.10.1.1

Yung, T. Y., Zhang, H., Tang, L. C., Zhang, L., Law, C. O., Tam, W. M., . . . Lin, Z. X. (2019). Acupuncture and herbal moxibustion for the treatment of ‘BiQiu’ (allergic rhinitis symptoms) in a Hong Kong Chinese medicine clinic: a randomized controlled trial. Chinese Medicine, 14(1). doi:10.1186/s13020-019-0272-7

Zhang, S., Xia, J., Zhang, A., Yang, W., Thien, F., Yunying, L., . . . Xue, C. (2014). Ear acupressure for perennial allergic rhinitis: A multicenter randomized controlled trial.