Do the Doo for Sleep Apnea
By Russell H. Greenfield, MD, Dr. Greenfield is Medical Director, Carolinas Integrative Health, Carolinas HealthCare System, Charlotte, NC, and Clinical Assistant Professor, School of Medicine, University of North Carolina, Chapel Hill, NC. Dr. Greenfield reports no financial relationships with companies having ties to the material presented in this continuing education program.
Source: Puhan MA, et al. Didgeridoo playing as alternative treatment for obstructive sleep apnoea syndrome: Randomised controlled trial. BMJ 2006;332:266-270. Epub 2005 Dec 23.
Abstract: This randomized controlled trial was designed to evaluate the effects of didgeridoo playing on daytime sleepiness and other outcomes related to sleep by reducing collapsibility of the upper airways in patients with moderate obstructive sleep apnea syndrome and snoring. Adults 18 years or older with an apnea-hypopnea index between 15 and 30 (n = 25) and who complained about snoring were included in the trial. Patients received didgeridoo lessons and were instructed to practice at home with standardized instruments daily for four months. Participants in the control group remained on the waiting list for lessons. Daytime sleepiness (Epworth scale from 0 [no daytime sleepiness] to 24), sleep quality (Pittsburgh quality of sleep index from 0 [excellent sleep quality] to 21), partner rating of sleep disturbance (visual analogue scale from 0 [not disturbed] to 10), apnea-hypopnea index, and health-related quality of life (SF-36) were assessed. Participants in the didgeridoo group practiced an average of 5.9 days a week (SD 0.86) for 25.3 minutes (SD 3.4). Compared with the control group, the didgeridoo group daytime sleepiness (difference -3.0, 95% confidence interval [CI] -5.7 to -0.3, P = 0.03) and apnea-hypopnea index (difference -6.2, -12.3 to -0.1, P = 0.05) improved significantly and partners reported less sleep disturbance (difference -2.8, CI -4.7 to -0.9, P < 0.01). There was no effect on the quality of sleep (difference -0.7, CI -2.1 to 0.6, P = 0.27). The combined analysis of sleep-related outcomes showed a moderate to large effect of didgeridoo playing (difference between summary z scores -0.78 SD units, CI -1.27 to -0.28, P < 0.01). Changes in health-related quality of life did not differ between groups. The authors concluded that training upper airway muscles for four months via playing of the didgeridoo reduces daytime sleepiness in people with snoring and obstructive sleep apnea.
The didgeridoo is an aboriginal musical instrument traditionally made from hollowed out tree limbs. The idea for this study came out of the personal experiences of the didgeridoo instructor employed in this trial and the theory that training of upper airway muscles might positively impact sleep disorders caused by airway collapse. Playing the didgeridoo requires mastery of a technique called circular breathing, where air is inhaled through the nose "while maintaining airflow through the instrument, using the cheeks as bellows."
Snoring and obstructive sleep apnea are caused by upper airway collapse, which is most often treated with continuous positive airway pressure (CPAP). Although CPAP is effective, compliance with treatment decreases over time. The trial had extremely high compliance; all 25 subjects completed the trial. Trial weaknesses included a small sample size and no sham group, which, as the authors point out, is a very difficult undertaking.
The apnea-hypopnea index measures number of episodes per hour, with levels between 15-30 reflecting moderate disease, more than 30 suggesting severe impact. The study excluded obese patients (BMI > 30 kg/m2). Members of the control group were offered didgeridoo training at the end of the four-month trial; participants were highly motivated, as evidenced by the degree of practice undertaken.
Considering the prevalence of such sleep disorders, and the fact that therapeutic intervention is often inadequate or at least unpalatable, any technique that could safely help should be considered. Certainly a larger trial would be welcomed. In the meantime, should you offer your patients training in the didgeridoo, stand to the side (it can get a little messy if you stand very close to the end of the instrument…).