Keywords oral breathing - telemedicine - internet - speech - language and hearing sciences
Introduction
Nasal breathing is important for craniofacial growth and development, adequate posture
of the mandible, tongue, tooth structures and orofacial musculature.[1 ] Genetic, obstructive, allergic and muscular factors may impair the nasal breathing,
leading to complete or partial replacement of nasal breathing with mouth breathing.[2 ]
[3 ]
[4 ]
Mouth breathing impairs the development of static and dynamic structures of the stomatognathic
system[5 ]
[6 ]
[7 ] and may also affect the school performance of students,[8 ] alter the body posture and balance[9 ] and favor the development of disorders in speech,[10 ] mastication[11 ] and swallowing.[12 ]
Mouth breathing requires multidisciplinary treatment. It involves mainly the participation
of otolaryngologists, to diagnose and eliminate obstructive factors;[13 ] allergists, for the treatment of respiratory allergies;[14 ] orthodontists, for correction of skeletal and occlusal alterations;[15 ] speech-language pathologists, who manage the orofacial musculature and stomatognathic
functions;[16 ] and physical therapists, to achieve adequate body posture and balance.[17 ] If necessary, other professionals may also participate in the team.
The alterations observed in oronasal breathers and their consequences highlight the
importance of studies for prevention, diagnosis and intervention in these individuals,
as well as diffusion of such information.
Currently, the internet is the most widely used medium for diffusion and search of
health information on websites, weblogs and social networks. This type of interaction
between health professionals and the population is important and should be valued,
since the internet is a fast and accessible option that reaches different age groups,
social backgrounds and regions.[18 ] A literature review retrieved only one website about mouth breathing that was made
available after a scientific investigation, namely the Portal dos Bebês (http://www.portaldosbebes.fob.usp.br ) (Corrêa et al, 2013), which provides information on the development of communication
and orofacial functions occurring in children aged 0 to 3 years, including information
on mouth breathing.
Searches in the internet about mouth breathing using descriptors as “oral breathing,”
“mouth breathing,” “breathe through the mouth,” “why do I breathe through the mouth”
easily retrieve websites and blogs on this issue. However, most online contents are
related to hospital, clinics, health professional's webpages and TV reports, thus
not being developed based on a scientific method. Some websites also provide outdated
or mistaken information or make use of language that is hardly understood by lay individuals.
This highlights the scarcity in the literature and websites of content on the breathing
function that presents scientifically based, correct and updated information in a
language accessible to the population. The general population should be more knowledgeable
about the breathing function, especially younger individuals, such as teenagers. Preventive
measures against breathing disorders might be adopted by the population, who may also
seek treatment based on knowledge of this issue.
This study comprised the development of a weblog addressing the breathing function,
targeted to young individuals, and analyzed the statistical data of views of its content
so far.
Method
The weblog was the page format selected to make the contents available in the world
wide web. A blog, the most known simplification of this term, offers advantages, such
as simple navigation with posts ordered by date and classified into categories, possibility
of interaction with users through comments, and easy retrieval by search engines.[19 ]
Development of the blog followed four out of five stages based on the instructional
design model suggested by Filatro and Piconez,[20 ] as follows:
Stage 1 - Analysis
This stage comprised research analysis and selection of the material and actual, scientifically
based information about breathing. This was performed by searching papers in reliable
scientific databases, such as PubMed, Lilacs and Scielo, besides books and educational
leaflets on this subject. The topics related to the issues that would be addressed
in the blog were surveyed and, after this definition, a deeper search of material
that described the selected topics accurately was conducted.
Stages 2 and 3 - Design and Development
These stages aimed at developing the product that would be made available on the blog.
Initially, the content was prepared and developed on the software Microsoft Word 2013
(Microsoft Corp., Redmond, WA, USA) before publishing in the internet. The texts were
prepared based on the topics selected in the previous stage.
All content was developed using adequate language to the targeted age range, avoiding
technical words and employing simple description of the subjects. Emphasis was given
to the utilization of images, practical schemes, inclusion of curiosities and a language
that might catch the reader's attention, so that reading was simultaneously didactic
and pleasant.
Images on the subject were selected on the Google image search engine. Some images
were edited on the software Adobe Photoshop (Adobe Systems Inc., Mountain View, CA,
USA) to make them more didactic to the target population. Proper references were included
for all images retrieved in that search.
Flesch Reading Ease Formula
Before the last stage, all texts were evaluated by the Flesch reading ease formula
(FREF),[21 ] a method developed by the Austrian author Rudolf Flesch in the 1940s to verify the
content language. This index analyzes the ease of text understanding, based on the
vocabulary employed and the structure of sentences, to make them as compatible as
possible with the language of the target population. The following equation is used
for calculation of values: FREF = 206.835 - ([1.015 × mean sentence length] + 0.846 × [number
of syllables per 100 words]).
The higher the score achieved, the better is the readability of the text analyzed.
The values may be scored as presented in [Table 1 ].[22 ]
Table 1
Classification of the Flesch reading ease formula
Score
Classification
75–100
Very easy—up to 4th grade of fundamental school
50–75
Easy—fundamental school after 5th grade
25–50
Difficult—high school and college
0–25
Very difficult—academic texts
In this study, the calculation was performed on the software Microsoft Word 2013,
which provides this tool. According to the values found, texts achieving at least
50% of readability were considered for the blog.
Stage 4 - Publication
This stage comprised publishing the blog on the world wide web. Based on the available
technological resources, this was performed using the tool Wordpress, which is freely
available in the internet. After selecting the best method, all prepared material
was properly edited and formatted for publication according to the standards of this
tool. The registry of authors was also performed, as requested by the tool.
Analysis of Statistical Data of Views to the Weblog
This was performed using the tool Google Analytics (Google LLC, Mountain View, CA,
USA), which is freely available by Google and compatible with the Wordpress system.
This tool is installed in the blog as a plugin and allowed analysis of some parameters,
such as number of visualizations (number of visits to the blog, being that each reader
may be counted in more than one visit), countries with greater number of views, search
terms employed (terms, words and sentences used by individuals in search engines to
locate posts and webpages, and through which the readers viewed the blog), most viewed
pages and number of comments in the blog. All these aspects were analyzed since the
date the blog was created until the present time.
Result
All stages followed to develop the blog were initiated in July 2014 and published
in the internet in November 2014. The stages that required more time were the analysis,
design and development, with nearly 4 months, and the publication occurred in the
last month. The blog was developed and published by two speech-language pathologists
with clinical experience in orofacial motricity.
Stage 1 - Analysis
As proposed, the study initially surveyed the issues related to breathing function
most cited and frequent in the literature, that is, of greatest relevance. The study
also selected subjects that might catch the interest of the target population. The
selected issues were: respiratory physiology; importance of nasal breathing; definition
of mouth breathing; characteristics of mouth breathers; symptoms of mouth breathing;
causes of mouth breathing (flu, physical activities, adenoid hypertrophy, allergic
rhinitis, nasal septum deviation, sinusitis, tonsils, presence of foreign bodies,
habit of mouth breathing); snoring and apnea related to mouth breathing; prevention
of allergies; nasal cleaning; olfaction and taste related to mouth breathing; hyponasality
related to mouth breathing; and utilization of nasal dilators. After definition of
subjects, the most pertinent texts of each subject were selected to prepare the content
for publication, based on scientific papers, books and clinical experience of the
authors.
Stages 2 and 3 - Design and Development
Aiming to construct a practical, didactic and dynamic environment targeted to a young
population, the blog was structured by pages organized in a menu. The names and selected
contents of each page are described in [Table 2 ].
Table 2
Name of each page in the blog and respective content
Page name
Content addressed
About
Welcome to the blog—introduction to the content.
The pathway of the air we breathe
Explanation about inspiration and expiration, highlighting the stages, structures
involved and importance of breathing to our body.
Why should we breathe through the nose?
Importance of nasal breathing.
Do I breathe well?
Symptoms related to mouth breathing.
Why do people breathe through the mouth?
Causes of mouth breathing: flu, physical activities, adenoid hypertrophy, allergic
rhinitis, nasal septum deviation, sinusitis, tonsils, presence of foreign bodies,
habit of breathing through mouth.
Breathing in sleep time
Explanation on what happens in our body while we sleep.
Why do people snore?
Description of the obstructive sleep apnea syndrome and snoring.
How can I help someone who snores?
Practical hints on how to guide people who snore.
What can I do to breathe better?
Daily actions to reduce the symptoms of allergies and contribute to reduce the mouth
breathing.
Cleaning the nose
Importance of nasal cleaning and accomplishment of this procedure.
Meet the authors
Presentation of the authors who designed the blog, specifying the name and college/university.
The blog also had a menu entitled “Did you know?” composed of curiosities related
to the breathing function, with the following pages: The “flu voice” is related to
breathing; How do we taste?; How do we smell?; In some situations, is it normal to
breathe through the mouth? and Why do some athletes use nasal dilators?
The figures were selected and designed aiming to be current, easy to understand and
able to catch the interest of the target population. All figures had legends to enhance
the understanding on what was being shown and to allow better browsing by the individual.
Flesch Reading Ease Formula
All texts developed were assessed by the Flesch reading ease formula. The percentages
and classification achieved in each topic are described in [Table 3 ].
Table 3
Percentage and classification for each page in the blog, according to the Flesch reading
ease formula
Page
Percentage
Classification
About
54%
Easy
The pathway of the air we breathe.
73%
Easy
Why should we breathe through the nose?
59%
Easy
Do I breathe well?
70%
Easy
Why do people breathe through the mouth?
59%
Easy
Breathing in sleep time
57%
Easy
Why do people snore?
50%
Easy
How can I help someone who snores?
73%
Easy
What can I do to breathe better?
72%
Easy
Cleaning the nose
77%
Very easy
The “flu voice” is related to breathing
91%
Very easy
How do we taste?
65%
Easy
How do we smell?
56%
Easy
In some situations, is it normal to breathe through the mouth?
63%
Easy
Why do some athletes use nasal dilators?
51%
Easy
Stage 4 - Publication
Within the Wordpress tool, the free theme Flounder was used, and setting templates were followed to design the esthetics and visual
availability of contents. The users are free to browse and view all contents according
to their interest, not requiring registry in the tool. A section for comments with
criticisms and suggestions was also included, which is controlled and replied by the
author.
Following are the main screens of the blog, available in the world wide web www.comoeurespiro.wordpress.com . ([Figs. 1 ]
[2 ]
[3 ]
[4 ]):
Fig. 1 Illustration of the initial page of the blog “How do I breathe?”
Fig. 2 Partial illustration of the page “The pathway of the air we breathe” of the blog
“How do I breathe?”
Fig. 3 Partial illustration of the page “Why do people breathe through the mouth?” of the
blog “How do I breathe?”
Fig. 4 Partial illustration of the page “How do we smell?” of the blog “How do I breathe?”
Statistical Analysis of the Weblog
[Fig. 5 ] presents the number of visualizations to the blog at each month, in the period from
November 2014 to November 2017. The number of visits increased after August 2015,
and the period with greater searches for this issue was May and June 2017. Overall,
since its publication until the present moment, the blog had nearly 47,000 visits.
Fig. 5 Number of visualizations of the blog, by month and year, in the period from November
2014 to November 2017.
The countries with more views to the blog were: Brazil (36,939 visits), United States
(6,192 visits), Portugal (1,719 visits), Angola (190 visits), Mozambique (150 visits),
European Union (133 visits), Germany (109 visits), France (85 visits), Japan (84 visits)
and Norway (70 visits). Thus, the greater number of visits was observed for Brazil,
followed by the United States and Portugal.
The search terms employed by the users are presented in [Table 4 ], as well as the number of visits to the blog from each term surveyed. Most visits
are related to unknown terms, that is, terms not recognized by the Wordpress tool.
Mouth breathing and difficulty to breathe through the nose are among the terms most employed by the users.
Table 4
Search terms employed by the users and number of visits to the blog from each term
surveyed
Search term
Number of visits
Unknown terms
26,410
“breathe through the mouth”
38
“where does the air we breathe go through”
21
“I breathe through the mouth”
21
“I cannot breathe through the nose”
19
“taste”
18
“mouth breathing”
12
“I cannot breathe through the nose, only through the mouth”
12
“pathway of the air”
12
“I only breathe through the mouth”
12
The pages in the blog with greatest number of visits are presented in [Table 5 ], in decreasing order. The most viewed pages are related to the contents explaining
the definition and causes of mouth breathing and the pathway of air in the human body,
followed by contents on breathing during sleep, the importance of nasal breathing
and presentation of the blog.
Table 5
Pages in the blog with the greatest number of visits in decreasing order
Page in the blog
Number of visits
Why do people breathe through the mouth?
18,808
The pathway of the air we breathe
17,883
Breathing in sleep time
2,075
Why should we breathe through the nose?
2,050
About
861
The “flu voice” is related to breathing
852
Why do people snore?
423
How do we taste?
370
What can I do to breathe better?
219
Do I breathe well?
217
After exclusion of spams and comments not related to the issue, it was possible to
analyze the comments received during the study period. Since its publication, the
blog received 30 comments, 14 from females and 15 from males. The comments were mainly
related to doubts on mouth breathing and personal and family reports, and complimentary
comments were also received.
Discussion
Currently, several options are available to share information on health promotion
on the internet. Among these possibilities, blogs and websites have been widely used
and have been achieving positive results with the combination of technology and information.[22 ]
[23 ]
[24 ]
[25 ]
[26 ] Thus, the internet is currently considered the most widespread communication tool
in the world and an excellent resource to provide information to the population.[27 ]
Within this context, this study developed a blog targeted to the young population
(adolescents aged 13–18 years old), addressing the breathing function. This issue
was selected due to the high rate of respiratory disorders observed in the Brazilian
young population, especially those related to allergic reactions, which affect the
performance of other orofacial functions, craniofacial growth and school performance.[1 ]
[5 ]
[8 ] Therefore, the access to reliable information on breathing using an adequate language
to this age group may be fundamental for health promotion and knowledge diffusion.
The creation of a website or weblog with health information requires care, attention
and responsibility from the authors, and such material should be developed by professionals
of the field, using scientific methodology to assure reliable results, encourage future
studies and collaborate with the construction of knowledge. It should be highlighted
that health information available on the internet may promote changes in habits and
consequently change the lives of users who access such information.[28 ]
Thus, the method chosen to develop this blog was the instructional design model. This
method was previously used in other studies that created blogs with health information,
and the authors considered the method satisfactory to achieve their goals.[24 ]
[25 ]
The stages of analysis, design and development were more time consuming, since it
was necessary to decide which subjects would be addressed, perform careful selection
of information and adapt the content to a language accessible to the population. This
was also found in a study that used the instructional design model.[25 ]
The blog format was selected for the stage of publication. This option for sharing
health information on the internet had been previously used in another study with
favorable results because it is a practical tool, accessible and easy to use,[24 ]
[25 ] considering the age range of the target population. The greatest difficulty at this
stage concerned the esthetics of the blog, since an attractive design is fundamental
to catch the attention of users and assure that browsing the blog would be pleasant.[29 ]
Due to the scarcity of studies on the population's knowledge about breathing and actions
in health education on this subject, it was difficult to establish comparisons between
research data and interpretation of results.
The number of views to the blog increased after August 2015. At that time, the study
was presented and awarded during the 14th Congress of the Otolaryngology Foundation, which probably contributed to increase
the visibility. Additionally, the blog was frequently used in clinical attendances
for myofunctional rehabilitation, campaigns for prevention of mouth breathing and
other events related to speech-language pathology to raise the population awareness
regarding the breathing function, increasing its diffusion. Concerning the highest
number of views between June and November, the literature shows that airway disorders
are more common in the cold seasons of the year,[30 ] which may have contributed to increase the search for information on the subject
in these months.
Regarding the countries with the highest number of views, it was expected that Brazil
would account for the highest percentage, since the study was prepared and diffused
in the country. It should be noted that countries as Portugal, Angola and Mozambique
have Portuguese as the official language, and the search terms employed by users were
probably in this language, which enhanced retrieval of the blog. Visualizations from
countries as United States, Germany, European Union, France and Japan may be related
to Brazilians living abroad and looking for information on the internet in Portuguese.
The search terms employed, and the most viewed pages of the blog evidenced that users
searched for information related to the causes of mouth breathing, aiming to understand
the reasons why individuals breathe through the mouth rather than through the nose.
When searching for health information on the internet, users commonly search for explanation
for some symptom.[28 ]
The option of comments in the blog enhanced the communication between authors and
visitors. This option is important, since it allows the professional to complement
the information on the subject according to the individual's doubts and guide the
search for a health professional for diagnosis and treatment, if necessary.
Continuing this study, the blog “How do I breathe?” will be evaluated by adolescents,
using specific tools. Thus, based on the responses and suggestions from the target
population, the content and means of presentation may be constantly updated and reformatted,
maintaining the proposal of dissemination of knowledge about the breathing function.
The clinical practice for the young population demonstrates that the utilization of
technological resources to explain and raise the awareness on breathing disorders
encourages young individuals to achieve better treatment outcomes, since they may
understand the problem and the importance of treatment and their compliance in the
therapeutic process. Therefore, utilization of this material in practices of pediatricians,
ear nose and throat doctors and speech-language pathologists is an awareness strategy
that may be adopted by professionals.
Additionally, providing young individuals with information on breathing allows them
to diffuse this knowledge to other individuals, enabling them to identify signs and
symptoms of breathing disorders in themselves and in other people, thereby contributing
to early diagnoses.
Conclusion
The virtual page “How do I breathe?” was developed in blog format, targeted to the
young population, containing information about the breathing function, and is available
in the internet address https://comoeurespiro.wordpress.com .
In the period from November 2014 to November 2017, there was a significant increase
in the number of views from other countries; the search terms employed by users and
the most viewed pages in the blog indicated interest in the definition and causes
of mouth breathing, and the users employed the comments option to send compliments
and questions.
