Sink against apnea: six months of shankh exercises improved sleep and reduced the number of breathing pauses

A randomized trial from India was published in ERJ Open Research: regular blowing of sound into a shankh conch (a traditional breathing practice) in adults with moderate obstructive sleep apnea (OSA) improved daytime sleepiness, sleep quality, and reduced the frequency of apnea-hypopnea episodes, especially in the REM phase, over 6 months. This is a simple, drug-free, and inexpensive upper airway muscle training - an addition to, not a replacement for, CPAP therapy.

Background

Why look for “add-ons” to standard OSA therapy?
Obstructive sleep apnea (OSA) is common and increases cardiovascular and neurocognitive risks. The “gold standard” of treatment is CPAP, but adherence to it in real practice is far from ideal, which prompts the search for affordable, safe adjunctive methods (myofunctional/breathing training) that can be added to basic therapy.

What was already known about upper respiratory tract training?

• Oropharyngeal exercises in a RCT reduced the severity of OSA and daytime sleepiness by strengthening the tongue, soft palate, and lateral pharyngeal walls.
• Didgeridoo playing (breathing with resistance and air column vibration) in an RCT reduced AHI and ESS in patients with moderate OSA - an early precedent for 'breathing training' as a therapy.

Where’s the shankh?
Conch blowing (shankh) is a traditional practice involving exhalation resistance and vibroacoustics that potentially trains upper airway muscles and reduces their collapse during sleep – mechanistically related to the didgeridoo and myofunctional therapy. The new work in ERJ Open Research is the first randomised trial to compare 6 months of shankh practice with ‘sham’ deep breathing in adults with moderate OSA, showing improvements in ESS/PSQI and reductions in AHI, particularly in REM sleep. It is positioned as an adjunct to CPAP, not a replacement.

Why is this important from an implementation perspective?
Methods that patients can do at home (15 minutes, 5 times a week) are cheap, culturally acceptable, and may improve overall treatment effectiveness, especially in those who have difficulty wearing a mask. But because of their small sample sizes and open-label designs, such studies need large, blinded RCTs before they can be recommended broadly.

Context summary.
The field of non-drug approaches to OSA already has evidence-based "building blocks" (oropharyngeal exercises, didgeridoo); shankh fits logically into this line as another option for training the airways. Next comes testing the reproducibility of the effect, dosage/intensity of training, and combination with CPAP/mouth guards/weight loss.

What exactly did they do?

• Who: 62 people were screened; 30 adults with moderate OSA (19–65 years) were included in the analysis.
• Design: Randomized controlled trial:
  • Shankha group - training, then minimum 15 minutes, 5 days a week, 6 months at home; monthly visits, monitoring of diaries and technique.
  • Control group - "fictitious" breathing training (deep breathing according to a schedule).
• Pre/post assessments: daytime sleepiness (ESS), sleep quality (PSQI), polysomnography with AHI calculation (total, NREM and REM), body weight and neck circumference.

The main results (after 6 months)

• Daytime sleepiness (ESS): -5.0 points in the shankha group (≈-34%) versus -0.3 in the control.
• Sleep quality (PSQI): -1.8 points in the shankha group versus +1.3 in the control.
• Apnea severity (AHI): -4.4 events/h in the shankha group and +1.2 in the control; between-group difference -5.62 events/h.
  • REM-AHI: approximately -21.8% (control - no significant improvement).
  • NREM-AHI: approximately -22.8%.
• Night oxygen saturation (minimum SpO₂): +7.1% in shankha vs. -1.7% in controls (outcome not predetermined, requires confirmation).
• Mechanistic signals: reduction in neck circumference and decrease in BMI (−0.33 kg/m² vs. +0.53 kg/m² in the control) – indirectly due to strengthening of the muscles of the pharynx and chest.

Why is this important?

• The CPAP adherence problem: CPAP remains the “gold standard,” but many find it uncomfortable—hence the demand for affordable adjunctive therapies for mild/moderate OSA and for those who cannot tolerate a mask.
• Training the muscles of the upper respiratory tract (as in playing a wind instrument) reduces the collapse of the pharynx during sleep; shankh is a culturally rooted, simple and minimally expensive way of doing this.

Important Disclaimers

• Small sample, single center, open design → effect may be overestimated; results require large blinded RCTs and assessment of long-term sustainability.
• The study was conducted in patients with moderate OSA; the findings do not apply to severe OSA and comorbid conditions.
• This is an addition to standard therapy, not a replacement for it: CPAP, weight loss, positional therapy and mouth guards remain the basis of treatment.

What does this mean for you (practically)

• If you have been diagnosed with moderate OSA and are looking for adjunctive treatments to your prescribed treatment, regular shankha practice may be an option (after discussion with your sleep doctor).
• The point is regularity: the research benchmark is 15 minutes, 5 times a week, 6 months plus the correct technique.
• Track objective metrics (PSG/home AHI, ESS/PSQI), not just subjective sensations.

Source: ERJ Open Research article (early view) and European Respiratory Society press release; detailed figures from publication summaries. https://doi.org/10.1183/23120541.00258-2025