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1 Perspectives in Nursing Science Vol. 14 No. 2, 64-69, October, 2017 ISSN 강승완 서울대학교간호대학 간호과학연구소조교수 The Relationship and Mechanism Underlying the Effect of Conscious Breathing on the Autonomic Nervous System and Brain Waves Kang, Seung Wan Assistant Professor, College of Nursing Research Institute of Nursing Science, Seoul National University, Seoul, Korea Purpose: Breathing can be controlled either unconsciously or consciously. In Asian countries, various conscious breathing-control techniques have been practiced for many years to promote health and wellbeing. However, the exact mechanism underlying these techniques has not yet been established. The purpose of this study is to explore the physiological mechanism explaining how conscious breathing control could affect the autonomic nervous system, brain activity, and mental changes. Methods: The coupling phenomenon among breathing rhythm, heart rate variability, and brain waves was explored theoretically based on the research hypothesis and a review of the literature. Results: Respiratory sinus arrhythmia is a well-known phenomenon in which heart rate changes to become synchronized with breathing: inhalation increases heart rate and exhalation decreases it. HRV BFB training depends on conscious breathing control. During coherent sinusoidal heart rate changes, brain waves could be enhanced. An increase in waves was also found and the synchronicity between heart beat rhythm and brain wave became strengthened during meditation. Conclusion: In addition to the effect of emotion on breathing patterns, conscious breathing could change heart beat rhythms and brainwaves, and subsequently affect emotional status. Key Words: Respiration, Autonomic nervous system, Brain waves, Electroencephalography, Synchronicity 서론 1. 연구의필요성 명상 (meditation) 은동양에서오랫동안심신의안정을도모하기위한자가훈련법으로활용되어왔으며 80년대이후에는서양에서도명상의효용성에대해알려지기시작하면서이를수행하는인구가꾸준히증가되어왔다. 1-4) 명상은일반인 들의관심뿐만아니라과학계의학술적관심도많이받기시작하면서그것의건강에미치는영향에대한연구도많이시행되어왔다. 1,2,5,6) 명상과관련된과학적연구는명상의종류, 연구참여자의인구학적특성이나건강상태, 효과에대한측정도구, 연구의디자인등에따라매우다양하다. 명상은여러가지로분류될수있으나일반적으로그형태에따라집중명상과비집중명상으로나눈다. 7) 집중명상 (attention meditation) 은명상을하는과정에서의식의집중을위 주요어 : 호흡, 자율신경, 뇌파, 뇌전도, 동기화 Corresponding author: Kang, Seung Wan College of Nursing, Seoul National University, 103 Daehak-ro, Jongno-gu, Seoul 03080, Korea. Tel: , Fax: , drdemian@snu.ac.kr - 이연구는서울대학교신임교수연구정착금으로지원되는연구비에의하여수행되었음. - This work was supported by Research Resettlement Fund for the new faculty of Seoul National University. 투고일 2017 년 9 월 27 일 / 심사완료일 2017 년 10 월 17 일 / 게재확정일 2017 년 10 월 20 일 c 2017 The Research Institute of Nursing Science Seoul National University

2 해만트라나숫자세기, 호흡조절등을활용하는형태의명상을의미하며, 비집중명상 (non-attention meditation) 은의식을집중하고자하는의도자체를내려놓고자신의마음에서일어나는감정의움직임을제삼자적입장에서관찰하며마음의고요함을추구하는형태의명상을일컫는다. 의도적호흡조절 (conscoius breathing control) 은여러형태가존재할수있으며그자체로서오랜역사동안심신수련및이완을목적으로활용되어왔을뿐만아니라집중명상으로분류될수있는여러명상수련법에서명상의효과적인유도와유지를위해많이활용되어왔다. 8) 현대의학에서는호흡리듬을컴퓨터로실시간모니터링하는과정을통해본인이스스로의도된조절을하게하는바이오피드백으로발전시켜활용하기도한다. 9,10) 반면비집중명상에서도호흡을중요한기재로다루기도하는데, 이경우에는의도적인조절보다는자신의호흡흐름을그저관찰하며지각하는데주안점을둔다. 7) 명상이나호흡, 혹은이둘의결합이인체에미치는영향을측정하기위하여주관적느낌의변화만이아니라객관적인생물학적, 생리적지표의측정이많이시도되어왔다. 또한최근들어서는명상이나호흡이뇌의구조적, 기능적변화에미치는영향에대한뇌과학적연구도많이시도되고있는데측정방법을보면기능적자기공명영상 (functional Magnetic Resonance Image fmri), 뇌자도 (Magnetoencephalography, MEG), 뇌전도 (Electroencephalography, EEG), 근적외선분광기 (Near infrared spectrometer, NIRS) 등다양한뇌영상기법이활용되고있다 ) 이중에서도 EEG는뇌의생리적변화를측정하는가장전통적인도구로서장비의가격이비교적저렴하고다양한환경조건에서측정할수있는장점이있어여러뇌기능측정연구에많이활용되고있고명상이나호흡의효능을뇌기능적차원에서연구하려는연구자들에게좋은연구도구가될수있다. 14) 2. 연구목적본종설에서는간호계에서도많은관심을받고있는호흡다스림의생리적작용기전을정리함으로서향후많은간호연구자들의연구설계와임상적활용에기여하고자한다. 호흡조절의듀얼메커니즘에대해고찰한다. 호흡리듬과자율신경, 심장박동과의상호연결성에대해고찰한다. 심장박동과뇌파와의상호연결성에대해고찰한다. 본론 호흡은의식하지않은상태에서생리적요구혹은감정상태에맞춰자동적으로이뤄지나필요에따라서는의식적으로도조절이가능하다. 본론에서는호흡이조절되는중추신경계듀얼메커니즘에대해간단히고찰한후의식적인호흡조절이자율신경계의조절및심장박동의리듬패턴에어떤영향을미치는지에대한고찰을할것이다. 그후변화된심장박동의리듬패턴이뇌파와어떤상호연결패턴을보이는지를고찰함으로서 의도된호흡 심장박동리듬 뇌파변화 의식변화 로이어지는관련성에대해기술할것이다. 1. 중추신경계의호흡조절기전호흡은우리가의도적으로조절할수도있지만의식하지않는상황에서도자동적으로조절되고있다. 호흡기계는심장과는다르게내재적인페이스메이커시스템이존재하지않기때문에뇌줄기에위치한호흡조절중추로부터신경계를통한명령을받아야만호흡근육에의한호흡이이뤄질수있다. 호흡중추는다리뇌 (pons) 와숨뇌 (medulla) 에위치한뉴론의집단들인신경절들로구성되어있다. 숨뇌에위치한호흡중추 (medullary Respiratory Center, MRC) 는일차호흡조절센터로불리며배쪽호흡군 (Ventral Respiratory Group, VRG) 과등쪽호흡군 (Dorsal Respiratory Group, DRG) 으로나뉘며몸의생리적리듬에맞는자율적인호흡조절을담당하고있다. 등쪽호흡군 (DRG) 는숨뇌의등쪽에위치하며거의대부분들숨을관장하는뉴론들로구성되어있다. 숨뇌의 MRC바로위에는전보찡어절 (pre-botzinger complex) 라고불리는뉴론군이존재하는데등쪽호흡군 (DRG) 의들숨뉴론과연결된이곳의뉴론들이심장의동방결절과같이자발적인리드미컬한활성화-불활성화의호흡사이클을반복하여들숨날숨을유지한다는것이알려졌다. 16) 숨뇌의배쪽호흡군 (VRG) 는평상시안정상태의무의식적호흡에서는꺼져있으나운동할때와같이많은호흡량을필요로하는상태에서복근과외측늑골사이근육을수축시켜강력한날숨을만들어내는데중요한역할을한다. 숨뇌의호흡중추는다리뇌의호흡중추의영향을받는데, 이곳에는호흡의빈도와깊이를조절하는호흡조절중추 (pneumotaxic center) 와지속흡입중추 (apneustic center) 가존재한다. 다리뇌의호흡중추는정서상태의변화나수의적조절등에대한정보를수용하여숨뇌의호흡조절중추에전달하여호흡의미세한조절에개입한다. Vol. 14 No. 2,

3 강승완 의식적호흡조절을할때는이곳다리뇌의호흡조절중추를통해호흡리듬을조절하는것으로예측된다. 17) 정서상태는호흡리듬의변화를동반하는데, 흥분을하거나불안감이증가하면호흡이얕고가빠지며이런상태가지속되는 과호흡증후군 상태에서는체내이산화탄소농도가감소되어호흡성알칼리증상황이유발될수있다. 반면에복식호흡과같이의도적으로호흡을깊고안정적으로조절하였을때정서적인안정감과긴장의이완을경험하기도한다. 이와같이정서와호흡패턴은서로에게상호영향을주지만, 호흡조절이어떻게정서적인변화를유도하는지에대한정확한기전은잘알려져있지않다. 이에대한작용기전을탐색하기위해호흡과심장박동의리듬과의관련성, 그리고심장박동리듬과뇌파와의관련성에대해논의할것이다. 2. 호흡리듬과자율신경, 심장박동과의상호연결성호흡의리듬은심장박동의리듬과밀접하게연관되어있다. 들숨을쉬는동안에심장박동은빨라지며날숨을쉬는동안심장박동은느려진다. 호흡과심박의이와같은연결성은호흡성동부정맥 (Respiratory Sinus Arrhythmia, RSA) 이라고불리는데, 오래전부터관찰되어왔지만아직까지그정확한이유와기전은명확하지않다. 18) 날숨을쉬는동안흉곽의압력은높아지고혈액의산소농도는낮아지므로에너지효율성측면에서심장의수축이감소한다는설명이존재한다. 심장박동은스스로조절되는자율신경계에의해조절되는데, 동방결절 (SA node) 의페이스메이킹에의해추동되는심장박동이날숨때감소한다는것은날숨으로인해동방결절에연결된부교감신경인미주신경이활성화된다는것을의미하는것이다. 이는의식적호흡에서도공통적으로나타나는현상이며심장박동과같은자율신경계가의식적호흡변화를통해조절이가능하다는것을암시한다. 실제로호흡수련이나호흡조절을활용한명상에서심박동수가감소하는자율신경의변화는여러연구를통해확인되어왔다. 19,20) 간호학계에서도많이활용하고있는심박동수변이도바이오피드백 (Heart Rate Variability Biofeedback, HRV BFB) 역시 RSA의원리를이용한다. HRV BFB은광학적원리를이용해손가락이나귓볼에서맥파 (heart beat wave) 를측정하는광혈류측정기 (Photoplethysmography, PPG) 센서를몸에부착하여실시간으로자신의분당평균심박수의변화를스스로모니터링하면서의도된형태의심박의증감리듬패턴이나타나도록훈련하는것이다. 이훈련과정에서자신의심박을조절하는중요한기제가호흡이다. 호흡은보통들숨 5 초, 날숨 5초로 10초동안한호흡사이클이반복되도록가이드되는데, 이렇게일정한리듬과깊이로들숨과날숨을반복하면분당평균심박수도일정한리듬으로빨라졌다느려졌다를반복하여호흡의들숨날숨리듬과심박증감의리듬이일치하는커플링 (coupling) 상태에이르게된다. 이때참가자는심신의이완, 맥박과혈압의감소및다양한임상증상의호전을경험할수있다. 3. 심장박동과뇌파와의상호연결성비록소규모이긴하나최근들어뇌과학계에서보여지는연구흐름중하나가몸과뇌의상호작용에관한연구가출현하는것이다. 그중에서아직그기전이명확히밝혀지지는않았지만심장과뇌의관련성에대한연구가상대적으로활발해지고있다. 이와관련된초기연구로서. Takahashi 등 21) 의명상연구에의하면명상을하는동안전두엽의뇌파측정부위인 F3, F4에서 fast theta와 slow alpha에해당되는뇌파영역 (6~10Hz) 이증가되는데이와함께 HRV 상에서저주파수영역 (low frequency, LF; 0.04~0.14Hz) 의감소및고주파수영역 (high frequency, HF; 0.14~0.4Hz) 의증가가관찰되었다. 뇌파의증감과 HRV의각주파수대역의증감간의통계적상관성분석에서 fast theta (6~8Hz) 의증가는부교감신경의활동성과관련이있는것으로간주되는HRV의 HF의증가와유의한상관성이있었다. 반면 slow alpha (8~10Hz) 대역의증가는 HRV의 LF 의감소와유의한상관성을관찰할수있었는데, HRV의 HF 영역은부교감신경의활동성을잘반영해주는반면 LF 영역은교감신경의활동성을반영해주는대역으로알려져있지만종종분당 6회가량의깊고느린복식호흡에서도이영역이활성화되기때문에해석상에유의를요한다. 이와유사하게 Kim 등 22) 의연구에의하면아우토겐명상을시행하는동안 HRV로측정된심장의코헤런스 (cardiac coherence) 지수가증가를하면두정엽에서측정된알파파의절대값이현저히증가함과동시에뇌전반적인영역에서도알파파의상대값이증가하였다. 뿐만아니라측정채널간의알파대역의기능적연결성도증가하였다. 이결과는심장박동의규칙적인증감의리듬패턴이이완상태에서증가하는뇌의알파파의활성화와유의한상관관계가있음을시사하고있다. 최근들어서는좀더고차원적인생체신호분석기법을도입하여심장과뇌의연결성분석이시도되고있다. Valenza 등 23) 은 22명의건강한참가자들을대상으로여러정서상태를유발하는그림카드를보여주면서정서반응에따른심장과뇌의커플링현상을 128채널고해상 66 Perspectives in Nursing Science

4 Fig. 1. Diagram of interconnection among respiration, heart beat and brain wave. 도뇌파측정기를사용하여실험하였다. 이실험에서전전두엽이뇌-심장커플링현장을조율하는데중요한역할을하는것이관찰되었으며, 측두엽에서뇌파의쎄타파 (theta wave) 대역이 HRV의 LF 대역과유의한커플링현상이나타났는데그러한현상은중등도수준의각성상태와부정적정서자극시더욱두르러졌다. 쎄타파는명상이나기억의회상, 어려운수학문제풀이등의식이내적으로몰입한상태에서강화되는서파대역임을감안할때쎄타파가특히심장과의리듬동조에관계된다는것은의미있는결과이다. 이런연구결과들을통해각각독립적으로조절되는듯한심장박동의리듬과뇌파의변화가상호연결성이있으며, 특성의식상태에서더긴밀한상호작용이일어나고있음을시사한다. 그러나아직두리듬이어떤기전으로상호영향을주고받으며, 더나아가심장과뇌두장기간에서로영향을미침에있어서어느것이다른장기의변화에더주도적인역할을하는지는아직충분히밝혀지지않았다. 한편 41명의운동선수들을대상으로 HRV BFB 훈련을적용한 Dziembowska 등 24) 의연구에따르면 HRV BFB 훈련을받은운동선수들에게서심장의유연성 (flexibility) 를반영해주는 HRV의총파워값의증가와함께설문지로측정된상태불안정도가유의하게감소하였다. 뿐만아니라뇌파의변화에서도대조군에비해쎄타파가증가하고전두엽좌우의알파파비대칭성이개선되는등유의미한지표변화가관찰되었다. 앞서기술한데로 HRV BFB은일정한주기와리듬의들숨과날숨을반복하여분당평균심박수증감을의도된리듬패턴으로조절하는훈련이다. 이연구에서참가자는의도적으로뇌파를조절하려하지않았고단지호흡조절을기반으로한 HRV BFB을하는과정에서심박의증감리듬패턴뿐만아니라뇌파의변화까지도초래하였다는것은심장과뇌의상호연결관계에있어서심장의리듬패턴의변화가뇌파의변화를이끌어낼수있다는것을암시하기도한다. 마음챙김호흡훈련이뇌파에미치는영향을살펴본 Bing-Canar 등 25) 의연구에따르면대조군에비해마음챙김호흡훈련을하는상태에서측정한뇌파에서알파파가유의하게증가되었으며, 마음챙김호흡훈련이끝난직후뇌파를측정하는상태에서시행한스트룹테스트 (Stroop test) 에서는오답선택시의알파파억제현상이대조군에비해더유의하게나타났다. 인지적행위를하지않는안정상태에서알파파의활성화는뇌의항상성유지에중요한역할을하지만주의를요하는상황에서는적절하게억제되어야효과적인각성상태에이를수있다. 이연구에서는마음챙김호흡훈련을통해단순히안정상태의알파파가강화되었을뿐만아니라스트룹테스트과정에서자신이실수를하는순간알파파가효과적으로억제되므로서 알아차림 의능력이보다개선될수있음을보여주고있다. 심박을실시간모니터링하면서호흡을특정한리듬에맞게의도적으로조절하는 HRV BFB과는달리마음챙김호흡훈련에서는호흡을의도적으로조절하지않고그저호흡이저절로일어나는것을의식적으로관찰하는것에머무른다. 즉이때호흡은흩어지기쉬운의식을내적으로집중하기위한하나의기재로활용되며거기에어떤조절의도를개입시키지않으나그렇게 깨어서관찰 하는것만으로도호흡을안정화시키는효과가나며, 이렇게의도를내려놓고깨어있는상태를유지하는것으로서알파파의활성화와내적안정, 그리고자신의행위에대한알아차 Vol. 14 No. 2,

5 강승완 림의능력을향상시켜줄수있음을알수있다. 명상에서는호흡조절을중요시여기지만, 항상호흡조절에의존하는것은아니다. 의식적인호흡이심장박동리듬을변화시키고이변화와커플링된뇌파의변화가유도되어명상상태로유도될수있지만마음챙김에서와같이의도를가지고호흡을조절하지않더라도명상을통한직접적인의식의변화가뇌파의변화로반영될수있다. 지난수십년간헬스케어영역에서다양한형태의명상이나호흡법등이소개되었고많은연구들을통해명상을통한호흡의안정화, 혹은의도적인호흡훈련이심신을안정시키고자율신경활동성이변화되며인지기능이향상되거나뇌파가변화하는결과들을관찰해왔다. 불안한감성상태는불규칙하고빠른베타파를유발하며심장박동을증가시키고 HRV를감소시키며호흡을가쁘게만든다. 역으로호흡을규칙적이고안정되게다스림으로서심장박동을감소시키고 HRV를증가시키며뇌에서는안정된알파파를활성화시키고고요하고편안한심리상태를유지하며 알아차림 의능력도향상될수있다. 심리적상태와생리적상태는서로긴밀하게연결되어있어서어느하나가변화되면다른한쪽도연동되어변화될수있음을알수있다. 결론 본종설에서는자율신경에의해조절되는호흡에우리가의식을기울임으로서, 혹은의도적인훈련을함으로서역으로자율신경의패턴을변화시킬수있는가능성과원리에대해알아보았다. 또한그러한호흡의다스림이심장박동의리듬패턴에영향을미칠수있음을확인해보았다. 호흡을다스릴때, 비단자율신경과심장박동의리듬패턴만변화되는것이아니라뇌신경의활동성을반영하는뇌파도연동되어변화함을알수있었다. 그러나호흡이뇌파의변화를유도하는기전이호흡과뇌파의직접적인커플링에의한것인지아니면심장박동의변화에의한 2차적인결과인지를명확히구분할수있는연구결과들은충분치않았다. 향후연구에서는생리신호간의인과성에대한실험적검증을통해이부분을보다명확히밝힐필요가있다. 서양의생리학적관점에서는호흡은산소를흡입하고이산화탄소를배출하기위한생리적행위일뿐이지만, 동양에서는호흡을의식적으로조절하고다스림으로서보다나은심리적, 생리적상태에이르기위한중요한중재기법으로활용되어왔다. 2,8) 마음은형체가없지만뇌파, 호흡, 심박등의몸의움직 임과리듬으로표현된다. 자율중추에의해조절되면서도수의적으로조절이가능한호흡은감정과자율신경계에우리의의식을개입시킬수있는훌륭한조절도구이며심신의전인적돌봄을위한중요한간호중재법이될수있을것이다. REFERENCES 1. Kabat-Zinn J. An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: theoretical considerations and preliminary results. Gen Hosp Psychiatry. 1982;4(1): Miller JJ, Fletcher K, Kabat-Zinn J. Three-year follow-up and clinical implications of a mindfulness meditation-based stress reduction intervention in the treatment of anxiety disorders. Gen Hosp Psychiatry. 1995;17(3): Marlatt GA, Kristeller JL. Mindfulness and meditation. In Miller WR, editor. Integrating spirituality into treatment: Resources for practitioners. reprinted. Washington, DC: American Psychological Association; p Murphy M, Donovan S, Taylor E. The physical and psychological effects of meditation: a review of contemporary research. Published by the Institute of Noetic Sciences Hilton L, Hempel S, Ewing BA, Apaydin E, Xenakis L, Newberry S, et al. Mindfulness meditation for chronic pain: systematic review and meta-analysis. Ann Behav Med. 2017;51 (2): Davidson RJ, Kabat-Zinn J, Schumacher J, Rosenkranz M, Muller D, Santorelli SF, et al. Alterations in brain and immune function produced by mindfulness meditation. Psychosom Med. 2003;65(4): Colzato LS, Ozturk A, Hommel B. Meditate to create: the impact of focused-attention and open-monitoring training on convergent and divergent thinking. Front Psychol. 2012; Brown RP, Gerbarg PL. Yoga breathing, meditation, and longevity. Ann N Y Acad Sci. 2009;1172(1): Nolan RP, Kamath MV, Floras JS, Stanley J, Pang C, Picton P, et al. Heart rate variability biofeedback as a behavioral neurocardiac intervention to enhance vagal heart rate control. Am Heart J. 2005;149(6):1137. e Lehrer PM, Vaschillo E, Vaschillo B. Resonant frequency biofeedback training to increase cardiac variability: Rationale and manual for training. Appl Psychophysiol Biofeedback. 2000;25 (3): Baron Short E, Kose S, Mu Q, Borckardt J, Newberg A, George MS, et al. Regional brain activation during meditation shows time and practice effects: an exploratory FMRI study. Evid 68 Perspectives in Nursing Science

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Abstract Background : Most hospitalized children will experience physical pain as well as psychological distress. Painful procedure can increase anxie

Abstract Background : Most hospitalized children will experience physical pain as well as psychological distress. Painful procedure can increase anxie Volume 12, Number 1, 92~102, An Intervention Study of Pain Reduction during IV Therapy in Hospitalized Children Myo-Jin Kim 1), Joung-Hae Bak 1), Won-Seok Seo 2) Mi-Young Kim 3), Sun-Kyoung Park 3), Jai-Soung