Amidst the heightened stress and anxiety caused by the pandemic, “better respiration” feels like an intuitive topic to tap into for various reasons.
Improving our breathing can have an underestimated impact on overall health. Humans take up to 22,000 breaths ), and have an incredible 1,500 mile (2414 km) airway length, with 2,000 gallons (7570 liters) of air exchanged over the course of a day— the size of a swimming pool. The respiratory illness, COVID-19, is caused by a type of coronavirus called the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
My heart goes out to all beings directly or indirectly affected by this crisis — especially my fellow New Yorkers. I have the deepest gratitude and admiration for all the frontline and essential workers globally.
The goal of this article is to inform on aspects relating to breathing, and to form hypotheses on breathing techniques that could be helpful for treatment and recovery of COVID-19 patients, based on existing studies and preliminary data.
Breathing techniques are unlikely to prevent transmission of the virus, or to help with severe symptoms, for instance, during ventilation. However, there are indicators that certain breathing techniques could shorten a potential mechanical ventilation and ICU stay, and help reduce hypertension, the main pre-existing condition of hospitalized people in the U.S.
The papers I cite in this post might be useful to research how breathing techniques could be practiced as therapeutic methods to possibly prevent potential inflammation.
Some breathing techniques are already being recommended for the recovery phase of COVID-19– for stress management, to reduce anxiety and depression, and to improve cognitive function.
The post will provide a brief overview on:
Breathing has multiple vital functions.
The lungs add oxygen to the blood and remove carbon dioxide in a process called gas exchange.
During weight loss, over 80% of body fat leaves the body via exhales.
Lungs have recently also been found to be “making blood.”
On a basic level, breathing happens through the creation of space inside the body.
The difference in pressure between the lung and external environment similar to atmospheric exchange and wind in the air.
On average, there are 480 million alveoli in the bronchial trees of the lungs, covering a total surface area of up to 750 square feet (70 m2), which is a considerably larger surface area relative to volume. The large surface area makes gas exchange with the bloodstream more efficient.
The more expansive the inhale, the more surface area is covered. The more air flows into the lungs, the more blood becomes oxygenated.
A simple sigh can be the simplest breathing exercise to bring in “twice the volume of a normal breath". According to , a professor of neurobiology at the David Geffen School of Medicine at UCLA and a member of the UCLA Brain Research Institute, "If you don’t sigh, your lungs will fail over time."
The COVID-19 virus seems to enter the body via cells in the nose and in the eye.
Inside the body, the virus hijacks the cell’s machinery, making myriad copies of itself and invading new cells. As the virus multiplies, an infected person may shed copious amounts of it, especially during the first week or two.
“After infection, symptoms might not develop for five to six days — or even two weeks. The time between catching the virus and showing symptoms is called the presymptomatic phase", according to the Annals of Internal Medicine.
“If the immune system doesn’t beat back SARS-CoV-2 during this initial phase, the virus then marches down the windpipe to attack the lungs, where it can turn deadly. The thinner, distant branches of the lung’s respiratory tree end in the tiny air sacs called alveoli.”
Symptoms may still be absent at this point. “Normally, oxygen crosses the alveoli into the capillaries, tiny blood vessels that lie beside the air sacs; the oxygen is then carried to the rest of the body. But as the immune system wars with the invader, the battle itself disrupts this healthy oxygen transfer.” The inflammatory response then leaves a stew of fluid and dead cells behind.
“This is the underlying pathology of pneumonia, with its corresponding symptoms:
● Coughing
● Fever
● Rapid, shallow respiration
The virus could also cause led to:
● Sore throat
● Loss of smell and taste
● Chills
● Muscle pain
● Headache
● Head and body aches.”
But others deteriorate, often quite suddenly, developing a condition called acute respiratory distress syndrome (ARDS). Oxygen levels in their blood plummet and they struggle ever harder to breathe.
On x-rays and computed tomography scans, patients’ lungs are riddled with white opacities where black space — air — should be. Commonly, these patients end up on ventilators. Many die.
Autopsies show their alveoli became stuffed with fluid, white blood cells, mucus, and the detritus of destroyed lung cells.”
With the onset of severe symptoms hospitalization and potentially mechanical ventilation and Intensive Care Unit (ICU) are necessary.
According to recent studies with over 1,000 patients, one study states 5.0% of COVID-19 patients were admitted to the ICU, 2.3% underwent invasive mechanical ventilation, and 1.4% died. “Compromised respiratory status on admission was associated with worse outcomes.”
Acute hypoxaemic respiratory failure (ARDS) is when gas exchange in the lungs is significantly impaired causing a drop in the levels of oxygen in the blood.
In the latest most comprehensive in the US so far, the overall length of hospital stay was 4.1 days and the average age of patients was 63 years. “Among patients who were discharged or died, 14.2% were treated in the intensive care unit (ICU), 12.2% received invasive mechanical ventilation, 3.2% were treated with kidney replacement therapy, and 21% died. Mortality rates for those who received mechanical ventilation in the 18-to-65 and older-than-65 age groups were 76.4% and 97.2%, respectively. 17.3% had a respiratory rate greater than 24 breaths/min, and 27.8% received supplemental oxygen. The most common comorbidities [pre-existing conditions] were hypertension (56.6%), obesity (41.7%), and diabetes (33.8%).”
On hypoxemia and the inflammatory responses of the body:
“Happy” or “silent hypoxia” is an unusual coronavirus effect baffling doctors.
Dr. Clifford Marks, MD and Trevor R Pour, MD, Emergency Medicine (both Mount Sinai Health System): “Still, mysteries hover around certainties. Doctors track the “oxygen saturation” of patients with covid-19 — they monitor the percentage of hemoglobin molecules in the bloodstream that are currently carrying oxygen. Ordinarily, in patients with healthy lungs, an oxygen-saturation level below ninety per cent is cause for grave concern: when vital organs such as the heart and brain become starved for oxygen, the risk of death skyrockets. But doctors are finding, bizarrely, that some covid-19 patients can remain subjectively comfortable even when their saturation levels fall far below these ranges.
This “silent hypoxemia” is frightening for physicians, who associate such low numbers with imminent death. And it’s deeply mystifying, since the numbers seem implausible.
Is silent hypoxemia a sign that, even though a patient feels relatively well, the bottom is about to drop out? Or is the virus somehow interfering with the blood’s hemoglobin, or with the parts of the brain that warn us when we need more oxygen? […] Faced with a cytokine storm in a patient, a doctor can try to modulate the immune system’s response. The problem is striking the right balance. While some patients may benefit from a degree of medically induced immunosuppression, there are others for whom such an intervention could cause great harm. Some hospitals have begun cautiously administering steroids or drugs that inhibit the cytokine IL-6. […] Our colleagues at Mount Sinai are actively embarking on dozens of research projects, ranging from ventilator-management strategies to social determinants of covid-19 mortality, but months will pass before these projects give us objective insight into the disease. ”
“Luciano Gattinoni, MD, guest professor of anesthesia and intensive care at the University of Gottingen in Germany,wrote an editorial in the journal Intensive Care Medicine and said “This is a kind of disease in which you don’t have to follow the protocol — you have to follow the physiology.” Gattinoni says doctors need to pay attention to how COVID-19 has affected the lungs and breathing of each patient they’re treating before deciding on treatment. Patients with more classic ARDS-type COVID-19 often need mechanical ventilation right away, which forces air into the lungs to increase oxygen.”
“On April 20 in the New York Times, an ER doctor named Richard Levitan who had been volunteering at Bellevue proposed that the phenomenon of seemingly stable patients registering lethally low oxygen levels might be explained by “silent hypoxia” — the air sacs in the lung collapsing, not getting stiff or heavy with fluid, as is the case with the pneumonias doctors had been using as models in their treatment of COVID-19. “
On asymptomatic patients:
On long term conditions and recovery:
“Recovery from lung damage takes time,” Panagis Galiatsatos, M.D., M.H.S., expert on lung disease at Johns Hopkins Bayview Medical Center says.
“Some COVID-19 survivors will never recover completely from a condition known as post-intensive-care-unit syndrome,” Dr. Amy Bellinghausen, a pulmonary and critical care fellow at the University of California, San Diego. says. It can produce long-term disabilities from muscle wasting, organ damage, brain damage, and PTSD.”
“Some COVID-19 survivors had a 20–30% drop in lung function after recovery and “gasp if they walk a bit more quickly,” doctors in Hong Kong told the South China Morning Post last month. […] Early evidence indicates some COVID-19 survivors may find their bodies changed long-term by the disease.”
Studies on breathing techniques might not be widely known. This could be due to the novelty of the research field, similar to studying mindfulness and meditation. But in recent years, even renowned National Medal of Science winnerDr. Michael Posner shifted some of his recent research focus to study meditation practices with peer-reviewed papers.Another reason there is limited research available on breathing techniques might be the lower financial revenue freely available breathing practice might generate. Maybe there is less of an industry to study and promote the techniques.
It is my hope that the cited, mostly peer-reviewed, studies I list here could be examined by healthcare practitioners and researchers, and taken into consideration to be studied in regards to COVID-19.
On inflammation:
In 2014, the study “Voluntary activation of the sympathetic nervous system and attenuation of the innate immune response in humans” was published in the Proceedings of the National Academy of Sciences of the United States of America (PNAS), and lead authored by Matthijs Kox. The subjects of two groups in the study were injected with endotoxemia (i.v. administration of E.coli endotoxin). The intervention group performed “breathing exercises as they received their toxin injections.”
“On average, recruits who underwent training by Hof reported fewer flu-like symptoms than those who did not. […] Trained recruits also produced lower amounts of several proteins associated with inflammation, and higher levels of an inflammation-fighting protein called interleukin-10. In the intervention group, practicing the learned techniques resulted in intermittent respiratory alkalosis and hypoxia resulting in profoundly increased plasma epinephrine levels. In the intervention group, plasma levels of the anti-inflammatory cytokine IL-10 increased more rapidly after endotoxin administration, correlated strongly with preceding epinephrine levels, and were higher.
Levels of proinflammatory mediators TNF-α, IL-6, and IL-8 were lower in the intervention group and correlated negatively with IL-10 levels.”
A recent COVD-19 study on lung inflammation and anti-inflammatory strategies states: “Suppression of pro-inflammatory IL-1 family members and IL-6 have been shown to have a therapeutic effect in many inflammatory diseases, including viral infections.” Another recent study on thrombotic microvascular injury suggests a panel to, among other topics, study: “pro-inflammatory cytokines, particularly IL-1 and IL-6.”
An extreme immune reaction, often referred to as a cytokine storm, that results in elevated levels of inflammatory cytokines including interleukin IL-6, appears to be linked to increased mortality from COVID-19.
In the mentioned PNAS-published study by Kox et al. (2014) “[…] the intervention group […] displayed a “remarkably mild innate immune response.” The significance was stated as “that, through practicing techniques learned in a short-term training program, the sympathetic nervous system and immune system can indeed be voluntarily influenced.
[This] has important implications for the treatment of a variety of conditions associated with excessive or persistent inflammation, especially autoimmune diseases in which therapies that antagonize proinflammatory cytokines have shown great benefit.”
On hypoxia:
Research on hypoxia, how blood cells adapt to different oxygen levels and role of oxygen plays in the human immune system was awarded the Nobel Prize of Medicine in 2019.
The authors of the study “Effects of Slow Deep Breathing at High Altitude on Oxygen Saturation, Pulmonary and Systemic Hemodynamics” conclude: “Slow deep breathing improves blood oxygenation (SpO2) and affects hemodynamics in hypoxic patients. […] Slow deep breathing improves ventilation efficiency for oxygen as shown by blood oxygenation increase, and it reduces systemic and pulmonary blood pressure […].”
Slow deep breathing improves blood oxygenation (SpO2) and affects blood flow in hypoxic patients according to prior studies. Could they help with hypoxia “silently killing” people often don’t notice at home before it is too late?
On length of treatment with mechanical ventilation and in the ICU:
Training the diaphragmatic and intercostal muscles responsible for breathing while experiencing mild symptoms might shorten a potential ventilation and ICU stay with severe symptoms, according to two recent studies.
In two recent studies on mechanically ventilated patients, one states “diaphragm thickening in the zone of apposition may be useful to predict extubation success,” and another “the decreased diaphragm and intercostal muscle thickness were associated with prolonged mechanical ventilation and length of ICU stay.”
Concluding, to train the diaphragmatic and intercostal muscles responsible for breathing while experiencing mild symptoms might shorten a potential ventilation and ICU stay with severe symptoms. Simply by training the breathing muscles.
Another study suggests that “high-intensity inspiratory muscle training results in increased contracted diaphragm thickness and increased lung volumes and exercise capacity in people who are healthy.”
On deep breathing techniques and hypertension:
Hypertension or high blood pressure is defined as abnormally high arterial blood pressure. It is the leading pre-existing condition of patients hospitalized with COVID-19.
Two Nature-published studies conclude for one study deep breathing “decreases blood pressure (BP) and pulse rate (PR), and these decreases correlated with the baseline BP and PR. […] In one group, BP was measured before and after taking 6 deep breaths over a period of 30 s, and in the other group BP was measured before and after a 30-s rest in a sitting position without deep breathing,” and another study states “[…] slow breathing results in coherence reduction of BP.”
Deep breathing has been studied to improve blood oxygenation and blood flow, and may help improve the blood oxygenation of COVID-19 patients as well.
For the study “Deep-Breathing Exercises Reduce Atelectasis and Improve Pulmonary Function After Coronary Artery Bypass Surgery“ the intervention group performed “30 slow, deep breaths with a positive expiratory pressure blow-bottle device hourly over the course of four days.” The “patients [..] had significantly smaller atelectatic areas and better pulmonary function on the fourth postoperative day compared to a control group performing no exercises.”
Nitric Oxide (NO) is also currently being investigated as COVID-19 treatment to study the cardiovascular effects aspart of a primary clinical trial. NO gas is produced by breathing from the nose and sinuses, and is inhaled with every breath. Humming during an exhale also increases nasal NO compared to quiet exhalation. NO is suggested “to enhance pulmonary oxygen uptake via local vasodilation [to lower blood pressure].” The increase of NO through nose-breathing could be helpful in treatment of COVID-19 patients, and some studies already focus on NO, but not using nose-breathing.
On deep breathing for recovery:
Dhruv Khullar, M.D., M.P.P., physician at NewYork-Presbyterian Hospital, writes in the New Yorker on April 23, 2020: “It will develop covid-19-specific protocols, which we hope will help patients progress to a fuller recovery. Patients will receive daily “pulmonary rehab” — a stepwise approach to reducing oxygen support and slowly building strength and endurance. They’ll learn breathing techniques and get help with gadgets they can use to clear mucus from the lungs.
On stress, anxiety and PTSD:
Breathing techniques have been already discussed in regards to COVID-19.
“What you’re really doing there is forcing air into the alveoli by taking big breaths in and holding the alveoli open, and that will help clear any excess mucus, pathogens, as well as stop them from becoming hardened, which can happen. This is with the caveat that you are safe to stay at home and you don’t need to be in hospital. If there’s any chance of pneumonia, you should be in hospital.” […] However, Laura Breach, a spokeswoman for the Association of Chartered Physiotherapists in Respiratory Care (ACPRC), says while the exercises should be harmless for healthy individuals, she would not advise them, adding that they could make symptoms worse in someone suffering breathlessness.”
The article “Could Deep Breathing Exercises Protect You From the Worst Symptoms of COVID-19?” written by Areda Cassoobhoy, MD, PH, states there is as of now no scientific evidence behind prominent people’s anecdotal storiesbreathing techniques helped to ease COVID-19 symptoms. The lack of scientific evidence can only be resolved with the start of studies focused on breathing techniques and COVID-19 symptoms.
The New England Complex Systems Institute (NECSI) published “Respiratory health for better COVID-19 outcomes”: “Deep breathing has been shown to improve respiratory health and patient outcomes across a number of conditions[…, and] for mild [COVID-19] symptoms standard breathing exercises may be beneficial.”
Breathing helps to get “a handle on the stress response” and belly breathing techniques are suggested by institutionsfor recovery and stress management of medical professionals.
With the ongoing development of COVID-19 vaccines lasting at least many months, if not years, breathing techniques can be safely studied without side effects. They would also be easy to practice by anybody at home. In an interviewwith author Scott Carney, Dr. Ashita Batavia, Infectious Disease Specialist, mentions herd immunity might result in the loss of 0.5–9M lives in the US.
The challenges with reopening businesses and public places also are manifold without any preventative drugs or vaccines. Most common masks are not sufficient and need to be taken off in restaurants and other public places. Many public places have air conditioning that circulates air, making these places prone to virus transmission.
Cited breathing techniques such as the Wim Hof Method breathing could be studied to prevent inflammations. They could be a crucial and accessible behavioral intervention most people could practice and learn before exposing themselves to potential transmission in public.
Breathing techniques, specifically deep breathing, can already reduce anxiety and improve physical and mental health at home. Maybe they can help with COVID-19 treatment and recovery as well?
If breathing can be beneficial for diseases or not, one thing seems certain: “Learning diaphragmatic breathing and relearning how to breathe from the diaphragm is beneficial for everyone.” — Harvard Medical School
A simple breathing technique is diaphragmatic breathing, also referred to as deep or belly breathing. Diaphragmatic breathing is an expansion of the belly at the start of inhale, and followed by an expansion of the chest.
Thereby, the creation of space inside the body leads to an increase of oxygen flowing into the lungs.
It is a simple technique anybody can practice.
Here also a short video explaining diaphragmatic “belly” breathing.
Between 2014 and 2016, I also researched mindfulness and breathing techniques at The Institute of Neuroscience at the University of Oregon, and how to integrate mindfulness into technology with the academic “Mindful Technologies” project.
If there is further interest in studying breathing techniques, I would be grateful to be able to contribute.
