Key Point

• The more comfortable the body tolerates higher levels of carbon dioxide, the more efficient the delivery of oxygen into the tissues. 

In Ayurvedic tradition, breathwork is a crucial tool for maintaining wellness in body and mind. When used properly, it can change a person’s health trajectory for the better. 

We know fear changes how we breathe in the moment, but few realize that stressors—big or small—can change our breathing pattern. In our fast-moving society, that stressed breathing pattern can quickly become our new normal. To make matters worse, this stressed breathing pattern will become permanent unless you make a concerted effort to relearn how to breathe. So, what can we do to fix it?

Recently, as I entered a restaurant and opened a door for a group of elderly folks, I noticed their mouths were cracked open as they labored to breathe while navigating their exit. They had become frail, shallow breathers battling numerous age-related health concerns. Sadly, no one told them that a simple, 5–10-minute daily breathing practice and keeping their mouths closed while walking and exercising could have prevented this from happening. 

Our medical system largely ignores the health implications of shallow breathing until it’s too late. No one told these elders that breathing could prevent and reverse their heartburn and blood pressure issues.¹ No one told them about the link between breath and cognitive decline—that proper breathing pumps cerebral spinal fluid in and out of the brain, removing more than three pounds of plaque from the brain’s glymphatic system each year.² No one told them that the most important breathing muscle (the diaphragm) is also the body’s main lymphatic pump, carrying the body’s immune system and removing metabolic waste from around the belly, chest, and head.

Luckily, with a few exercises and concentrated focus on where and how we breathe, MTs and their clients can improve their breathing techniques, reduce the number of potential health problems associated with mouth breathing, and improve their well-being.

Reviewing the Research

Some of the strongest evidence to date comes from the Journal of the American Heart Association, which suggests breath-resistance training can impact heart disease and blood pressure.³ In this study, participants took 30 deep inhalations daily for six days each week over the course of six weeks. They took these breaths using an inspiratory muscle strength-training device to provide either low resistance or high resistance during their breaths. The results for the group who used high resistance were astonishing: The study documented up to a nine-point reduction in systolic blood pressure. This simple change in breathing provided blood pressure improvements similar to the benefits one would see from consuming certain blood pressure medications or from taking a 30-minute walk. 

The researchers also saw a 45 percent improvement in endothelial function of the lining of the arteries. This was measured by increased production and absorption of nitric oxide (NO). NO, which is produced when you breathe through your nose, serves as a natural antiseptic and repair agent.

Other studies have repeatedly shown that inspiratory muscle training, used in hospitals around the world, can improve heart, lung, and digestive function. Research demonstrates that breathing exercises to strengthen the diaphragm can restore healthy function of the lower esophageal sphincter, which has been found to be an effective therapy for gastroesophageal reflux disease (GERD) and other acid-related upper digestive health concerns.

In addition to being the primary breathing muscle, the diaphragm is also a major pump for the lymphatic system and the cerebrospinal fluid, which acts as a brain-washing fluid for the brain’s lymphatic system. Strengthening the diaphragm has been shown to support healthy brain function and ward off age-related cognitive decline.⁴

If Athletes Need to Learn How to Breathe, So Do We!

Whether you are an elite athlete, a casual exerciser, or someone aspiring to move more, we all need to relearn to breathe. In a 2023 study, 91 percent of athletes tested had dysfunctional breathing patterns in which the diaphragm was not relaxing and contracting fully.⁵ If athletes do not have a functional diaphragm, it is safe to assume that most of us do not either.

The rib cage has an important job: to contract like a cage around the lungs and diaphragm to help the body’s effort to exhale fully. The average rib cage has become more rigid with years of stress, shallow breathing, excessive sitting, and increasingly sedentary lifestyles. This makes it more difficult to breathe deeply into the lower lobes of the lungs. The lungs are a gravity-fed system in which the vast amount of blood available for oxygen exchange resides in the alveoli in the lower lobes of the lungs. The lower lobes are predominantly innervated by parasympathetic receptors that rebuild, rejuvenate, and help the body digest. The upper lobes of the lungs are primarily accessed by mouth breathing and are innervated by the fight-or-flight sympathetic nervous system. Mouth breathing directs air into the upper lobes of the lungs, while nose breathing forces the air through a narrow series of turbinates that spins the air like a turbine to drive the air deeply into the lower lobes. 

Shallow Breathing vs. Lateral Breathing

When the diaphragm contracts, it draws oxygen into the lungs, forcing the rib cage to expand. Over time, as the rib cage becomes more rigid, the diaphragm weakens and cannot fully contract on inhalation and relax on exhalation. This means the breath pattern becomes shallow.

Over the years, we are likely to become shallow breathers, engaging in what is called overbreathing. During shallow breathing, 75 percent of the oxygen we inhale is exhaled unused. Shallow breathing also forces us to breathe out excessive carbon dioxide. In this shallow breathing state, the oxygen levels in the blood stay high while CO2 levels plummet. This is the perfect storm for anxiety, which is why when folks have a panic attack, they try to boost carbon dioxide levels by breathing into a paper bag. While chronic blood levels of excess oxygen and low carbon dioxide increase the body’s stress response, rising blood levels of carbon dioxide actually have a sedation effect on the body.

In this state of overbreathing, with high oxygen and low CO2 levels, the bond between the oxygen and the hemoglobin in the blood tightens. This tightening forces the oxygen to linger in the blood, delaying oxygenation of the body’s tissues. Known as the Bohr effect, this helps explain the importance of nose breathing. Nose breathing will slow and lengthen the breath, allowing time for better oxygen exchange and a healthy buildup of carbon dioxide. The more comfortable the body tolerates higher levels of carbon dioxide, the more efficient the delivery of oxygen into the tissues will be. 

To resolve these shallow breathing issues, most of us have to relearn how to breathe properly into the lower lobes of the lungs through lateral breathing. When you watch a dog or a horse breathe, you see their rib cage expand laterally while their shoulders remain still. Most humans have adapted to a stressed breathing pattern by engaging their shoulders and sometimes even the neck to pull air into the upper chest. This is because the rib cage has literally become a cage, squeezing down on the heart and lungs about 26,000 times a day. As the rib cage narrows to support shallow vertical breathing, the diaphragm weakens and fails to fully contract and relax. But this is not a situation of permanency. Here is one breathing exercise that works to strengthen lateral breathing. 

The Two-Step Lateral Breathing Exercise 

Step 1: Lie down on your back or sit up comfortably. Take a slow breath in through the nose into the lower abdomen, but do not move the chest or shoulders. Fill your belly a little, then try to breathe into the lower rib cage and expand the ribs laterally out to both sides. As you breathe into these lateral ribs, keep filling the rib cage as far as you can. Keep inhaling and try to push the breath into the ribs that wrap around your back. This is called lateral breathing. Continue for 10 breaths. Do 2–3 sets of 10 breaths twice a day.

Step 2: Raise your arms over your head and laterally bend to the right. Once you are in a maximal but comfortable lateral bend, take a long, slow, deep lateral breath through your nose, pushing the lower left rib cage out to the side. Once you reach your max, you can take some small sips of air through the mouth to expand the lateral rib cage even further. As you slowly exhale, laterally bend to the left side, releasing all air from the lungs. Repeat this 10 times on the right and 10 times on the left with full exhales each time. Do 2–3 sets of these side-bending breaths twice a day.

Comparing Nose vs. Mouth Breathing During Exercise

In 1996, I coauthored a study in the International Journal of Neuroscience comparing nose breathing to mouth breathing during exercise.⁶ According to our study, breathing deeply through the nose into the lower lungs is the secret to entering “the zone.” Nose breathing during exercise produced bursts of alpha brain waves, which are typically only seen in a meditative state. Nose breathing also creates a state of brain wave coherence, which is when all parts of the brain function in coherence with each other. In contrast, during mouth breathing, the brain becomes incoherent with predominantly beta (stress-associated) brain waves.

One definition of being in “the zone” is experiencing your best race as your easiest race. To measure this in our study, we used the Borg scale of perceived exertion. Twenty high school athletes rode a stationary bicycle at 200 watts of resistance while mouth breathing (control/conventional group) or nose breathing on consecutive days. During mouth breathing, the average perceived exertion was a 10 out of 10 (10 being the most intense experience of exertion). In stark contrast, athletes using nose breathing perceived the same workout at just a 4 out of 10 on the exertion scale.

A full breath acts as a waste remover for our respiratory system as it is an oxygen delivery system. One of the causes of exertional fatigue is an inability to efficiently breathe out metabolic waste, which is best removed when the lower lobes of the lungs are engaged with each nasal breath. Nose breathing slows the breath, allowing time to maintain that critical balance of oxygen and carbon dioxide. During our study, breathing rates for the same vigorous workout plummeted from 48 breaths per minute with conventional mouth breathers to 14 breaths per minute with nose breathers. 

Nose breathing during exercise forces the diaphragm to engage, reverses the negative effects of overbreathing, and delivers NO, which has been found to act as an anti-inflammatory, antiseptic, and repair agent for the entire respiratory tract and digestive system.⁷ Research shows that NO is produced in the paranasal sinuses.⁸ There is no nitric oxide produced when we breathe through the mouth. 

The 3-Phase Nose Breathing Workout

I introduced these nose-breathing principles in my 1994 book Body, Mind and Sport based on our research with these athletes. To this day, workouts are based on the concept that you have to break the body down to build the body up: The more you stress the body with exercise, the greater the muscle breakdown, followed by a better recovery and greater strength. We continue to break world records because this model works; however, it doesn’t work forever. We are ultimately limited by how much exercise stress we can endure, and by age 30, most professional athletes have reached the end of their careers. Why? Because there is a limit as to how many years you can break the body down to build it up and stay competitive. 

The 3-Phase Nose Breathing Workout is based on Ayurvedic principles, which suggest that less can be more and the right amount of exercise rejuvenates. 

Warm Up: Perform 5–10 minutes of a yoga breathing practice with synchronized breath and movement, such as sun salutations. Establish a long, slow, deep rhythm of the breath through the nose. Here we are creating rib cage flexibility and building a base for respiratory efficiency.

Phase 1 (Resting Phase): For the next 5–10 minutes, walk or exercise slowly and breathe deeply in and out through the nose with a similar rhythm you had during the sun salutations. Notice there is a slight but natural pause between the inhales and exhales. This is not a breath hold but a natural linking of the breaths. Maintain a comfortable space between each breath. Here we are exercising the lungs first, allowing the diaphragm to fully contract and fully relax.

Treadmill Working: Set your treadmill to 2 miles per hour at zero degrees of elevation and walk slowly while breathing as described above.

Phase 2 (Listening Phase): As you begin to walk faster or exercise harder, continue to maintain the pause between each inhale and exhale. Keep slowly picking up the pace until you feel the space between the breaths getting shorter. As soon as you notice the pause between the breaths shorten, slow your pace and reestablish the space between breaths. If you have to open your mouth to breathe, you are in an emergency response and have pushed the pace too hard or too fast. Once you have slowed down, resetting the original nose breathing pattern with space between breaths, start increasing the speed or pace again. You will notice that you will be able to exceed the pace from the last set with the same breathing pattern. Each time you increase the pace and see the space between the breaths shorten, slow down and reset the original rhythm of the breath. Here, you are listening and learning what it feels like to go from a parasympathetic-dominant pace to a sympathetic-dominant pace.

Treadmill Workout: At 2 miles per hour, increase the elevation by one degree every 15 seconds. As soon as the elevation causes the breath rate to speed up and the space between breaths shortens, lower the elevation back to zero degrees. Once the breath is reset, increase the elevation again one degree every 15 seconds and measure your improvement with each subsequent set of elevations.

Phase 3 (Performance Phase): This phase is a natural continuation of the listening phase. During the listening phase, you likely noticed that the breath rate shortened with a certain amount of exertion. In the performance phase, your pace and exertion increase, but your breath rate can naturally become longer, slower, deeper, and more efficient. Here, as the breath rate deepens, access to the alveoli-rich lower lobes of the lungs increases, allowing you to enter “the zone,” where your best race is your easiest race.

Cool Down: Perform 5–10 minutes of a synchronized yoga breathing practice, again like sun salutations. Take long, slow, deep nasal breaths to finish the cool down.

The 3-Phase Nose Breathing Workout can be adapted to any sport, workout, or fitness routine. Training your diaphragm to function properly and working to breathe through your nose is a powerful way to improve your life, your health, your exercise performance, and that of your clients. 

Notes

1. John Douillard, LifeSpa.com, “A Breathing Practice for Occasional Heartburn,” June 27, 2020, https://lifespa.com/ayurvedic-lifestyle/breathwork/breathing-practice-heartburn-2.

2. John Douillard, LifeSpa.com, “Nasya, Pranayama, and the Science of Brain Lymph,” March 27, 2024, https://lifespa.com/health-topics/brain/nasya-pranayama-brain-lymph.

3. Michael J. Joyner and Sarah E. Baker, “Take a Deep, Resisted, Breath,” Journal of the American Heart Association 10, no. 13 (June 2021): e022203, www.ahajournals.org/doi/10.1161/JAHA.121.022203. 

4. John Douillard, LifeSpa.com, “How to Detox Your Brain + Cerebrospinal Fluid (CSF),” February 14, 2019, https://lifespa.com/diet-detox/brain-detox.

5. Yuka Shimozawa et al., “Point Prevalence of the Biomechanical Dimension of Dysfunctional Breathing Patterns Among Competitive Athletes,” Journal of Strength and Conditioning Research 37, no. 2 (February 2023): 270–6, https://pubmed.ncbi.nlm.nih.gov/35612946.

6. F. Travis et al., “Invincible Athletics Program: Aerobic Exercise and Performance Without Strain,” International Journal of Neuroscience 85, nos. 3–4 (April 1996): 301–8, https://pubmed.ncbi.nlm.nih.gov/8734567.

7. Jon O. Lundberg, “Nitric Oxide and the Paranasal Sinuses,” The Anatomical Record 291, no. 11 (November 2008): 1479–84, https://pubmed.ncbi.nlm.nih.gov/18951492.

8. J. O. Lundberg et al., “High Nitric Oxide Production in Human Paranasal Sinuses,” Nature Medicine 1, no. 4 (April 1995): 370–3, https://pubmed.ncbi.nlm.nih.gov/7585069.