Entering the World of Breath Therapy

It was a crisp spring morning, and I was on a bike ride with a colleague. We were discussing our exposure to breath therapy from a shared mentor. This mentor had recently started teaching other physical therapists on how to incorporate breath work into their practice. A large component of the philosophy is getting patients to tolerate pure nasal breathing. “Do you think you can maintain nasal breathing at this pace?”, my colleague asked. “I’m not sure. Let’s give it a try”, I said. We both shut our mouths and attempted to solely breathe out of our nose. We didn’t change our pace. Not that we were racing. In fact, I would describe our pace as slightly above a leisurely stroll. As our attempt at nasal breathing progressed, the sound of our breath became heavier. It was obvious we were both uncomfortable. We pushed further anyway. Speaking for myself, my body wanted a big gulp of air. I felt the air hunger deep in my lungs. Eventually we both caved and reverted to our mixed strategy of in through the nose out through the mouth. It’s a strategy that is commonly used in exercise class instruction, so it must be okay, right? Is it necessary that we always breathe in and out of the nose?

It had to be okay. It felt physically impossible to maintain the pure nasal method. I considered myself to be in decent shape, and yet that method seemed unattainable. When describing how to best transition to higher level activities with my patients, I often talk about getting the boat close to the dock before jumping. My breath work boat seemed like it was a mile offshore. I guess that’s why I became fascinated with it. Could I master something that seemed unattainable? I was going to give it a try. I would start with doing some breath therapy on myself. If I wanted to work with patients in this way, I had to experience it firsthand. I talked to my mentor, who suggested reading both “Breath” and “Oxygen Advantage”. Eventually, I enrolled in his courses and certification process to officially bring breath work into my practice.

Through all the reading and course instruction, one thing was clear. Nasal breathing is the most efficient and healthiest way to breathe. It maintains moisture in the body and keeps you hydrated longer. Nasal breathing also filters out particles from the air, warms the air before entering the lungs, and changes your blood chemistry to allow for a smooth transition of oxygen from your blood to your muscles and organs. Physiologically, it all made sense. The problem was that as soon as I started exercising with any form of intensity, I needed to incorporate some breaths out of the mouth.

Committing to this meant making some sacrifices. I loved pushing myself on the bike. That occasionally involved riding hard with a group, or maybe even a solo ride with a lot of climbing in the hills. To truly work on this, I had to give that up for a bit. It was humbling, but I slowed my pace on the bike WAY down. I stayed away from the hills I loved to climb. For a full week, I rode slow enough to maintain nasal breathing. If I felt anything stronger than light air hunger, I slowed my pace even further. In total, it was 150 miles worth of slow riding just to maintain nasal breathing. After a week, something started to shift. I noticed my speed was starting to pick up a bit, but I was still breathing through the nose. The air hunger was either not present or light, and still, I could feel myself getting faster. This continued throughout the second week. I continued to gain speed without utilizing the mouth for breathing. It was incredible, thinking about how impossible it felt just a month earlier, my body was obviously making gains. By the third week, I was able to incorporate hills. I continued to keep the pace at a level that was maintainable for solely nasal breathing. Sure enough, my pace on hills was picking up as well. By the fourth and fifth week, on steep segments that often made my legs burn, I was riding hard, breathing in and out of the nose. While I did feel some air hunger, I didn’t notice the burn in my legs as much. The nasal breathing kept the effort in an aerobic state that didn’t result in lactate building up. I was also setting personal records. It was incredible. Six weeks earlier, I couldn’t maintain nasal breathing while riding easy. Now I could ride tempo up a hill and maintain nasal breathing, only needing to utilize mouth breathing if I were to sprint.

So, what does this mean? In general, I can take advantage of the benefits listed above. My bottles last longer on rides because I’m not dehydrating as fast. I’m also operating more efficiently than before. Intensities that used to require anaerobic efforts were now staying purely aerobic. The heart rate was lower for any given effort compared to the month before. If I need to lift the effort to keep up with a group, I have more reserves to do so now. Also, because the nose filters the air, I’m no longer coughing for an hour or two after a longer ride.

How does this shift happen and can anyone do it? Prior to initiating breath therapy practices for myself, my body prematurely decided to breathe heavier because it was uncomfortable with the rising level of carbon dioxide in my system. That was despite carbon dioxide not reaching a level which required heavier breathing. None the less, I would breathe heavier anyway because I had conditioned that response over a period of time. The slow riding and forced nasal breathing eventually retrained my body to tolerate appropriate levels of carbon dioxide. My system recalibrated and I was eventually able to return to my hard efforts on the bike, and because of that recalibration, my brain wasn’t freaking out over the carbon dioxide. So yes, anyone can do it. Some may require dedicated practice at rest before jumping into exercise-based practice, but this is modifiable in everyone.

Most of my patients entering breath therapy never attempt to maximize their exercise efforts with nasal breathing because that wasn’t the goal to begin with. I highlighted my dive into breath work because it at least sheds some light on the practice and potential benefits. Most of my patients are interested in improving breathing strategies that help them with chronic pain, stress, anxiety, sleep apnea, asthma, and vocal cord dysfunction. There are numerous things in our world that can cause us to over breathe. These include posture, stress, and nutrition. Over time, these learned strategies become our go to habits, and the body becomes oversensitive to carbon dioxide. Just like mine was when I attempted to nasal breathe on the bike for the first time and found it to be impossible. The good news is, it can be changed, and rather quickly. The benefits will be widespread. You’ll notice improved sleep, decreased muscular tension, decreased stress and pain. If you often feel like you’re stuck in “fight or flight”, you’ll feel yourself shifting away from that.

In short, I consider the breath to be a pillar of health. Just like sleep, exercise, and nutrition, mastering your breathing strategies, whether that be at rest or heavy exercise, you’ll allow the body to operate more efficiently. For some, that means performing better in a race. For others, that means reducing sleep apnea symptoms and sleeping more soundly at night. Or it just means you are able to naturally reduce stress and tension from your crazy day. The effects are far reaching, and you’ll be happy you took the dive. I know I am.

Ray Arreguin Jr., PT, DPT, OCS, COMT, FAAOMPT