The current COVID-19 pandemic has been a significant adjustment for everyone worldwide and has increased stress and anxiety to unprecedented levels. It is likely you are getting questions from your patients regarding breathing techniques that have been mentioned in the media and on YouTube as a means to cope with stress and anxiety during this pandemic. The ACAAI Integrative Medicine Committee has put together this article to highlight a few effective breathing techniques that promote relaxation/stress reduction and increase respiratory efficiency, which are especially important for our patient population. We know through research that psychological stress plays a role with asthma. It can make asthma more difficult to control and increase the likelihood of asthma flares. And it can also increase the duration and severity of symptoms. Breath control and meditation practices have been shown to play an important role in stress reduction and asthma control (1,2,3). You may use the breathing techniques outlined below for yourself and/or share them with your patients. You do not need formal yoga practice experience or any extensive training to learn these simple and effective techniques. Simply read through each section, watch the videos, and experiment with your own body and breath.
The basics of breathing
Just breathe! is a common phrase used in the media and by many health providers. However, it’s not enough to simply “breathe,” it must be done effectively. If you’re holding your breath or hyperventilating, you are technically breathing, but just not as effectively as possible. In fact, it has been shown that this type of shallow rapid breathing can actually make you feel more stress during trying times. In order to practice effective breathing, it’s important to understand the role of the diaphragm in optimal respiration. Our diaphragm is a major muscle of the respiratory system involved in the expansion of the ribcage and rising of the chest under voluntary control. When we inhale, the diaphragm contracts and moves down; when we exhale the diaphragm relaxes and it moves up. The greater the degree of movement of the diaphragm between inspiration and respiration, the greater the tidal volume – amount of air that moves in or out of the lungs with each respiratory cycle. Controlled diaphragmatic breathing (taking in slow, deep breaths) increases tidal volume and has been shown to improve ventilation efficiency of the lungs, pulmonary gas exchange and arterial oxygenation (4, 5). Furthermore, the lung base has the greatest blood flow/perfusion and is often not utilized in thoracic (shallow/rapid) breathing; diaphragmatic breathing allows one to activate the bases of the lungs (5).
Breathing and the autonomic nervous system
The autonomic nervous system has two arms that exert opposing control over the heart – sympathetic (fight-or-flight/cardiac acceleration) and parasympathetic (relaxation/cardiac slowing). Parasympathetic activity is the dominant arm of the autonomic nervous system, providing a homeostatic level of control over the heart rate under resting conditions. Prolonged periods of stress can set an imbalance to the autonomic system with a shift toward more sympathetic activity (4). Heart Rate Variability (HRV) is an interesting and noninvasive way to identify imbalances in the autonomic system. It is measured as specific changes in time (or variability) between successive heart beats. When one is more frequently activating the parasympathetic nervous system such as when under stress, the variation between subsequent heartbeats is low. If one is in a more relaxed state, the variation between beats is high. In other words, the healthier one is, the faster you are able to switch gears, showing more resilience and flexibility. Over the past few decades, research has shown a relationship between low HRV and worsening depression or anxiety (6,7). A low HRV is associated with an increased risk of death and cardiovascular disease (6). Diaphragmatic breathing activates the parasympathetic system via the vagus nerve and improves this balance. Research shows that prolonged practice of slow breathing can play an important role in achieving a shift toward parasympathetic dominance and enhance autonomic reactivity to physical and mental stress (4).
Watch William Silvers, MD, member of the ACAAI Integrative Medicine Committee, demonstrate the diaphragmatic breathing technique:
Other techniques to stimulate the vagus nerve and bring about the relaxation response:
Prone position breathing
Prone (lying face down) positioning for breathing (also called Crocodile pose in yoga) can increase oxygen delivery to the lungs. This positioning is being used in hospitals on COVID-19 patients to improve their blood oxygen levels. In many cases this has helped patients breathe easier and avoid needing a ventilator as they fight and recover from the viral infection. It is also being used on ventilated COVID-19 patients to improve oxygenation (8,9,10). Studies on hospitalized COVID-19 patients showed that more lung alveoli were “recruited” (or opened up) during prone positioning, which improved oxygen exchange and resulted in better outcomes. This positioning allowed the posterior segments and lower lobes of the lungs to drain excess fluid and become filled with air in those with COVID-19 pneumonia (8,9,10). Even if you are not sick and don’t need extra oxygen, Crocodile pose can be a very relaxing pose and a way to begin sensing the natural patterns of breath, especially abdominal breathing. It is a pose frequently used in restorative yoga that helps promote a sense of calm and stillness.
Undulating wave breathing
Lay face down on a mat with forehead on the ground. Belly breathe by allowing your belly and chest to fill with air, and then exhale letting your lungs deflate. Feel the spine undulate as you breathe– the whole body moves like a wave from the head to the toes. This is a good way to become aware of the breath and its dynamic motion involving the spine. It is a calming practice that promotes better oxygen delivery throughout the body. The more you concentrate on the breathing technique, the better results you will achieve.
Yoga breathing practices
The beneficial health impacts of yoga techniques, particularly the breath work called pranayama, on stress exacerbated conditions like hypertension, heart disease, as well as mood disorders such as anxiety and depression has been well studied. Patients have experienced improvement in all of these conditions with a regular practice of yoga, pranayama and meditation techniques (11). Yoga pranayama breathing techniques can help with the sensations of shortness of breath and asthma. With obstruction of the lung breathing tubes in asthma, there is difficulty in exhaling completely. This creates the sensation of shortness of breath because the lungs become overfilled and you cannot take in additional air (air trapping). Completely exhaling using your abdominal and rib cage muscles can help one take a deeper breath of fresh air and improve this sensation of shortness of breath. Dirgha Pranayama is a yoga technique also called the “three-part breath” because you are actively breathing into three parts of your abdomen. This breathing technique is ideal for asthma.
Watch Atoosa Kourosh, MD, member of the ACAAI Integrative Medicine Committee demonstrate the dirgha breathing technique:
Below is a series of additional breathing exercises and yoga breath practices and poses for anxiety prevention and treatment. You can use any of them alone or all of them together. They can also give you energy when feeling tired and help you assist your body to heal the respiratory tract.
- Nadi Sodhana (alternate nostril breath) 3 cycles minimum and up to 12 cycles per session (can be practiced several times a day if needed) – as a preventative measure, it helps bring calm awareness and makes panic attacks less frequent. It’s important to blow your nose (even clean it out with saltwater spray) before practice so your nostrils are more clear.Nadi Sodhana has also shown to help increase alertness, mental and emotional balance and ultimately restful sleep. It should not be done once you’re in bed as it can lead you to be calm but alert and that’s a time when you want to be sleepy.
- Bumble Bee breath – can help when you are feeling anxious and can bring you to a moment of calm. You can practice this breath in 3-5 cycles as needed when feeling anxious.
- 4-7-8 Breath – Relaxing practice with a focus on a longer exhale.
- Breath of Joy to energize and de-stress.
- Try this easy vagus nerve access breathing practice using a pillow. Here are some more practices for the vagus nerve and more information to read about it.
We’d like to thank the ACAAI Integrative Medicine Committee for their work in developing this article. A special thanks to Atoosa Kourosh MD, Payel Gupta, MD, Dipa Sheth, MD, Maeve O’Connor, MD, and William Silvers, MD for reviewing the available literature, identifying the best practices and developing content for this article.
- Liccardi, G, et al. Anxiety and asthma in inner-city black adolescents: What could be the underestimated, possible connection? Correspondence and Reply, Vol. 6, No. 3, May 01, 2018.
- Mekonnen, D, et al. Clinical Effects of Yoga on Asthmatic Patients: A Preliminary Clinical Trial. Ethiopian Journal of Health Science, July 2010.
- Is It Asthma or Anxiety? Premier Health, Apr 5, 2017. https://www.premierhealth.com/your-health/articles/women-wisdom-wellness-/is-it-asthma-or-anxiety-
- Russo, MA, et. al. The physiological effects of slow breathing in the healthy human. Breathe, Vol. 13, No. 4, December 2017.
- Zaccaro, A, et al. How Breath-Control Can Change Your Life: A Systemic Review on Psycho-Physiological Correlates of Slow Breathing. Front. Hum. Neurosci., 07 September 2018.
- Buccelletti, E, et al. Heart rate variability and myocardial infarction: systematic literature review and metanalysis. European Review for Medical and Pharmacological Sciences, July-August 2009.
- Tsuji, H, et al. Reduced heart rate variability and mortality risk in an elderly cohort. The Framingham Heart Study. Circulation, August 1994.
- Wuhan study shows lying face down improves breathing in severe COVID-19. (News Release). American Thoracic Society, March 24, 2020. https://www.eurekalert.org/pub_releases/2020-03/ats-wss032420.php
- Ghelichkhani, P, et al. Prone Position in Management of COVID-19 Patients; a Commentary. Arch Acad Emerg Med. 2020; 8(1): e48, April 11, 2020.
- ‘Such a simple thing to do’: Why positioning Covid-19 patients on their stomachs can save lives. CNN, April 14, 2020. https://www.cnn.com/2020/04/14/health/coronavirus-prone-positioning/index.html
- Sengupta, P. Health Impacts of Yoga and Pranayama: A State-of-the-Art Review. Int J Prev Med. 2012 Jul; 3(7): 444–458.