Sonoma County Medical Association | Sonoma Medicine Magazine

What could be more natural than breathing? From the moment we take our first breath at birth to our last at dying, without our having to pay any conscious attention to the mechanics, our bodies inhale oxygen essential to our physiologic processes and exhale carbon dioxide, our metabolic waste.

As we learned in pre-med physiology class, the basic mechanics of breathing involve the respiratory diaphragm, along with intercostal, abdominal and scalene muscles. Inhalation is an active process of diaphragmatic contraction and descent into the abdominal cavity, accounting for about 75% of the air volume that is brought into the lungs by increasing negative intrapleural pressure. External intercostals assist the thoracic expansion, and for the deepest breathing, the scalenes act as accessory muscles of respiration to elevate the clavicles for upper lung expansion. Exhalation is largely passive, with diaphragm relaxation/elevation and elastic recoil of the lungs and chest to their resting volume, assisted by contraction of internal intercostal and abdominal muscles.

What we may not remember is how breathing acts as a gateway to the autonomic nervous system (ANS). Our breath pattern, whether unconscious or under voluntary control, involves visceral, brainstem, limbic, cortical and neuroendocrine feedback mechanisms. Furthermore, the link between the breath and the ANS is bidirectional. Sympathetic nervous system (SNS) stimulation for “fight or flight” leads to, and is stimulated by, short, rapid, shallow upper chest breathing. Conversely, parasympathetic (PNS) activation for “relax and regenerate” is associated with long, slow, deeper diaphragmatic breathing.

All too commonly, with the accumulation of life stress and physical or emotional trauma, we lose our natural diaphragmatic breath and develop severely dysfunctional breath patterns. These include the shallow, upper chest breathing mentioned above, breath holding (usually after inhalation), hyperventilation (leading to reduced CO2 levels and respiratory alkalosis), and reverse breathing (chest expansion with abdominal contraction on inhalation; chest collapse and abdominal expansion on exhalation).

Dysfunctional breath patterns, besides leading to poor oxygenation of the tissues, create imbalance in the ANS toward chronic SNS dominance. This imbalance significantly impacts a wide variety of conditions involving multiple organ systems, including cardiovascular disease; COPD and asthma; anxiety, depression and PTSD; peptic ulcer disease and IBS; endocrine conditions such as diabetes and osteoporosis; autoimmune disorders; chronic somatic or visceral pain; and even recovery from injury or surgery. It is well recognized that chronic stress plays a huge role in causing and/or perpetuating these conditions, but the powerful and direct role that breathing has to play is largely ignored in medical practice. Stress and dysfunctional breathing is a chicken-and-egg cycle spiraling out of control.

The good news? Long-established, powerful, simple, effective, non-invasive, low-tech, low-cost techniques are available to tip the balance toward better health and vitality: breathing exercises.

Your practice environment should be quiet and at a comfortable temperature.
Clothing should be comfortable and non-constricting.
Stomach and bladder should be empty.
Make sure you allow enough time to not rush your experience.
Take a few moments at the beginning of every exercise to nonjudgmentally observe your breathing (quality, rate, rhythm) before beginning any intervention.
Your breathing should remain smooth and steady, regardless of the technique practiced. If it becomes rough, choppy, strained, gasping, or leads to a sensation of “air hunger” or anxiety, immediately relax your efforts and return to your usual unaltered breathing for as many cycles as needed until you feel ready to try again with far less effort.
Start practicing the exercises for a short period of time, with intervals of “usual” breathing in between. As your comfort increases, you can increase the cycles of exercise.

The focus here is on retraining the respiratory mechanism. Keep breath comfortably slow and only moderately full; chest should move only minimally if at all. You can perform the exercises while supine, prone or seated.

Supine: Lie on your back with knees bent, neck and head with support. Rest your hands across your lower rib cage/upper abdomen, or place a hardbound book or a 5-10 pound bag of rice on the upper abdomen. On the inhalation, expand into your hands (or the bag/book) upwards (toward the ceiling) and slightly outwards (laterally). On the exhalation, release back to your resting dimension. In this position, the emphasis is on the abdominal movement upward.

Prone: Lie on a firm surface, arms folded on the ground with the forearms stacked one on top of the other, shoulders slightly off the ground, head slightly dropped so the forehead rests on the arms. Inhale and feel the limit of abdominal movement, causing expansion to continue laterally and posteriorly in the lower ribs and low back. Exhale release to resting dimension.

Seated: Sit at the edge of a relatively firm chair, both feet planted on the ground, spine lifted, with slight chin tuck. Put your hands on your upper belly/lower ribs as in the supine position. In the seated position, the movement is more predominantly in the rib cage, lateral and slightly upward (cephalad).

Note: Diaphragmatic breathing is often incorrectly taught and/or interpreted by patients as “pushing the stomach out.” Remember: on the inhalation, the diaphragm movement is active, but the abdominal movement is passive. Both are passive on exhalation.

Lie supine, with knees bent, and neck and head with low support if needed (avoid excessive neck flexion). Place your hands on your lower belly/hip bones. On the inhalation, feel the low back gently lift from the floor, belly expand softly upwards, hip bones rotate toward the thighs, tailbone toward the floor. On the exhalation, feel the belly drop toward the spine, gently pressing the back into the floor, hip bones rotating toward the waist. Continue for several breaths.

The following exercises, in addition to the ones discussed above, can be used for respiratory conditions. Exhaling through pursed lips can be used for COPD and asthma, and Buteyko breath training for asthma.

Should be learned from a trained instructor. Highlights include always breathing through the nose; consciously reducing respiratory rate and volume; shortening inhalation to achieve a 1:2 ratio of inhalation to exhalation; and practicing lengthening the retention of breath held out until the impulse to breathe is felt. The subsequent inhalation is to be steady, not deep or gasping.

In Sanskrit, prana means the life force of the universe, and yama means restraint or control. The ultimate goal of breath practices in yoga is self-transformation to a state of full balance and realization. However, as I like to tell my yoga students, along the way we can achieve some clarity and calm, as well as beneficial side effects such as increased aerobic and vital capacity, and balance of the ANS generally toward increased vagal tone.1-3 There are many different practices with specifics of rate, volume, ratio of inhalations, exhalations or retentions of breath held in or out, or nasal versus mouth breathing.

Breath is long, slow and comfortably deep. Short pause between inhalations and exhalations, no retention per se. No inhale/exhale ratios; goal is evenness. Essentially an extension of the diaphragmatic breath.

Be seated as in the diaphragmatic breath exercise. You may place one hand on the abdomen, the other on the chest. Inhale and expand sequentially your abdomen, ribs and chest. Feel the abdominal movement first, then the chest. On exhalation, sequence is reversed with relaxation of scalenes, some assist from internal intercostals, and completed by pulling abdomen in toward the spine. To begin the next inhalation, relax your abdomen to passively expand without pushing, and continue the cycle. Visualize not just upward/downward movement, but an expanding and receding long balloon in all directions: to both sides, front and back, even down toward the pelvic floor.

The breath rate/ratios for Ujjayi (sound-producing) breath are as in Long Deep Breathing. A slight contracture of the muscles around the throat throughout the breath cycle creates a soft whispering “wind in the trees” sound, which should not be audible more than a few feet away. Similar to a nozzle on a hose, the contracture helps evenly “spread“ the breath throughout the body, enables more direct monitoring and control, and is particularly helpful for lengthening the breath cycle. The Ujjayi breath can also be done while practicing yoga asanas (postures). Research shows particular enhancement of several markers of vagal tone.3

Classical yoga texts discuss a cyclical nostril dominance of air flow. Traditionally, the left nostril corresponds to lunar, cooling, inward; the right to solar, outward, dynamic. Modern studies with EEG confirm these general principles, with “unilateral forced nostril breathing” (breathing through just one nostril by closing the other with gentle pressure with the thumb or ring finger tip medially) specifically altering EEG activity and vascular tone in each brain hemisphere, corresponding to PNS or SNS stimulation.4-5 The classic goal is balancing the flow in the energy channels of the body for purification and “elevation.”

There are many variations, but a basic practice is to be seated as in the diaphragmatic breath exercise, with your left hand relaxed in your lap. Place your right hand near your nose, with the second and third finger curled into your palm. Your breath should be relaxed and comfortably slow, with an even ratio of inhale/exhale and brief pauses between.

After a few complete breaths, occlude the right nostril with the thumb and inhale slowly through the left nostril. Pause briefly while you release the thumb and occlude the left nostril with the ring finger, then slowly exhale through the right. Pause, slowly inhale through the right, pause, switch nostrils, exhale through the left. Pause, inhale through the left, pause, switch nostrils, exhale through the right. Continue for several breath cycles. It is important to keep the right shoulder relaxed, arm and elbow down by the chest.

Reversing decades of bad breathing habits takes time and practice. Whether your goal is to reduce stress and anxiety, or to prime your respiratory system for greater efficiency and aerobic capacity, be steady and consistent in your practice. Yoga classes can help, but they vary in how much pranayama is emphasized.

When you have had personal experience with the difficulties and ultimate successes of the breathing exercises, try to incorporate breath awareness into your patient encounters. Such awareness may be as simple as leading three long diaphragmatic breaths at the end of a visit, or suggesting even one long deep breath in the middle of a discussion of stressors, or between blood pressure readings, to give an experience of potential change. Basic breath practices make a good homework assignment for patients.

Many athletes cross-train with yoga postures, and yogic breathing exercises will benefit athletic pursuits as well. While walking, hiking or jogging, engage Complete Breath, nasal breathing as much as possible, and play with the 1:2 inhale/exhale ratio, timing your breath counts (e.g., 2:4, 3:6) with each step, or at least keep exhalation longer (e.g., 4:6, 3:5). You will enjoy gains in aerobic capacity and endurance.

For further exploration of breath combined with movement, Breathwalk is a complete system blending walking and several different breathing patterns, each with a specific effect on mood and energy, which adds a great new dimension to physical and mental fitness, even on a treadmill!

Birkel DA, Edgren L, “Hatha yoga: improved vital capacity of college students,” Alt Ther, 6;6 (2000).
Raghuraj P, et al, “Effect of two selected yogic breathing techniques of heart rate variability,” Indian J Physiol Pharm, 42;4 (1998).
Brown R, Gerbarg P, “Sudarshan Kriya yogic breathing in the treatment of stress, anxiety and depression,” J Alt Comp Med, 11;1 (2005).
Shannahoff-Khalsa DS, “Selective unilateral autonomic activation: implications for psychiatry,” CNS Spectr, 12;8 (2007).
Telles S, et al, “Breathing through a particular nostril can alter metabolism and autonomic activities,” Indian J Physiol Pharm, 38;2 (1994).