Positive Health Online

Most forms of alternative medicine touch on breathing to some extent, and for mind-body-spirit practices, such as yoga or Qi Gong, it is of central importance. Within each tradition there is a set of accepted "truths" about breathing that are sometimes directly contradicted by the beliefs of another tradition. There is no widespread consensus here, even on some of the most basic notions. Tolerance of a diversity of views is, of course, one of the strengths of alternative medicine, but the fact that there is also little debate here means that a valuable opportunity to compare and cross-fertilise is being lost.

You can check whether you are using your diaphragm or your upper chest in breathing, by the following experiment. Bend over and hold the back of a chair, with your back, head and arms forming a straight line at right angles to your legs. In this position, breathing with the upper chest is extremely difficult, whereas breathing with the diaphragm is easy. If you find it reasonably easy to breathe while in this position, then you are probably breathing well normally. If it is difficult to breathe in this position, then you are not using your diaphragm, and would benefit from breathing retraining

I would like to open up a debate about breathing with this article, which I hope will lead to a deeper understanding, and a more fruitful application of breathing techniques. I also hope that this article will inspire replies from those who are experts in different fields, and begin a process of dialogue.

My interest in this subject began, in part, through research for a book on asthma; there will therefore be a certain emphasis on asthmatic breathing. Among the clients who come to alternative therapists seeking help, many are asthmatics, and the numbers grow every year. What do you tell them about the causes of their breathing problems? Can it be useful to teach them breathing exercises? And to what extent do the asthmatic's problems with breathing relate to the population at large? (There are more connections than you might think.)

The Whole Person

Human breathing is an extraordinary and unique business. If you want to dive underwater you could easily hold your breath, but if you decided to commit suicide by holding your breath, you simply couldn't do it. Your highly evolved human breathing controls would find themselves overruled by deep-rooted animal instincts.

This is the paradox of breathing: at one level, it is a basic biological activity, as automatic for us as it is for a lizard or a mouse. At another level, breathing is orchestrated by the conscious mind to allow us to speak, shout, sing or whistle. Breathing is the key to all these uniquely human means of expression and creativity.

And then there is a third aspect of breathing, its complex connections with emotion. Without breath you could not laugh, sigh or sob – but are these changes in the breathing pattern consciously or unconsciously controlled?

The answer is that they can be either, but the deliberate, calculated laugh of someone scoring-a-point bears no relation to the warm spontaneous belly-laugh of a person who has just seen the joke – in the same way, everyone can tell the difference between simulated crying and the real thing. When we are startled or frightened there are other spontaneous and unconscious changes in the breath – a gasp, a scream, or 'catching the breath'. As children, we may live in such a state of tension and anxiety that this momentary breath-holding becomes a permanent feature, and body-psychotherapists believe that this imposes a habitual fixity of breathing that affects our posture and general health, and limits our capacity for emotional growth.

Breathing is truly a function of the whole person – mind, body and spirit, past as well as present.

But that does not mean that every disorder of breathing has a psychological cause. Talk to asthmatics in their fifties and they will tell you how bad the 'bad old days' were, when doctors and society at large stigmatised them for their asthma, believing it was a shameful 'nervous' ailment. With increasing medical understanding of what causes asthma, all this has changed, to the great relief of older asthmatics. Certainly, getting stressed will make asthma worse, and crying or laughing can sometimes provoke an attack by pulling a big rush of cold air into the lungs, but asthma is not fundamentally psychological. Sadly, a lot of alternative therapists are still telling their clients that it is, creating another generation of confused, self-blaming asthmatics.

Achieving Balance

At its most basic physiological level, breathing is about taking in oxygen, and removing the waste gas carbon dioxide. But it is wrong to think of oxygen as wholly good and carbon dioxide as wholly bad. In fact, pure oxygen is lethal. The first life-forms on earth lived in an oxygen-free atmosphere and thrived. When the earliest forms of microscopic plant life first pumped oxygen into the air, millions of other primitive life-forms died out, literally poisoned by the new gas.

The trouble with oxygen is that it binds to bio-molecules, particularly those in cell membranes, and changes them by oxidising them. Our own one-celled ancestors, faced with this toxic threat, evolved means of coping with oxygen by mopping it up chemically. Haemoglobin, the red oxygen-carrying pigment in the blood, began life as a protective antioxidant. From there, by a series of steps, our microscopic forbears progressed to using oxygen to break down food more efficiently. This was a quantum leap in their physiology that meant the beginning of high-energy living and larger multicellular animals. But oxygen kept its toxic nature as well, and the need for antioxidants in our bodies (and in our diet) is a reflection of this. As long as we are breathing ordinary air, we cannot take too much into the body – the chemistry of the blood ensures that (the claim, made in some breathing books, that over-breathing can raise the oxygen level in the blood is wrong). But antioxidants are still needed to help protect the body from a whole range of oxidizing chemicals, both age-old natural ones and modern synthetic ones.

Both oxygen and carbon dioxide have a correct level in the blood, and there should not be too little or too much of either – what matters is getting a good balance.

Hyperventilation

Carbon dioxide, dissolved in the blood, makes it mildly acidic. When the level of carbon dioxide in the blood rises or falls, as it does with each breath, the acidity of the blood changes. The healthy functioning of the body's cells, particularly nerve cells, depends upon the acidity of the blood staying within these normal limits, and fluctuating in a regular way.

One form of breathing disorder, hyperventilation or over-breathing, pushes the carbon dioxide down so low at times that the blood's acidity goes outside these limits. This produces what doctors call 'bizarre neurological signs' – dizziness, tingling hands and feet, numbness, muscle cramps, twitches, migraine, spaced-out feelings, confusion, hallucinations, panic attacks, fear of sudden death (this is typical of hyperventilation), anxiety, mood swings, ringing in the ears and blurred vision.

Many of the patients visiting alternative practitioners may well be suffering from mild hyperventilation because it is often overlooked by GPs, or dismissed as 'nerves'. As an author, I have received heartbreaking letters from readers who have suffered from it for years, lost their jobs and suffered rejection from family, friends and the medical profession.

When they finally find the answer – a list of symptoms in a book that they recognised instantly – they are astonished that it is something so simple and so easily treated. Some of these people are over-sensitive to caffeine, which triggers the hyperventilation.

The involuntary control of breathing depends on part of the brain called the respiratory centre. It receives information about the levels of carbon dioxide and oxygen in the blood, and uses this to adjust the breathing rate and depth of breathing. Normally, the level of carbon dioxide in the blood is the main source of information for the respiratory centre, which is another reason why wildly fluctuating levels of carbon dioxide can have such disastrous effects on the hyperventilator. Many feel breathless or 'hungry for air' and take very deep sighing breaths (or yawns) at intervals. Sometimes this is an audible clue for the practitioner.

The Buteyko Method

One of the most publicised developments in alternative therapy in the past few years has been the Buteyko Method, which has had impressive results with asthmatics by treating – in its view – hyperventilation. Buteyko trainers say that all asthmatics hyperventilate and that this is the basic cause of asthma. Conventional medicine holds that some asthmatics hyperventilate and that this can make asthma worse, while other 'asthmatics' are actually just hyperventilators who have been misdiagnosed because they report breathlessness as their main symptom. One of the key issues at stake here is the proportion of asthmatics affected by hyperventilation: is it a minority as conventional medicine suggests or the majority?

The Buteyko programme is really very simple: unblocking the nose to stop mouth-breathing, learning to take fewer breaths and pausing between breaths. One version of the daily exercise consists of breathing normally, then stopping for as long as possible at the end of an out-breath. When this becomes unbearable, the asthmatic begins breathing in, but does so very gradually, with a series of small breaths. This is followed by breathing normally for 5-10 minutes, concentrating on taking shallow breaths.

It is unpleasant to do, and does not feel 'healthy' for anyone who has practised deep diaphragmatic breathing, yet it seems to work surprisingly well. In an 'open' study in Australia1, Buteyko trainers reported that about 85% of asthmatics going through the programme reduced their use of reliever inhalers, while 75% had fewer asthma symptoms and 51% found they could control all or most attacks. In a more thorough study2, doctors at Mater Hospital in Brisbane found that the overall use of reliever inhalers (e.g. Ventolin) by those trained in Buteyko, dropped substantially during the treatment programme and was still much lower 3 months later. On average, those who did the Buteyko training also felt a little better, but there was no change in their peak flow or other tests that measure narrowing of the airways (which undermines the claim that hyperventilation causes asthma). The strange thing is that, although the average level of carbon dioxide in the blood was low in the asthmatics, it did not change with Buteyko treatment.

This is one reason to question the claim that Buteyko treats hyperventilation.

One of the most surprising things about the Buteyko programme is the emphasis on shallow breathing, and the fact that most Buteyko teachers make no mention of using the diaphragm rather than the upper chest to breathe.

This is considered crucially important, not just in the alternative field but also among conventional doctors treating hyperventilation. Although there is no single medical view of hyperventilation, most doctors agree that hyperventilation involves habitual use of the upper chest, under-use of the diaphragm, and rapid shallow breaths – all of which need to be addressed, along with any psychological problems underlying the hyperventilation.

Buteyko teachers tell their asthmatic clients to breathe less deeply whenever they think of it during the day. This could, in some asthmatics, make the airways contract even more. Physiologists have shown that taking a deep breath stimulates the airways of non-asthmatics to relax by a nerve-reflex, and while this response is absent in some asthmatics (an abnormality that contributes to their asthma) it does occur in others. For them – and for the rest of us – taking a deep but slow breath from time to time, when we feel the need, is an excellent idea. Indeed, researchers have found that by prohibiting healthy people from taking deep breaths they can turn them into 'asthmatics', in that they respond to a standard test called a Metacholine Challenge as asthmatics do. What surprised the researchers was that the effect persisted for a while, even after deep breaths had been allowed once more.

Too Much Breathing – or Too Little?

In the media excitement over Buteyko, something rarely reported is that Professor Konstantin Buteyko blames hyperventilation for causing no less than 150 different diseases and symptoms, including allergies, insomnia, bronchitis, eczema, emphysema, high blood pressure and haemorrhoids. In other words, many of the ills that plague Western society are being caused by an epidemic of hyperventilation.

This contrasts sharply with the belief system of most other 'breathing therapies' – that we Westerners are not breathing enough, failing to give our bodies the oxygen they need. Dennis Lewis in The Tao of Natural Breathing expresses this common view: "Our chronic shallow breathing reduces the working capacity of our respiratory system to only about one-third of its potential, diminishes the exchange of gases and thus the production of energy in our cells…" Or, as Carola Speads puts it in Ways to Better Breathing "Health, moods, energy, creativity – all depend on the oxygen supply provided by our breathing. But the pressures of our modern-day life have created an almost literally breath-less culture. How many of us are living in a state of inadequate respiration?"

Is one of these views right and the other wrong? Perhaps half of us are over-breathing and the other half under-breathing? Or is it just that the whole thing is far more complex, and trying to explain everything in terms of basic respiration, oxygen and carbon dioxide, is a mistake? My personal guess is that the latter is correct – diaphragm breathing probably does you good for various reasons, some of which have nothing to do with oxygen.

Breathing into the diaphragm has profound effects on the body that anyone can feel for themselves. As it moves downwards, the diaphragm presses onto everything that lies below: the stomach, intestines and bladder. They become increasingly squashed, and eventually stop the diaphragm moving any further. But the diaphragm goes on contracting, and this is what pulls the lower ribs upwards and, therefore, outwards.

As well as this action on the ribs, there is a detectable response in the abdomen itself, that is less easy to describe in conventional scientific terms: it is a feeling of stimulation, of energy flow, of chi or qi moving downwards towards the intestines, the genital area and the legs. This flow can be opposed by emotional holding and tension in this area, which is why diaphragmatic breathing may be upsetting for some people, as the breath-induced movement challenges their protective emotional blocks, but intensely relaxing for others as the tensions are released. With continued practice over time, the energy flow often loosens up noticeably, with beneficial emotional and physical effects. Digestion, sexual functioning and blood circulation to the feet may all improve.

Breathing with the diaphragm is no guarantee of this, however. Osteopath and yoga teacher Peter Blackaby emphasises that "In learning to breathe with the diaphragm it is important not to go too far and become a 'belly breather', whose abdomen bulges out with every in-breath. This is a mistake sometimes made by those who consciously set out to improve their breathing." The firm opposition of the abdominal muscles is the key. And hyperventilation is a hazard, even while breathing with the diaphragm – many people hyperventilation when they start learning diaphragmatic breathing exercises, inducing a dizzy headachey state.

Diagnosing Hyperventilation

It may be difficult for clients to recognise their own hyperventilation, because their habitual pattern of breathing obviously seems 'normal' to them. You can make the point with the 'paper bag test'. When suffering symptoms, the client holds a clean paper bag over the nose and mouth and breathes normally. By re-inhaling air just breathed out, the level of carbon dioxide in the blood is increased. If the symptoms promptly disappear, they are very likely due to hyperventilation. Do not try this during an asthma attack. Another approach is to choose a time when there are no symptoms, and deliberately breathe faster for a few minutes, to see if the symptoms appear.

Exercises or Explorations?

Buteyko is a relative newcomer, but there are also profound disagreements among the more long-standing breathing therapies. Many disciplines, such as yoga, lay down standard breathing exercises that everyone follows. Other practitioners in this field regard such formal breathing exercises as inherently problematic, because they prevent an individual from arriving at his or her own healthy pattern by a natural means. As Dennis Lewis puts it: "Instead of trying to learn to breathe naturally, many people impose complicated breathing techniques on top of their already bad breathing habits."

Most of the twentieth-century pioneers in the breathing field have maintained that clients should be encouraged to find their own way. Carola Speads wrote "Because interferences with breathing vary as much as individuals do, breathing work has to be geared to individual needs. There is no set routine to be followed." Moshe Feldenkrais, who called his breathing techniques 'explorations' rather than 'exercises' had similar ideas. Ilana Nevill, a respected Feldenkrais teacher, says "The important thing about Feldenkrais is that it doesn't tell you what to do. When I work with the breathing of a person I am not saying to them: 'I will show you how to do it'. I am saying 'You can work it out, and I can help you discover things you never would have thought of before.' I get them to try anything – the crazier the better, even doing it very badly – that's good too, that's how you learn."

Robin Monro, director of the Yoga Biomedical Trust accepts that trouble can arise when tense, stressed, achievement-oriented Westerners apply their habitual behaviour patterns to yoga breathing exercises (pranayama). "The most essential part of pranayama is relaxation – if you try to do it without relaxing you will not get any benefit. This is one of the least developed sides of yoga teaching in the West, because the main emphasis is on asanas, or poses, and a lot of teachers do very little pranayama."

Support for the benefits of formal breathing exercises comes from another quarter entirely. Many asthmatics have found that their asthma improved substantially when they took up an instrument such as the flute or trumpet, trained as singers or learned a martial art. Helen, an asthmatic in her thirties, says 'I saw the doctor recently, because I had an asthma attack, and he did various measurements of my breathing. He was really surprised – because he could hear how badly I was wheezing – at how much lung strength I had. I said, "Perhaps that's because I sing in a choir" and he said "Oh yes, that'll be it…" I feel sure the training for singing has helped with my asthma.'

There is now scientific evidence to support this. When several asthmatics who had undergone operatic training reported a great improvement in their asthma, Dr Michel Girodo of the University of Ottawa carried out a full scientific trial. He found that, after doing these rigorous exercises for 4 months, the asthmatics were, on average, using 50% fewer drugs. Their asthma attacks were much less severe than before, allowing them to engage in three times as much physical activity. (Instructions for doing these exercises are published for the first time in our new book on asthma – see below.)

The benefit of these exercises to asthmatics seems to be that they strengthen the breathing muscles and so help overcome the constriction of the airways during an asthma attack. Something similar has been achieved with a mechanical device, the Inspiratory Muscle Trainer, now on sale as the 'Powerbreathe'.

Take a Big Breath

As I said at the outset, there are a lot of big questions here, but few answers and very little debate. I keep imagining this conference where the yogis and the Buteyko trainers meet, the Feldenkrais therapists do their thing to the Qi Gong teachers, and vice versa. Everyone has a go with the Inspiratory Muscle Trainer, and tries out the exercises for would-be opera singers. Perhaps there should be a few trained opera singers there too, and some trumpet-players and flautists, along with asthmatics and bronchitics, and ordinary people willing to give it all a try, and a bunch of respiratory physiologists to take measurements. It would take at least a couple of weeks for everyone to grasp what everyone else was doing, but it might be worth it.

Because you can only learn about breathing by doing it, not by talking or reading about it. In the end, you have to live it and breathe it.

Exercises to develop the diaphragm and other breathing muscles, originally devised for opera singers, have been tested by Dr Michel Girodo and other researchers at the University of Ottawa in Canada with asthmatics. They found that, after doing these exercises for 4 months, the asthmatics were, on average, using 50% fewer drugs. Their asthma attacks were much less severe than before, allowing them to engage in three times as much physical activity. Unfortunately, they lost all these improvements within two months of stopping the exercise programme. The exercises should be practised every day.

References

1 The Buteyko asthma breathing technique, Berlowitz D. et. al., plus a reply by Graham T., Stalmatsky A. and Drake, C. Medical Journal of Australia 1995, 162, p.153 (both on same page)
2 Buteyko Breathing techniques in asthma: a blinded randomised controlled trial, Bowler, S., Green, A. and Mitchell C.A., Medical Journal of Australia 1998, 169, pp. 575-8

Further Reading:

Lewis Dennis. The Tao of Natural Breathing. Mountain Wind Publishing. 1997.
Speads Carola. Ways to Better Breathing. Felix Morrow. 1978 (but still in print).
Nagarathna R, Nagendra H and Monro R. Yoga for Common Ailments. Gaia Books. 1990.
Pike Geoff and Pike Phyllis. Ch'i the Power Within: Chi Kung breathing exercises for health, relaxation and energy.
Brostoff Jonathan and Gamlin Linda. Asthma – The Complete Guide Professor. Bloomsbury. 1999.