Two years ago, I was sitting in my therapist’s office. She was teaching me abdominal breathing as a therapeutic tool to soothe my hyper-anxious mind. Her instructions were to breathe through the nose and from the belly. Each step—inhaling, holding and exhaling—had to be done to the count of four. Repeat till you feel relaxed, she said. Deep, gradual and expansive breaths are a signal to the parasympathetic nervous system to slow down the heart rate, relaxing the body.
Three months ago, I got covid-19. Despite the high fever and exhaustion, I had no cough or shortness of breath. It could have been the combination of breathing exercises—bhastrika and anulom vilom, two pranayama practices for controlled respiration—that I began early in 2021. Or maybe the unpredictable virus just affected me differently.
Two months ago, while doing the dishes and listening to a podcast—the only way to make this chore tolerable—I heard something that made me catch my breath. In the episode on wellness on Harvard Business School’s After Hours podcast, Prof. Mihir Desai says, “I think breathing is spectacularly important for wellness and totally under-appreciated.” He named two books that had him “transfixed”—science-adventure journalist James Nestor’s Breath: The New Science Of A Lost Art and pulmonologist Michael Stephen’s Breath Taking: The Power, Fragility, And Future Of Our Extraordinary Lungs.
That day, I bought Nestor’s Breath. It made me wonder why something as vital as breathing isn’t part of millennial-speak the way gut health is. Ever since the lockdown last year, my inbox has been filled with mails about immunity-boosting foods, brands turning turmeric into supplements, and celebrity health instructors. To double-check, I rummaged through emails on better eating, better skincare and a better body but there was nothing about better breathing beyond the universe of yoga. The time is ripe to unpack the often overlooked aspects of inhale and exhale over and above the 30 minutes of daily pranayama.
“You can’t just practise breathing for 10 minutes and say you are fine,” Nestor tells Lounge. He estimates we take 25,000 breaths a day and most of us are doing it completely wrong. We breathe through the mouth instead of the nose, take rapid short breaths and chew food improperly. Apart from contributing to several respiratory maladies like sleep apnea and snoring, mouth breathing is the No.1 cause of cavities, “even more damaging than sugar consumption”. These habits harm the nasal passages, worsen anxiety, and are linked to diseases such as high blood pressure and asthma. Mouth breathing also slows recovery from respiratory conditions like covid-19. Over time, he writes in the book, human beings have become the worst breathers in the world.
When I ask Nestor about his breathing habits, he answers with caution, pointing out that he is no guru. He wrote a book by speaking to leading experts, deeply researched the topic for years, participated in studies, and adopted a few daily practices. Through the day, he focuses on slow and even nasal breathing: “By doing this, you not only regulate your nervous system but also your immune function,” he says.
This wisdom was first imparted to me by psychologist Ankita Gandhi Kamath of Mumbai’s MindCare clinic, two years ago. I found her technique of belly breathing a useful tool to rein in racing thoughts. It is a prelude to identifying, challenging and altering them—the premise of cognitive behavioural therapy. “Anxiety comes so effortlessly to us because our brains are habituated to it,” Kamath explains.
Her appointment slots are full with clients dealing with health-related anxiety during the pandemic. The complaints range from worrying about personal health and that of loved ones to coming to terms with grief and struggling with the effects of long covid. “The worst part: It’s a pandemic of respiratory illness and anxiety also hits you there,” she says. Fear, stress and anxiety often manifest as chest heaviness, a shortening or speeding up of breath, or a sense of being unable to breathe. And calming the breath can soothe the mind into a feeling of safety.
To rewire and train the mind, Kamath introduces belly breathing in a measured manner: Each step in the model of inhale-hold-exhale starts with counts as low as three and then goes up to six. Practice is key. “If you don’t practise, when unwanted thoughts and emotions hijack your mind, belly breathing could take longer to work. You might feel the technique is ineffective but it’s not true. Everything requires discipline,” she says. The idea is to practise enough to trick your brain to relax.
It stems from simple science. “Neurons that fire together, wire together” is a phrase first used by Canadian neuropsychologist Donald Hebb in the context of associative learning. It’s a quote that Jo Aggarwal, founder of the mental health app WYSA, uses to explain the link between breathing and self-sabotaging thoughts and emotions. The human body is a mysterious wonder of cause and effect. To simplify this interdependence, picture this: Breathing is linked to the seat of emotions, which is our endocrine system; it is also connected to the brain, which bears thoughts. And then there is the subconscious: a cauldron of thoughts and emotions. At times, these thoughts can be unsettling and unreasonable: “I am a failure”, “I struggle”, “I suffer”. Aggarwal says such thoughts seem to come out of the blue, causing the mind to lurch towards panic or fear, while the body responds with shallow breathing. “It’s impossible for these thoughts to stay when you are breathing deeply and slowly,” she says. “Your body is trying to focus on the irrational thoughts and making them look bigger than they are. It perceives them as leading to physical danger, reduces your breath and activates the fight-or-flight response. When you start breathing deeply, your body is led to believe it’s safe, which in turn dissolves those thoughts and emotions.”
Breathing is one of the essential tools for psychotherapy because it is both a voluntary and an involuntary act. The lungs continue to inhale and exhale whether or not one is conscious of the process. Aggarwal says, “Think of breathing as a gateway between the voluntary and involuntary part of the brain.”
And then she asks: Have you read James Nestor?
Nestor’s book is a fascinating take on the science and philosophy of breathing that combines modern respiratory research and the ancient breath-work doctrines of yoga, Taoism and more. His take is that prayer is another word for slow breathing. The Buddhist mantra Om Mani Padme Hum, which needs six seconds of inhalation and exhalation each, follows the same pattern of Om chanting and Kundalini yoga’s sa ta na ma mantra. He cites a research study at the University of Pavia in Italy, conducted in 2001, where two dozen people chanted a Buddhist mantra and the original Latin version of the Catholic prayer Ave Maria. There were sensors to measure their blood flow, heart rate and nervous system feedback. The cycle of inhalation and exhalation, while reciting the prayers, averaged at 5.5 breaths a minute. They found this breathing pattern increased blood flow to the brain while the body reached a state of coherence “when the functions of heart, circulation, and nervous system are coordinated to peak efficiency”. It almost matches the three-increasing-up-to-six counts inhale-exhale cycle adopted by Kamath. Prayer and therapy can heal.
In his quest to study breathing, Nestor casts his net wide. He analyses record-breaking athletic performances that were made possible solely by improved breathing techniques. There are case studies of people who reversed autoimmune disease and others who healed from incurable conditions like scoliosis, where the spine curves sideways. His book traces the remarkable journey of Katharina Schroth, who had a distinctive sidewards curved spine. Doctors had written her off as someone who would be in a wheelchair for life. But she trained herself to breathe right and after several years of this practice, she “breathed her spine straight again”. She went on to open a rehabilitation centre for scoliosis patients in Germany and helped hundreds. Now, the Schroth Method for scoliosis is offered as a physical therapy at The Johns Hopkins University in the US.
It is this university that contacted Nestor after the book was published in May 2020. He has received calls from Harvard and Stanford too. Each has the same intention—to introduce breathing studies. Nestor took about 10 years to research and write his book. “The nose is the silent warrior: the gatekeeper of our bodies, pharmacist to our minds, and weather vane to our emotions,” reads a poetic line. Perhaps it wouldn’t be too farfetched to link it to a medical practice, the Breathing Thinking Functioning model, which is used to manage breathlessness.
The Breathing Thinking Functioning (BTF) approach was pioneered by the UK’s Cambridge Breathlessness Intervention Service (Cbis) in 2012 as a palliative measure to tackle breathlessness. Cbis doctors found that breathlessness stems from maladaptive patterns that involve inefficient breathing, anxious thinking and declining lung function. For example, people with conditions like chronic obstructive pulmonary disease (COPD) are often vulnerable to worrying thoughts about breathlessness, such as “I can’t breathe and I will die”. Debilitating thoughts, unfortunately, beget breathlessness. It is a vicious cycle and is the Thinking aspect of the Cambridge model. The Functioning aspect implies the deconditioning or decline of lungs and related muscles due to breathlessness. It prevents people from being active, often leading to isolation. The third aspect of breathlessness is straightforward: breathing. In other words, a cycle of bad habits like fast inhalation and exhalation causes insufficient intake of oxygen and expulsion of carbon dioxide, and therefore breathlessness, which leads to anxiety and further breathing difficulty. The BTF approach, Cambridge experts claim, breaks each of these vicious cycles. For better breathing, patients are trained in efficient inhalation and exhalation techniques with therapies that include singing—a practice that combines fun with correcting breathing patterns. For spiralling thoughts, patients are taught mindfulness and relaxation. For better lung function, patients are encouraged to exercise. It is, overall, palliative care that goes hand in hand with COPD drugs.
Rajani Bhat, a Bengaluru-based pulmonologist, has adopted the Breathing Thinking Functioning model as part of her work. She practices both palliative and interventional pulmonology. “They are the two ends of the spectrum in pulmonology. Interventional is all hi-tech with endoscopic procedures that include scopes and stents. Palliative involves working with the BTF model. Both help release the symptoms of breathlessness and cough,” she explains. “Breathlessness occurs when I am not able to increase the supply of oxygen as per the demand.” For instance, when you run up a flight of stairs, the respiration would in most cases settle into a regular pattern after a period of heavy breathing—but if it doesn’t, it could signal trouble. “It means the lungs are trying their best but their effort goes unrewarded,” says Dr Bhat.
Healthy lungs respond to the body’s demands for oxygen and restore it to a normal state where you are unconscious of your breathing, says Dr Bhat. So, what happens to the lungs during covid-19? To answer this question, Dr Bhat narrates an engaging story filled with analogies of soap bubbles: The lungs contain the main breathing tube, divided into the right and left. Within the lungs, the tube forks out into smaller and smaller branches to end up as tiny, microscopic air sacs known as alveoli. Imagine them as delicate soap bubbles. The air that’s inside the soap bubbles is what you have breathed in. There are tiny little networks of blood vessels around the air sacs and the oxygen diffuses from the sacs into the blood cells. When you are exposed to covid-19, the virus comes in through the nasal passage, travels down the respiratory tract and eventually reaches the air sacs. It causes inflammation in their fine lining. These fine soap-bubble-like structures start thickening and the oxygen molecules find it harder to move into the blood vessels. When this happens, there is a feeling of breathlessness. Doctors try to remedy the situation before the thickening causes the air sacs to close and collapse.
Apart from medication, one way to ease the situation is by proning, where the doctor lays the patient on the stomach with a pillow beneath. This position opens up more surface area for breathing. “You have a larger part of the lung engaged in oxygen exchange, which will keep your oxygen levels up. We are just using simple physics. Proning is standard medical practice. It is recommended for cases that are on the cusp of going from mild to moderate,” she explains.
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Dr Bhat believes that the pandemic has made people more aware of their health and breathing. She says people have become more committed to tracking vitals like blood pressure, pulse rate, oxygen levels and sugar levels more closely. Many of her patients have focused on improving their health during the pandemic.
Does anything else impact breathing? She responds, “Air pollution.”
THE AIR AROUND US
India has some of the world’s most polluted cities. More than 120 cities, including Delhi, Bengaluru and Ahmedabad, do not meet the National Ambient Air Quality Standards. Different government programmes have been rolled out to address air pollution but it’s hard to measure their outcomes.
Tanushree Ganguly, programme associate at the Council on Energy, Environment and Water, a Delhi-based think tank, is an air quality researcher who is developing a data-driven approach to clean air policymaking in India.
Between March-September last year, Ganguly says, restrictions on activity and mobility ensured a significant reduction in carbon dioxide emissions, whether from vehicles, industrial operations or construction. Air quality improved. It led to the realisation that if there are significant cuts in emissions, India can achieve the National Ambient Air Quality Standards. “There is a consensus across the board but has it translated into any significant air quality policy at the national level? Not so much. But some cities are becoming more particular about planning their mobility strategies,” says Ganguly. She cites the example of Bengaluru, which is planning its mobility infrastructure in such a way that it can cut down the need for personalised motorised transit.
Ajay Nagpure, the Delhi-based head of Air Quality and Sustainable Cities at the World Resources Institute (WRI) India, says that while vehicular pollutants may have reduced during the pandemic, emissions caused from cooking with biomass, like cow dung, firewood and crop residue, have not. This is the main contributor to indoor air pollution in urban and rural homes. “People are not talking about indoor air pollution because they are not aware that 30-40% of outdoor air pollution too is contributed by the biomass used for cooking,” he says. Job losses over the past year have forced more people to shift from expensive LPG to cheaper biomass. Nagpure suggests ways to tackle this problem: Reintroduce subsidies for cooking gas targeting income groups below the poverty line and create awareness programmes. “We have observed in low-income households where a woman is the decision maker, they tend to use more LPG compared to those where men take decisions. So we need to target the awareness campaign to women,” he says.
Breathing is the most intimate connection that we have with our surroundings, writes Nestor—an alarming idea for city dwellers breathing in polluted air. His advice for those living in a polluted cities is to breathe very slowly and deeply, through the nose.
For those wondering how to breathe with a mask on, Nestor again recommends nasal breathing with the mouth shut. Yoga has some answers too. “Breathing practices become even more pertinent when you wear a mask,” says Uttarakhand-based yoga teacher Vishnu Joshi. He has been conducting online yoga sessions for students around the world during the pandemic. He teaches practices like bhastrika, which involves forceful exhalation, and alternate nostril breathing, with a focus on breathing out. “One needs to exhale completely to expel all the stale air. When you are breathing with a mask on, you are taking in stale air too,” he explains.
Improving exhalation is key for those with asthma. It is impossible to take in a large generous breath until the lungs have been emptied. “In asthma, the exhalation is short, which does not give room for fresh air to come in. The cycle worsens when the attack happens. Until you breathe out fully, how will you pump in fresh air? That’s why all asthma exercises are primarily about breathing out and how to strengthen your lung capacity to do so efficiently,” explains Vijay Nallawala, author and founder of the mental health support group Bipolar India. He was diagnosed with asthma at the age of 14 and bipolar disorder at the age of 40. Now, at 59, he says he feels fitter than ever.
Nallawala’s asthma was severe. He had to be rushed to the ICU twice as a young man and was on 24 inhaler doses a day in his 20s. But his life transformed when he met the late Mumbai-based pulmonologist Pramod Niphadkar, who told him, “My medicines will not heal you, your discipline will.” Apart from medical treatment, Dr Niphadkar encouraged him to do cardio exercises like brisk walking for 45 minutes daily and pranayama. Nallawala changed his diet, staying away from sour and cold foods.
“But now I am stronger and once in a while, I sneak in an ice cream.”
He says that the discipline to manage asthma—he has never missed his daily pranayama since the age of 29—offered him a model to deal with bipolar disorder. His condition makes him vulnerable to stress triggers. When he starts feeling upset, an emotion that manifests in his body as a pounding heart and his mind as racing thoughts, he consciously slows down his breathing. “When I can sense that an experience like this can lead to an episode, I completely cut myself off from it. It is done by slow breathing, which slows down my thoughts too.”
Medicines are essential to manage symptoms for many but following a routine with exercise and diet is a more rounded approach to better health. “Our lungs are elastic, like balloons. But asthma makes them stiff. To keep them elastic and functioning at their optimum, you need to do breath work and cardio. One can rewire the body. This applies to everyone,” he says.
In July, Nallawala had covid-19 with traces of pneumonia infection. He recovered in home isolation. “My pulmonologist said my fitness ensured healing. My oximeter readings are the best in my family,” he says. His joy in his healing through breathing right is infectious.
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