What is a Breathing Pattern Disorder?

Why abnormal breathing patterns can affect movement, stamina and performance, and what you can do to improve dysfunctional breathing.

Did you know that the way you breathe every day can affect the way you feel? Poor breathing mechanics can affect movement, make exercise feel harder and contribute to fatigue, tension and poor sleep.

Even if your breathing feels okay, your sporting performance can plateau when breathing is sub-optimal. And too often, the advice to "take a deep breath," given by everyone from sports coaches to yoga teachers, can actually make dysfunctional breathing worse, including when there is an obvious issue like exercise-induced asthma.

What Is a Breathing Pattern Disorder?

"A breathing pattern disorder, or dysfunctional breathing, is a condition in which breathing is problematic and produces symptoms such as breathlessness.

It manifests as a psychologically- or physiologically-based habit, such as breathing too deeply, breathing too fast (both symptoms of hyperventilation), upper chest breathing during rest, or breathing irregularly with frequent breath-holding or sighing.

Breathing pattern disorders affect 9.5% of the studied adult population, rising to 29% among people with asthma and 75% of those with anxiety.

These figures are not surprising, given that asthma, anxiety, panic attacks, and stress, all negatively influence breathing patterns, feeding back to create a vicious cycle of inefficient breathing." (Patrick McKeown, The Breathing Cure)

These estimates come from questionnaire-based studies, and figures vary depending on how dysfunctional breathing is defined and measured. What is clear is that many people develop dysfunctional breathing patterns, and they rarely have a single cause. Habit, stress and anxiety, posture, physical constraints such as a blocked nose, illness and nervous system state can all play a part.

Signs you may have a breathing pattern disorder:

• You experience symptoms that have no obvious medical cause
• You gas out or get tired too soon during exercise
• You breathe fast and hard into your upper chest
• You often feel like you can never quite get enough air, sigh or yawn frequently, or regularly experience cold hands and feet, or feelings of panic and anxiety
• You snore or mouth breathe at night, and regularly wake in the morning feeling exhausted
• You have frequent or chronic back or neck pain, or repetitive strain injury

Many of these signs can accompany chronic hyperventilation: habitually breathing more air than your body needs, which lowers carbon dioxide in the blood. Over-breathing is often fast, upper-chest breathing, and it frequently goes hand in hand with mouth breathing. But breathing route alone does not determine whether someone is over-breathing. You can over-breathe through your nose, and you can breathe through your mouth without over-breathing.

These symptoms can also have other causes, so if they are new, severe or unexplained, see your doctor first.

If you often feel unwell, this may already be making sense. And if breathing feels like hard work, it is understandable that exercise may not feel enjoyable.

But if you are fit and healthy, surely your breathing is functional, right?

Can Athletes Have Breathing Pattern Disorders?

Yes. It is common for athletes to have dysfunctional breathing. Fitness and breathing function are not the same thing, and we regularly work with athletes whose breathing is sub-optimal when they begin breath training.

In a study of 1,933 competitive athletes in Japan, around 91% were classed as having a dysfunctional, upper-chest dominant breathing pattern on screening [1].

Asthma and exercise-induced bronchoconstriction are common in some groups of athletes, particularly in endurance sports. Elite athletes frequently experience high levels of stress. Pro rugby players, boxers and weightlifters may be more likely to have sleep apnea.

Training and travel schedules can lead to sleep deprivation, just when quality sleep is most needed. And most of us have never been taught how breathing affects physical and mental states.

What Is the Correct Breathing Pattern?

Dysfunctional breathing often involves fast, shallow, upper chest breathing. Mouth breathing is often part of the picture. Just like any movement pattern, these types of breathing become habits.

To address them, we need to replace these habits with new, healthy ones. And the first stage is always awareness.

Functional breathing is breathing that is appropriate to the situation. At rest and during sleep, healthy breathing is quiet, nasal, slow and low. During exercise, it is large enough to meet the body's demands. Under stress, it is adaptable rather than unnecessarily amplified. You can build healthy everyday breathing patterns by practising light, slow, and deep (LSD) breathing.

Healthy breathing is through the nose

When it comes to breathing, the nose is an extraordinary organ. It filters, warms and humidifies air as you inhale, and helps retain moisture as you exhale. It traps particles and allergens before they reach your lungs, and the nasal airways produce nitric oxide, which has antimicrobial properties.

The mouth serves as a back-up route for air when the nose is blocked, or when exercise is so intensive that a larger volume of air is needed.

As a rule, nose breathing is much better for you at rest and during everyday activity. If you experience exercise-induced asthma, mouth breathing may be part of the problem. Open mouth breathing sends colder, drier air straight into the lungs, which can irritate the airways. In people with asthma, breathing through the nose during exercise markedly reduced exercise-induced bronchoconstriction compared with mouth breathing [2].

Nose breathing adds resistance to breathing. It slows the breath, which can help calm the nervous system, and it encourages the diaphragm to engage.

Mouth breathing during sleep is associated with more snoring and more severe obstructive sleep apnea. Sleep apnea involves both the structure of the airway and other factors, such as how stable breathing control is during sleep, so anyone with suspected sleep apnea should be assessed by a doctor.

Sleep-disordered breathing impacts sports performance

Poor sleep has been linked to reduced speed, endurance, strength, reaction time, attention, learning, mood and skill accuracy. If your sleep is less than optimal, you are unlikely to be on top form.

Switching to nose breathing day and night may help reduce snoring and support more settled sleep. Sleep-disordered breathing is serious. Left untreated, sleep apnea can be deadly.

Changing the habit of mouth breathing

• Begin to pay attention to your breathing. Notice when you breathe through an open mouth. Train yourself to walk and exercise at easy intensities using only nasal breathing.
• Recreational athletes can maintain nose breathing for most low to moderate intensity exercise. If air hunger becomes too strong during your workout, slow down until your breathing is under control.
• Competitive athletes can maintain nose breathing during low-to-moderate intensity training. At high intensities, mouth breathing is normal and necessary.
• Use MyoTape to support nose breathing at night and MyoTape Sport to help train nose breathing during exercise. If you notice your mouth is open when you concentrate, at work, driving or watching TV, spend time wearing lip tape during the day.
• Mouth taping is only suitable if you can breathe comfortably through your nose, and it is not a treatment for sleep apnea. Combined with breathing exercises, it can help build the habit of nasal breathing.

Healthy breathing is light breathing

When you exercise, your working muscles use more oxygen and produce more carbon dioxide. CO2 and acidity help red blood cells release oxygen to your tissues (the Bohr effect). CO2 chemoreception is also a powerful feedback regulator of breathing, although breathing is driven by several interacting inputs, not CO2 alone.

When breathing is fast and hard at rest, you can blow off too much CO2. Low CO2 (hypocapnia) narrows blood vessels in the brain and makes haemoglobin hold on to oxygen more tightly, which can leave you lightheaded, tingly or anxious, even when your blood is fully saturated with oxygen.

Light breathing trains you to reduce unnecessary ventilation when demand is low. Softening your breathing creates a mild air hunger, a feeling of wanting to breathe a little more. Air hunger arises when the brain's drive to breathe is slightly higher than the breathing you are allowing [3].

The Breathe Light exercise gives you practice at staying relaxed with this sensation. When you understand that mild air hunger during the exercise is safe and not a sign of danger, it becomes easier to work with the discomfort. Over time, many people find their breathing becomes quieter and calmer, and breathlessness during everyday activity decreases. This change may reflect altered perception, breathing behaviour, or possibly changes in chemical sensitivity. The exact mechanism is still being researched.

Healthy breathing is slow breathing

During heavy, sustained exercise, the breathing muscles can fatigue. Fatiguing respiratory muscles can trigger a reflex that reduces blood flow to the legs, adding to leg fatigue and the sense of effort [4]. This is one reason inefficient breathing and weak breathing muscles can limit your capacity for hard exercise.

Slow breathing can improve breathing efficiency. For the same amount of air per minute, slower breaths mean less air is spent filling the airways (dead space) and more reaches the alveoli, where oxygen and carbon dioxide are exchanged. In people with chronic heart failure, slow breathing improved blood oxygen saturation and exercise performance [5]. Remember that slowing down is not the same as breathing less air. If each breath gets bigger, total breathing can go up. Slow isn't the goal. Light is.

Slow breathing also helps activate the parasympathetic nervous system, your body's rest-and-digest response, balancing stress and building resilience.

The Breathe Slow exercise trains you to breathe at around 4.5 to 6.5 breaths per minute. The best rate varies from person to person. Many people find this reduces breathlessness and stress and helps them sleep better.

Nasal breathing also carries nitric oxide from the nasal cavity into the lungs. Nitric oxide helps defend the airways and may help open blood vessels in the lungs, supporting oxygen uptake to the blood [6].

Learn more about the 30 functions of the nose and why nasal breathing matters far beyond just filtering air.

Healthy breathing is deep breathing

Breathing patterns play an important role in the mechanical stability and mobility of the spine and trunk. When you breathe from your diaphragm, every breath creates pressure within the abdomen.

This intra-abdominal pressure (IAP) supports your spine and pelvis. The diaphragm is integral to core strength, not just the abs. Deep breathing does not mean big breaths. You don't have to breathe big to breathe deep.

This is one reason athletes with abnormal breathing patterns may experience musculoskeletal problems and altered motor control. The ideal resting breathing pattern is driven by the diaphragm with expansion of the lower ribs [7].

According to an article in the International Journal of Sports Physical Therapy, dysfunctional breathing, such as chronic hyperventilation, has been associated with musculoskeletal pain [8].

Upper chest breathing also relies on smaller accessory muscles. These muscles are not designed to be active all the time. Just as muscular imbalance around a joint can contribute to strain, this overuse may contribute to trigger points, back and neck pain and tension.

The bottom line: breathing and movement are closely linked, so breathing is worth assessing whenever movement is a problem.

How to Check Your Breathing Pattern: What the Science Says

Healthy everyday breathing is light, slow and deep (LSD) and through the nose. Breathing pattern disorders involve three dimensions: biochemical, biomechanical and psychophysiological.

1. Biochemical: how well breathing matches the body's needs. During chronic hyperventilation, blood carbon dioxide can become too low, which can reduce blood flow to the brain and make it harder for haemoglobin to release oxygen to the tissues.
2. Biomechanical: the proper functioning of your breathing muscles, especially your diaphragm, rib cage and airway.
3. Psychophysiological: the two-way connection between emotions, attention and the breath. For example, anxiety can make breathing fast and shallow, and fast, shallow breathing can feed anxiety.

Until recently, there was no single screen to identify dysfunctional breathing patterns that acknowledged all three dimensions.

In 2017, Dr. Kyle Kiesel, Professor and Program Director of Physical Therapy at the University of Evansville, developed a breathing screening tool for coaches, instructors and healthcare professionals. Here is a quick summary:

• Kiesel tested 51 subjects.
• For biochemical results, he measured end-tidal carbon dioxide (ETCO2), the percentage of CO2 in exhaled air, which gives a good indication of blood CO2.
• For biomechanical results, he used the Hi-Low test, a simple measure of abdominal movement during breathing.
• He tested psychological components using the self-evaluation of breathing (SEBQ) and Nijmegen (NQ) questionnaires.

Kiesel found that breath-hold time on its own missed many people with dysfunctional breathing. Combining a breath-hold time of 25 seconds with answers to four simple questions gave a much more useful screen [9]. A BOLT score is a practical version of this breath-hold test.

Breathing Pattern Disorder Signs and Symptoms

The four questions in the dysfunctional breathing screen are:

1. Do you feel tense?
2. Do you feel a cold sensation in your hands or feet?
3. Do you notice yourself yawning?
4. Do you notice yourself breathing through your mouth at night?

If you answer "no" to these questions, and your breath-hold time after exhalation is greater than 25 seconds, there is an 89% chance that dysfunctional breathing is not present [9].

Symptoms of an ineffective breathing pattern

A low BOLT score can be a sign that your breathing needs attention, but it is not a diagnosis. BOLT measures how quickly you feel the first clear urge to breathe during a comfortable breath hold, and it is influenced by several factors, including chemical sensitivity, starting blood gases, breathing pattern, respiratory sensation, lung volume and psychological state. Not everyone with a low BOLT has dysfunctional breathing, and not everyone with dysfunctional breathing has a low BOLT. BOLT also does not predict athletic performance [10].

Dysfunctional breathing patterns, including hyperventilation syndrome and fast breathing, can produce respiratory alkalosis, a condition in which over-breathing lowers CO2 and makes the blood more alkaline. This can affect physiological, psychological and neural states, with knock-on effects for health, performance and the musculoskeletal system.

Symptoms associated with over-breathing can include headache, dizziness, chest discomfort, trouble sleeping, breathlessness, light sensitivity, exhaustion, muscle pain and cramps. Athletes with abnormal breathing can experience muscle fatigue and excessive breathlessness during physical exercise [8]. Because symptoms like chest pain and breathlessness can also have medical causes, get these checked by a doctor first.

How common is dysfunctional breathing?

In one small study of 34 healthy men and women, over 70% had irregular breathing patterns [11]. Dysfunctional breathing has also been linked with conditions such as chronic fatigue, back pain, and jaw and neck pain.

You can read more about the connection between abnormal breathing patterns and health in Patrick's 2021 book, The Breathing Cure.

In the same study, those with an irregular breathing pattern scored worse on the Functional Movement Screen (FMS), a tool used to screen movement quality in athletes. Notably, 87.5% of participants who passed the FMS exhibited abdominal or diaphragmatic breathing [11]. This shows a link between breathing and movement quality, although it does not prove that one causes the other.

Is a breathing pattern disorder curable?

Breathing pattern disorder treatment involves re-education of breathing habits. Most people can improve irregular breathing patterns by consistently practising a handful of simple breathing exercises. Because breathing pattern disorders are multidimensional, the best approach addresses breathing mechanics, breathing chemistry, and attention and emotional state together [12].

Because breathing is such an important motor function and is so connected with your nervous system, retraining breathing may also help restore healthier motor control patterns [8]. Progress takes consistent practice, and results vary between individuals.

5 Steps to Restore Functional Breathing

1. Start by restoring functional everyday breathing and correcting dysfunctional patterns before moving to more advanced exercises. Steer clear of any breathing exercise that involves deliberate hyperventilation until you have normalised your everyday breathing pattern and achieved a BOLT score of 25 seconds or more.
2. Measure your BOLT score to see where you are today. BOLT measures how quickly you feel the first clear urge to breathe during a comfortable breath hold. Use it as a personal baseline to track your own progress, alongside how your breathing feels day to day. If your score is less than 25 seconds, there is likely room for improvement.
3. Practise breathing light, slow and deep (LSD) to retrain your everyday breathing pattern.
4. Breathe through your nose at rest and during low to moderate intensity exercise. Use nasal dilators if airflow feels restricted.
5. Reduce your breathing volume before bed and use MyoTape to support nasal breathing during sleep. This can help you sleep more soundly for better recovery and mental focus.

Fix Your Breathing Pattern with Oxygen Advantage

The Oxygen Advantage method was built on the understanding that dysfunctional breathing can contribute to many chronic health complaints, poor performance and unnecessary fatigue.

By retraining breathing through nasal breathing, light breathing, slow and diaphragmatic breathing, and breath hold exercises, the method addresses all three dimensions of breathing pattern disorder: biochemical, biomechanical and psychophysiological.

If you are interested in trying the OA method for yourself, why not try our online breathing course, become a certified breathwork instructor, or find an Oxygen Advantage instructor near you.

References

1. Shimozawa Y, Kurihara T, Kusagawa Y, et al. Point prevalence of the biomechanical dimension of dysfunctional breathing patterns among competitive athletes. J Strength Cond Res. 2023;37(2):270-276.
2. Shturman-Ellstein R, Zeballos RJ, Buckley JM, Souhrada JF. The beneficial effect of nasal breathing on exercise-induced bronchoconstriction. Am Rev Respir Dis. 1978;118(1):65-73.
3. Banzett RB, Lansing RW, Binks AP. Air hunger: a primal sensation and a primary element of dyspnea. Comprehensive Physiology. 2021;11:1449-1483.
4. Romer LM, Polkey MI. Exercise-induced respiratory muscle fatigue: implications for performance. J Appl Physiol. 2008;104(3):879-888.
5. Bernardi L et al. Effect of breathing rate on oxygen saturation and exercise performance in chronic heart failure. Lancet. 1998;351:1308-1311.
6. Lundberg JO, Weitzberg E. Nasal nitric oxide in man. Thorax. 1999;54(10):947-952.
7. Hansen-Honeycutt J et al. A clinical guide to the assessment and treatment of breathing pattern disorders in the physically active: part 2, a case series. International Journal of Sports Physical Therapy. 2016;11(6):971.
8. Chapman E et al. A clinical guide to the assessment and treatment of breathing pattern disorders in the physically active: part 1. International Journal of Sports Physical Therapy. 2016;11(5):803.
9. Kiesel K et al. Development of a screening protocol to identify individuals with dysfunctional breathing. International Journal of Sports Physical Therapy. 2017;12(5):774.
10. Kowalski T, Rębiś K, Wilk A, et al. Body Oxygen Level Test (BOLT) is not associated with exercise performance in highly-trained individuals. Frontiers in Physiology. 2024;15:1430837.
11. Bradley H, Esformes J. Breathing pattern disorders and functional movement. International Journal of Sports Physical Therapy. 2014;9(1).
12. Courtney R. Breathing training for dysfunctional breathing in asthma: taking a multidimensional approach. ERJ Open Research. 2017;3:00065-2017.