Breathwork Essentials

What I tell my patients

Dysfunctional breathing mechanics are at the root of many health issues.

Yet most people know nothing about breathing mechanics. Most practitioners and coaches do not know how to screen for, let alone treat, dysfunctional breathing mechanics.

I took Patrick McKeown's Oxygen Advantage instructor course years ago. It radically changed my practice. I also started to see the power of breathwork first-hand in my patients.

Could you have hyperventilation syndrome?

Despite the fact that you may never have heard of it, this is a common problem we face in clinical practice. Most clinicians have never heard of it, let alone treated it. Some will even deny that it exists. I assure you that it does.

Key symptoms include:

• Shortness of breath or feeling unable to get enough air

• Lightheadedness, dizziness, or feeling faint

• Chest pain, tightness, or discomfort

• Rapid, deep, or fast breathing (tachypnea or hyperpnea)

• Palpitations or a pounding, racing heartbeat

• Numbness or tingling (paresthesia) in the hands, feet, or around the mouth

• Muscle spasms or cramps, especially in the hands and feet (tetany)

• Weakness or confusion

• Sleep disturbances

• Belching, bloating, or dry mouth

• Anxiety, fear, panic, or a sense of impending doom

• Difficulty focusing or thinking clearly

• Frequent sighing or yawning

Whenever we see these symptoms, we focus on breathing mechanics first and foremost.

What Do Healthy Breathing Mechanics Look Like?

First of all, how are we supposed to breathe? What do functional, healthy breathing mechanics look like?

First, you should breathe with your diaphragm. This means that your chest wall should move in and out with each breath. It should expand both front and back and on each side. Put your hands on your rib cage. As you breathe in, try to move your hands "out," away from your core. This is circumferential expansion and it is essential for optimal breathing mechanics.

Second, you should breathe no more than 14 times per minute (on average, based on a fitness tracker). We have long documented in medicine that the patients with the fastest respiratory rate (taking the most breaths per minute) have the shortest life expectancy.

Third, you should breathe through your nose, not your mouth. Short of severe nasal deformities, you should be able to breathe through your nose. If you can't breathe through your nose, try holding your nose and your breath at the same time, and nodding your head back and forth. This usually triggers your body to clear your nasal passages. If holding your breath is too hard, start with short intervals, but keep going. Most people can relieve nasal congestion with enough of this exercise.

Chronic nasal congestion is often partly due to mouth-breathing. Just by increasing the amount of time spent breathing through the nose, many people see their chronic sinus congestion improve or even entirely resolve.

The Surprising Truth About Why You Breathe

What drives breathing? Most people are surprised to discover that it is carbon dioxide, rather than oxygen.

You breathe when carbon dioxide reaches a certain level in your blood. You can adjust this level by re-training your breathing mechanics.

This is life-changing for many people.

What Drives Dysfunctional Breathing Mechanics?

Stress, biomechanics (how you move your body), and nasal deformities and congestion drive respiratory mechanics.

Stress triggers the release of hormones and neurotransmitters that cause us to breathe more. Stress is a major contributor to dysfunctional breathing mechanics.

We sit now more than ever before. We move less and less. Even when we do move, it tends to be more repetition than variety. Eventually, people lose mobility in their chest and start taking shallower breaths. To make up for the smaller breaths, people then take more breaths. This is a disaster for breathing mechanics.

Last, nasal deformities and congestion lead to mouth breathing. Your sinuses produce a vital chemical called nitric oxide that you need to inhale into your lungs and blood stream. Nitric oxide lowers blood pressure, modulates the immune system, and improves blood flow. Nitric oxide is the neurotransmitter that is responsible for sexual stimulation, specifically erections and clitoral engorgement. There is a strong association between mouth-breathing, obesity, heart disease, and erectile dysfunction. Nitric oxide is the thread that connects them, and its story starts in your nose.

The Three Pillars of Functional Breathing

Functional (healthy) breathing mechanics come down to:

1. Breathing through your nose

2. Not breathing too many times per minute

3. Using your diaphragm to breathe

How We Assess Breathing Dysfunction

We use a questionnaire in my practice to evaluate patients for hyperventilation syndrome. It is called the Nijmegen questionnaire.

Nijmegen Questionnaire Study

If you score over a 9 on the Nijmegen questionnaire, you have dysfunctional breathing mechanics until proven otherwise. We will follow up with you on your breathing mechanics until we have hit certain targets.

For optimal breathing mechanics, I look for:

• Respiratory rate under 14 breaths per minute, based on a fitness tracker

• Respiratory rate under 14 based on someone else counting your breaths-per-minute

• Control pause greater than at least 20 seconds, and ideally over 30

• Nasal breathing

• Diaphragmatic breathing and circumferential expansion

Important note: Do not try to measure your own respiratory rate. You will underestimate it, because watching your breathing changes how you breathe. Either have someone else measure it while you distract yourself with something like a crossword or Sudoku puzzle, or use a fitness tracker.

My Starting Breathwork Protocol

Here's the starting breathwork protocol I share with patients to start:

Starting Breathwork Protocol

Control Pause (5 Minutes, Twice Daily)

Overview

This protocol emphasizes the “Control Pause” (CP), a core concept from Buteyko breathing. The CP measures your body’s tolerance to carbon dioxide and helps retrain functional breathing patterns.

Instructions

• Sit upright, relaxed, and breathe through your nose.

• Keep your mouth closed throughout the practice.

Protocol (5 Minutes)

1. Settle and Prepare

   • Breathe gently through your nose for 1 minute, focusing on soft, light breaths.

   • Breathe in for four seconds and out for four seconds.

2. Control Pause Measurement

   • After a normal exhalation, pinch your nose and hold your breath.

   • Time (in seconds) how long it takes until you feel the first definite desire to breathe (note, this is not as long as possible).

   • Release your nose and resume gentle nasal breathing.

   • Take a few recovery breaths.

3. Repeat

   • Perform 5-10 rounds of the Control Pause within the 5-minute session.

   • Between each round, continue gentle nasal breathing.

Key Points

• Do not force the breath hold; stop at the first urge to breathe.

• Aim for light, silent nasal breathing before and after each CP.

• Over time, your CP may increase, indicating improved breathing efficiency.

Frequency

• Practice for 5 minutes, twice daily (morning and evening).

Again, our goal is to increase control pause to 20-30 at least. If we have respiratory rate data from some kind of fitness tracker, we will aim for a respiratory rate of under 14 breaths per minute.

Why This Matters More Than You Think

I will be blunt when it comes to the importance of breathing mechanics.

I have learned the hard way that no amount of supplements, drugs, hormones, biohacks, or fancy wellness protocols will make up for dysfunctional breathing mechanics. It is like trying to win a triathlon with a boat anchor tied to both feet.

Usually, the starting breathwork protocol is enough for people. Sometimes we send them a more advanced protocol.

When You Need Additional Support

If nasal congestion due to allergies is contributing to dysfunctional breathing mechanics, we use homeopathics. I will write more on how we relieve nasal congestion in a future post. Stay tuned!

If poor posture or anatomical constraints are impairing chest-wall expansion, we will refer to my friend Jim Laird, who is a brilliant strength and conditioning coach. He often refers practitioners who have trained with the Postural Restoration Institute.

Until next time, be well,
Dr. Stillman