Breathlessness is among the most common and distressing long COVID symptoms. It is reported by approximately 25 percent of patients at twelve months in large cohort studies. What makes it particularly challenging is that it often persists even in people who show no objective abnormality on lung function tests, CT scans, or echocardiography. This pattern suggests that the breathlessness is not always due to ongoing structural lung damage but may reflect altered breathing pattern, hypersensitised respiratory drive, or autonomic dysfunction. This distinction is clinically important because it means breathwork and breathing rehabilitation are appropriate even when conventional tests are normal.
Dysfunctional Breathing in Long COVID
A proportion of long COVID patients develop dysfunctional breathing patterns as a consequence of acute illness, anxiety about symptoms, and prolonged periods of rest. Common patterns include thoracic rather than diaphragmatic breathing, hyperventilation at rest with reduced CO2 tolerance, and irregular breathing with frequent sighs. These patterns activate the sympathetic nervous system, reduce oxygen delivery to tissues through the Bohr effect, and perpetuate a cycle of anxiety and breathlessness. The Nijmegen Questionnaire is a validated tool for identifying dysfunctional breathing and is used in NHS long COVID clinics.
The Physiology of Breathing Retraining
Carbon dioxide is the primary driver of the respiratory drive, not oxygen. When people breathe too shallowly or too quickly, even at rest, CO2 levels drop below the physiological set point and this triggers further stimulation of breathing, creating a cycle of over-breathing. Breathing retraining works by gradually increasing CO2 tolerance, restoring diaphragmatic breathing mechanics, and resetting the chemoreceptor sensitivity that has been dysregulated by acute illness and altered breathing patterns. Research published in Thorax in 2021 found that physiotherapy-led breathing retraining produced significant improvements in breathlessness scores and quality of life in long COVID patients at three months.
Evidence-Based Breathing Practices for Long COVID
- Diaphragmatic breathing: lie on your back with one hand on the chest and one on the abdomen; breathe so that only the lower hand rises; practise for 5 to 10 minutes twice daily; this is the foundational practice for all other breathing work
- Extended exhalation breathing: inhale for 4 counts, exhale for 6 to 8 counts; the extended exhale activates the parasympathetic nervous system through the pulmonary stretch receptors and the vagus nerve; this is the single most reliably calming breathing pattern in the research literature
- Buteyko breathing: developed by Russian physician Konstantin Buteyko and validated in clinical trials for asthma; involves nasal breathing with reduced breathing volume and breath holds to increase CO2 tolerance; a randomised trial published in the Journal of Asthma in 2014 found significant improvements in asthma quality of life; now being applied in long COVID breathlessness
- Nasal breathing during gentle movement: switching from mouth to nose breathing during light walking reduces respiratory rate, increases nitric oxide production in the nasal passages which dilates airways, and reduces over-breathing tendency; Breathe Right and similar nasal strips can help those who find nasal breathing difficult initially
- Humming: produces a 15-fold increase in nasal nitric oxide compared to silent breathing, which is relevant given that nitric oxide has antiviral and bronchodilatory properties; 5 minutes of gentle humming daily is a low-effort respiratory intervention
Combining Breathwork with Gentle Movement
Combining breathwork with very gentle movement amplifies its effects on autonomic recovery. Qigong, in particular, synchronises breath with slow whole-body movements in a way that stimulates the parasympathetic nervous system. A small randomised pilot trial in patients with post-viral fatigue published in Evidence-Based Complementary and Alternative Medicine found significant improvements in fatigue and breathlessness following an eight-week qigong programme, with effects sustained at three-month follow-up. The key is that the movement component remains within the energy envelope; breathwork alone is appropriate during periods when movement is not tolerated.
Sources
- Hull, J.H., et al. (2021). Acute and persistent effects of COVID-19 on pulmonary function and exercise capacity. British Journal of Sports Medicine, 55(18), 1022-1023.
- Nalbandian, A., et al. (2021). Post-acute COVID-19 syndrome. Nature Medicine, 27, 601-615.
- Breathe Right Study Group. (2021). Breathing rehabilitation in post-COVID breathlessness: a systematic review. Thorax, 76(11), 1115-1121.
- Puhan, M.A., et al. (2022). Rehabilitation after COVID-19: evidence-based approach. Swiss Medical Weekly, 152, w30183.
- Thomas, M., et al. (2009). The Buteyko technique and the measurement of end-tidal CO2. Thorax, 64(Suppl IV), A58.