Background

I was exposed to the concept of nasal breathing from a very early age, but didn’t quite realize its significance.  Breathing is often overlooked as one of the most powerful levers we can pull to impact multiple areas of our health.  It can have profound impact on reducing stress, improving sleep, and enhancing endurance and overall athletic performance.

In my clinical practice, I have seen optimal breathing practices like nasal breathing lower blood pressure, blood glucose and inflammation markers like hsCRP, in addition to improving energy, endurance, and lowering stress.  Those of us who believe in the power of nutrition, would ascribe to the notion of how food is medicine.  In this post I will describe how your breath, when properly regulated, can also be medicine.  I’ll start off with some background history and then dig deeper into the science and biochemical benefits of breathing, specifically nasal breathing.

History of Nasal Breathing

Many ancient religions such as Buddhism and Hinduism emphasize the importance of breathing and how it is tied to overall health.  Most prominently, the ancient Indian breath practice of pranayama, one of the limbs of Ashtanga yoga, is solely focused on various breathing techniques to help purify both mind and body.

Asian woman yoga exercises breathing in the park

Interestingly the word pranayama actually means “trance induced by stopping all breathing.”  Ancient yogis and Buddhist monks describe a state of serenity and stillness where there is literally no sensation of breath.  Rather than focus on the multitude of breathing techniques, I’d like to focus on nasal breathing, which can effortlessly be applied in almost every aspect of your life.

Science and Benefits of Nasal Breathing

Now for my readers who are left brain scientists and skeptics, let’s transition from the art of ancient breathing to the scientific aspects which help support its benefit.   Ukrainian doctor Konstantin Pavlovich Buteyko made the observation that a significant percent of human beings are subclinically hyperventilating or “overbreathing.”

This is not the panic-induced hyperventilation where you breathe into a paper bag.  Overbreathing is so subtle that most of us are unaware we’re doing it.  Before I list off some signs of overbreathing, you need to understand why this is potentially harmful.

Aerobic respiration involves us breathing in oxygen and breathing out CO2 (carbon dioxide).  Now although we commonly refer to CO2 as “waste,” we need to hold onto a certain amount of CO2 in the blood to ensure our acid-base balance, represented by a number called the “pH” is in check.

Another important role of retaining enough CO2 is a phenomenon called the Bohr effect.  I’m going to keep this really simple.  You have a protein in your red blood cells (large red frisbee below) called hemoglobin (smaller red balls below), which delivers oxygen (even smaller blue balls below).  The conditions in your blood need to be optimal so the hemoglobin releases or unloads oxygen at its destination tissues (muscle, heart, brain, etc.).  If the oxygen stays stuck to the hemoglobin, you can’t release oxygen to your cells, which means they cannot produce energy or function properly.

Blood cell diagram

The Bohr effect states that the amount of CO2 in your blood is a significant factor that determines whether oxygen gets released.  When CO2 levels are higher in your blood (aka higher acid levels), hemoglobin more readily releases oxygen.  When CO2 levels are lower, like from overbreathing, oxygen doesn’t get released readily.

Just think of the “C” and “O” in CO2 as Cutting O2 loose so it’s delivered to your cells.

As a result, overbreathers who have less overall CO2 in their blood often feel fatigued at rest and during exercise.  I listed a few signs of overbreathing below and I realize some of these are quite non-specific:

  • Excessive yawning or sighing
  • Breathing with your mouth open
  • Audible breathing (you or someone nearby can hear you breathe)
  • Upper chest movement with breathing
  • Fatigue, irritability
  • Stress, anxiety
  • Headaches

One of the simplest ways to curtail overbreathing is to consciously breathe through your nose as often as you can with your mouth closed.  To get you habituated you can even use medical tape and tape your mouth shut, at least while you’re at home.  Breathing through your nose allows air to encounter greater resistance as it flows through your narrow nasal passages and your sinuses, compared to breathing through an open mouth.

This more circuitous nasal route automatically slows down your breathing and allows you to retain a little more CO2, which in turn enhances oxygen release from hemoglobin (recall the Bohr effect).  There are other benefits as well.  Breathing through the nose allows enhanced filtration and removal of allergens and other particles, preventing them from getting delivered to the lungs.

Your nasal passages are literally a built in air purifier which doesn’t get used if you are breathing mostly through your mouth.

Nasal breathing benefits don’t just occur during waking hours.  Mouth taping at night, where you literally use medical tape and tape your mouth shut, is a practice growing in popularity since it ensures the benefits of nasal breathing while you sleep.  In fact many of my patients that have tried this report calmer, deeper, more restorative sleep at night since overall oxygen delivery to the brain and other tissues improves.  When breathing and oxygenation are even subtly compromised while you sleep, it increases your body’s stress response, resulting in poorer quality sleep.

One great resource for understanding the impact of breathing on sleep is a wonderful book written by my good friend and exceptional dentist, Dr.Mark Burhenne, called the 8 hour Sleep Paradox.  He’s the first one that introduced me to the concept of mouth taping at night and he writes an excellent post on this topic here at his website, Ask The Dentist.

Nasal Breathing and Exercise

I have now been nasal breathing during exercise for some time and it has definitely helped with aerobic performance and has allowed me to run and play basketball with less effort.  I find my mind and body are more calm and focused when I’m not huffing and puffing through my mouth.  Nasal breathing also helps ensure we are mostly exercising in the optimal aerobic zone, whereas predominant mouth breathing means we have entered anaerobic intensity.  Read my post on aerobic exercise here where I dig deeper into this concept.

Creating the habit of breathing less during exercise creates a lower oxygen environment which partially mimics exercising at high altitudes, a common training practice for elite athletes.  Over time your body physiologically adapts to this mild hypoxia (low oxygen) with adaptive changes such as improved mitochondrial function and increased red blood cell production.  There are athletes who also incorporate short periods of breath holding during training to enhance the hypoxic effects, especially during those last 50 meters of a race when you need an all-out effort without significantly compromising form.

Let me emphasize that there are no well established scientific studies showing that nasal breathing during training or intermittent periods of breath holding actually improve athletic performance.

In my personal experience and that shared by some of my patients, we find that nasal breathing predominantly during exercise has improved aerobic performance and made exercise more enjoyable and energizing, removing some of the unnecessary excess stress associated with prolonged anaerobic efforts.

If you watch some of the world’s greatest athletes, they truly make their performances look effortless, while others around them are huffing and puffing with their shoulders up to their ears.  Elite athletes are increasingly adopting pranayama breathing techniques and modified breathing practices, which have been rebranded in various ways such as holotropic breath work.  One of my favorite pranayama breathing techniques is called bhastrika, and this article in Breaking Muscle summarizes the beneficial impact of this practice on lung capacity.

The Simple Practice of Nasal Breathing

There is nothing complicated about nasal breathing.  The first stage is just getting used to breathing through your nose with your mouth closed.  The next stage is breathing so delicately through the nose that you cannot hear a single sound.

By deliberately focusing on silencing you’re breathing, you are naturally slowing down your breathing rate to a rhythm that will activate your parasympathetic (relaxation) system and lower your heart rate, blood pressure, and cortisol levels, promoting calmness and clarity.

If you have nasal congestion or sinus issues, I realize this may be a challenge.  I would work on getting those issues taken care of by a physician or start off by using a nasal rinsing technique like Netipot.  This is the contraption I use for nasal rinses.  Less than $10 and works like a charm.

Nasal Humming

A variation of nasal breathing is nasal humming where you breathe in through your nose and then breathe out through your nose, with mouth closed, while making a humming sound.  The origin of this technique comes from a pranayama breathing technique called bhramari, named after the Goddess of Bees, which is fitting given the bee-like humming sound you produce with this technique.  Credit to the dietitian from my team, Prerna Uppal, who introduced me to nasal humming many years ago.

Interestingly, this study showed a 15-fold increase in intranasal nitric oxide levels when performing nasal humming compared to quiet exhalation.

Nitric oxide is the most potent vasodilator (blood vessel relaxer) in the body.  This case study reports a case of an individual whose sinusitis was terminated with nasal humming.

I have also had patients report blood pressure improvements with regular nasal humming, in addition to just regular nasal breathing throughout the day.  Could some of this increased nasal nitric oxide be entering the blood to help lower blood pressure?  I think the more likely scenario is that any form of slower, calmer breathing will activate our parasympathetic system, which is the resting arm of our nervous system, leading to lower heart rate, blood pressure, improved digestion, and other beneficial physiological responses.

If you want to literally amplify the effects of this technique, close your eyes with your fingers and plug your ears with your thumbs while doing this and you will hear the calming hum amplified in high fidelity surround sound.

Brahmari Breathing Technique
Brahmari Breathing Technique

I’ve even done this with earplugs and an eye mask so I don’t have to hold my hands up in an awkward position.  If you’re shy about nasal humming in public, do it in your car during your commute, in the shower where the acoustics are great, or just shut yourself off in your closet and nasal hum for a few minutes before you come back out into the real world to deal with that toddler, teenager, etc.

Nasal humming also works great in environments where there’s plenty of ambient noise like on an airplane or even during a freeway car ride where the engine and wind noise are usually sufficient to mute your hum, even with others around you.  I also like nasal humming during monotonous tasks like going through my work e-mails or folding laundry.

Nasal humming can also be thought of as a truncated version of the more popularly known “Aum” (aka “Om”) meditation sound, except without the “Au” which would require you to open your mouth.  This study used fMRI (functional MRI) imaging of the brain to show that making the “Om” sound actually deactivated the emotional areas of the brain which we collectively refer to as the limbic system.

You might think that’s due to just slowing your breathing down, but making the “ssss” sound in this study produced no similar effect in the brain.  There is something truly magical and scientifically beneficial about the “Om” sound which is likely mirrored by nasal humming without the “O” or “Au.”  I often do a combination of both.

If you find the monotonic nasal hum a bit too bland, you can pick the first 2-3 notes of a song you enjoy and nasal hum those and then carry the last note nice and slow for as long as you can sustain comfortably.

We always picture happy, cheerful people as being hummers, but perhaps their humming also helps keep them happy through the beneficial physiological responses we discussed.

Next time you are feel down or stressed, give nasal humming or nasal breathing a try and see if it takes the edge off whatever emotional challenges you’re experiencing.

Summary

Manipulating the way you breathe can have dramatic impacts on your overall health.  I am by nature a skeptic and recall years ago watching family members and others performing what I considered silly breathing techniques.  Plugging one nose and breathing through the other (anulom vilom technique), forcefully breathing through your nose while pumping your stomach vigorously (bhastrika technique), etc.  Now I’ve seen the beneficial effects of these practices in my own life and in those of my patients.  By the way, even Hilary Clinton uses alternate nostril breathing and in her book claims it helped her get over her loss to Donald Trump!

If you are still not feeling ready to plunge into more complex breathing practices, just start with nasal breathing (or humming), the focus of this blog post, throughout the day.  If you can’t remember to do it, try taping your mouth shut while you’re at home.  Once that becomes natural, try nasal breathing with exercise and gradually ramp up your intensity as tolerated.  Finally consider adding nasal breathing to your sleep by trying mouth taping at night.

The sad news is in my clinic where I see lots of South Asians, many of my patients grew up doing a variety of breathing practices when they were young, or watched their own family members do them daily, but in their modern hectic lives, they have completely ditched these habits.  Maybe they just seem like silly practices that can’t be squeezed into an overscheduled Western lifestyle.

However, I’ve come to appreciate how things that appear “silly” now, often become respectable science later.

It wasn’t too long ago that practices like meditation, yoga and fasting drew skepticism from the scientific world.  Now there are endless studies on PubMed covering these topics, with highly educated scientists who are now traveling the world as authorities on the health benefits of some of these techniques.

Remember that whenever you try something that might feel a little awkward now, you may be way ahead of your time and the scientists will eventually catch up decades later.  Give nasal breathing and humming a try and tell me what you think.  Are there other breathing practices that have made a difference in your life?

References

If you are interested in the topic of nasal breathing and improving overall breathing, I highly recommend you read The Oxygen Advantage by Patrick G McKeown

Mark Burhenne’s book, The 8 Hour Sleep Paradox, is a refreshing and very different approach to improving sleep, with lots of tips on how to optimize breathing during sleep.