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Breathing Exercises For Chronic COVID-19: What They Are and How They Help

Marion Mackles, PT, LMT, with patient at the Pulmonary Wellness & Rehabilitation Center
Marion Mackles, PT, LMT, works with a patient building strength after COVID-19.

Key Takeaways

  • Patients recovering from chronic COVID-19 and long-term symptoms may benefit from breathing exercises.
  • These breathing exercises follow a tiered approach, building in intensity as patients master each phase.
  • Long-haulers must take recovery slowly in order to avoid setbacks.

When the pain begins, it doesn’t start from one specific source. Those who experience it say it's not something you can pinpoint or put your finger on. For so many COVID-19 long-haulers—a cohort of people who have recovered from COVID-19 only to experience countless residual symptoms—the pain is often systemic and all-encompassing. Call it a post-COVID-19 syndrome. Call it a long-hauler syndrome. Call it anything, they say. Just find a remedy for it. 

But how can you heal something that you can’t even name?

According to Marion Mackles, PT, LMT, it all begins with the breath.

Mackles is a cardiopulmonary physical therapist based in New York City and the director of the Airway Clearance Unit of the Pulmonary Wellness & Rehabilitation Center. She tells Verywell that breathing exercises are especially important for long-haulers because they can increase lung capacity, improve the function of the diaphragm, and restore respiratory muscle balance.

Since the start of the pandemic, the Pulmonary Wellness & Rehabilitation Center has dedicated its resources to launching the COVID Rehabilitation & Recovery Series to aid long-haulers in their recovery. At the helm of these virtual exercises and educational sessions is a series of breathing techniques tailored to the needs of long-haulers. Little by little, these exercises are alleviating many patients' symptoms when not much else can.

"The breathing exercises have helped me immensely—it truly has been an anchor in the tumultuous sea of post-COVID uncertainty," Dawn Christensen, 52, an expressive arts counselor based in Suffern, New York, tells Verywell. Christensen contracted COVID-19 in March and still experiences a myriad of lingering issues, including shortness of breath, congestion, difficulty swallowing, chest tightness, and more. "This whole situation has been so scary and daunting. The practice of coming together and breathing and being guided has been such a blessing and gift. It has been a source of peace and calm when I feel overwhelmed by being short of breath."

Dawn Christiansen, COVID-19 Patient

The breathing exercises have helped me immensely. It truly has been an anchor in the tumultuous sea of post-COVID uncertainty.

— Dawn Christiansen, COVID-19 Patient

Mackles emphasizes the cognitive component of these exercises, and how they can help a patient feel more grounded in a body that has betrayed them.

"My breathing exercises tend to be more meditative in nature—helping patients start to become more aware of their breath, their bodies, and their surroundings—and then their breath in their bodies in their surroundings," Mackles says. "For a lot of people, that's where I stop. It’s really like taking them way back to the very roots of the breath."

According to Mackles, for many long-haulers, there's an element of relearning how to feel comfortable both breathing and living with chronic symptoms.

“It’s important to reteach the body that it doesn’t have to be afraid of breathing," she says. "[We] focus on how our breath feels, how the air around us feels, and let our body know that it is okay. We are not the inability to breathe. We are not our symptoms or our condition. We are not our heads feeling light or heavy or our stomachs hurting, or our fatigue.” 

Mackles combines elements of Tai Chi and Qigong into her breathing exercises, which focus on synchronizing the breath with movements. Research has shown that the soft movements of Qigong help to disperse blood and oxygen throughout the body, promoting healing and replenishment. It also suggests Qigong may boost overall lung and immune system function. 

Breaking Down The Breathing Exercises

Mackles employs multiple different breathing practices and tries to tailor them to the audience enrolled in her classes—which can be up to 300 people on a Zoom call. The types of breathing her team's COVID Bootcamp focuses on include:

  • Diaphragmatic breathing: A breathing mechanism that aims to slow the breathing rate and decrease oxygen demand. Here, patients lay down and place one hand on their chest and the other on their stomach and modulate their breathing by feeling the expansion in their abdomen.
  • Pursed lip breathing: A breathing method that aims to control shortness of breath, improve ventilation, and expand the airways by having patients inhale through their nose and exhale through their pursed lips. Typically, this is done by counting to two seconds on the inhale, and four seconds on the exhale. 

Mackles recommends that long-haulers do these exercises every day, twice a day. She says you can start the breathing exercises as soon as you feel physically up for it, whether that’s after hospital discharge or once the worst symptoms of the virus have passed. She will repeat each session with a patient for two to three days and only move on if the patient reports that they have not experienced any negative physical responses.

She breaks the exercises down into different phases: 

First Session

Mackles tells patients to lay on their back with their feet on the ground or propped up over pillows. She starts by having patients close their eyes and take in their surroundings. She tells them to pick a spot in their room to center them and to turn back to that spot as their home base throughout the exercises.

With their eyes closed, patients move their hands through the air to send their body a message that this is what the air around them feels like, and that it is safe to breathe it in. In this session, Mackles says that it’s not so much about breathing in a pattern as it is about sending signals to the brain.

Throughout the session, Mackles asks patients questions such as “how does the air feel? Is it heavy, is it light, is it thick, is it thin, does it help you?” Patients breathe in through the nose and lightly blow out through pursed lips. This will take around three to five minutes.

Second Session

This session focuses more on the lower body. Here, Mackles instructs patients to “breathe through their feet” by either having them bend their knees and touch their feet, rub their feet together, or press their feet to their beds. The idea is to trigger the sensation of "groundedness" during breath, because many long-haulers feel overwhelmed by a sensation of lightheadedness when standing up.

Sometimes, Mackles instructs patients to inhale for two counts then exhale for four, or in for three and out for five or six, but she says it varies from patient to patient.

Third session

Building on the mind-body connection developed in the prior two sessions, Mackles uses session three to bring all the elements together in an upright position. She tells patients to slowly explore what these movements and breaths feel like while sitting up.

Fourth session

Part four of therapy is done standing up, which is an important step to transition long-haulers back to everyday tasks.

For many long-haulers who've been bedridden, standing up requires an extreme amount of effort. Mackles says it’s important to practice patience while mastering this step.

The Full-Body Effect of Breathing Exercises

Noah Greenspan, DPT, CCS, EMT-B, a cardiopulmonary rehabilitation specialist who has been working with Mackles since 1994, says these conscious breathing exercises can help reduce inflammation throughout patients’ bodies—a key feature present in COVID-19 patients—and help quiet the hyper-reactivity of the nervous system.

“A lot of times, we really have to slow people down, and sometimes people need a complete reset,” Greenspan, who founded the Pulmonary Wellness & Rehabilitation Center and the COVID Bootcamp, tells Verywell. "They need to quiet the inflammatory apparatus."

Greenspan believes that by reducing the work of breathing and the anxiety associated with being short of breath, patients can reduce what he calls the sum inflammation: not just inflammation in the airways and the lungs, but other organs throughout the body.

“I didn’t realize until I started COVID Bootcamp that breathing involved so many tiny muscles, and that COVID-19 could lead to those muscles becoming de-conditioned after being constricted for so long," Jenny Berz, 50, a clinical psychologist and COVID-19 long-hauler in Massachusetts, tells Verywell. "Dr. Greenspan and COVID Bootcamp have taught me so much about the mechanics of breathing, as well as how to do breathing exercises that lead to increased strength and easier, more productive breath. No matter what symptoms I’m experiencing, I have found that taking a series of five or 10 deep, slow breaths helps me feel better both mentally and physically."

What This Means For You

For long-haulers, COVID-19 recovery is a slow process. But a commitment to rehabilitation, including breathing exercises, can lead to physical and mental improvement.

A Non-Linear Road to Recovery 

Mackles and Greenspan emphasize the importance of long-haulers not overdoing it. Scientists aren’t yet sure what the exact mechanisms behind this are, but when long-haulers exert too much physical effort—whether that’s by taking that extra step, or in some cases, that extra deep breath—they sometimes circle right back to where they started. This could be a result of chronic fatigue syndrome (CFS), which has been found to emerge after a viral infection.

“What we found when we started working with these patients is that Bootcamp would be working for them and they would be feeling great, and then, all of a sudden, out of nowhere, they can’t get out of bed for multiple days," Mackles says. "We’ve learned to make the process incredibly slow—slower than our original Bootcamp that was developed for people with cardiovascular and pulmonary diseases."

Joel Hough echoes that sentiment. The 56-year-old software engineer based Manassas, Virginia, tells Verywell that because of a COVID-19 infection in April, he developed CFS-like symptoms in May. He initially pushed himself too much on breathing exercises and bike riding, and wound up immobile for over three days. Since discovering this Bootcamp and its pacing practices, he says his heart rate is lower, his oxygen rate is higher, and he is slowly recovering—making sure to moderate his movements.

"The Bootcamp program is helping my muscles get stronger and more relaxed," he says. "I am breathing better and stronger now."

Greenspan advises his patients to pace themselves throughout the recovery process, and only increase their efforts by 5% to 10% at a time over their previous best effort. 

"Many patients start to feel better and overdo it," Greenspan says. "If the furthest you’ve been able to walk is 100 feet, that doesn’t mean go out and walk a mile. That means walk 110 feet. I will always recommend stopping before you think you need to stop. Err on the side of caution."

Noah Greenspan, DPT, CCS, EMT-B

If the furthest you’ve been able to walk is 100 feet, that doesn’t mean go out and walk a mile. That means walk 110 feet.

— Noah Greenspan, DPT, CCS, EMT-B

Greenspan says it’s important to redefine what we know about the body when it comes to COVID-19 and start from scratch. In order to do that, patients must become the teachers.

“It’s so complex because people have all these different symptoms superimposed and intertwined with each other, so we’re trying to help unravel their condition strand by strand by strand," he says. “For some of the exercises that we do, I start off by saying: ‘This may feel like you're doing nothing, but you are.’ And many patients have commented that they ‘suck at doing nothing.’"

While recovery isn’t linear, that doesn’t mean it has to be at a standstill. Greenspan emphasizes that the body needs time to recover, but he believes that eventually, it will heal. In the meantime, many patients are reasserting their power over their illnesses in small, day-to-day victories, whether it’s by walking down a block for the first time in months, going up a full flight of stairs instead of an elevator, or relearning how to take a small, but meaningful breath.

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