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Breathing Pattern Disorder in Long Covid

It’s been exactly a year since I’ve written a blog post. I’ll be honest, my last blog got a lot of traction and attention and I felt a bit exposed and vulnerable, so I retreated to the safety of anonymity! The curse of the introvert.

The other reason I stopped writing was because I didn’t think I could top it. But I’ve gotten over myself and if I write something which is seen by one person and helps just one person then it’s worth it. So, here goes…

I’ve been working with people with Long Covid (LC) since August 2020. I do not claim to treat it. If somebody does make this claim, run away from them. It’s not true. Yes, there’s anecdotes that some amazing treatment fixed one person but look, LC is not one thing (in my opinion) and therefore there is not one treatment.

LC sits in the too hard box and the best that you can do at this point in time is manage the symptoms. Is this ideal? No. And I genuinely hope there is a magic silver bullet in the future but currently it just doesn’t exist. But there is a lot of research which is great.

Before covid was a thing I was a respiratory physio who helped people’s breathing through one way or another and that’s what I’m doing with LC. I treat the breathing pattern disorders exacerbated or caused by covid. It’s not new. It’s scientifically based and supported by research.

So as breathing is what I know (I started training as a physio 18 years ago and have built up a fair bit of knowledge during that time) I thought I’d share what I’ve seen to date in LC.

As always this is my clinical experience and my thoughts based upon what I’ve seen and treated.

What is a breathing pattern disorder (BPD)?

I won’t bore you with huge amounts of detail here – I’ve written about it in previous blogs, posted about it on social media and spoken about it on the LongCovid Podcast so if you want more info you can check out those places or just use the power of Google.

Basically, a BPD is when your breathing is knocked off balance by a trigger or multiple triggers. A trigger can be a one-off illness (e.g. covid), emotional stress, stimulants, heat, humidity, tight clothing, pain, diet, the list goes on.

Your breathing changes and this creates a physiological and/or biomechanical change to your body which gives you horrible symptoms.

Symptoms include:

· Air hunger

· Shortness of breath

· Chest pain

· Fatigue

· Poor exercise tolerance

· Brain fog

· Pins and needles

· Gastrointestinal changes

· Palpitations

· Cold hands and feet

· Anxiety

· Again, the list goes on…

What am I seeing??

I’m going to outline the common faulty breathing issues that I’m treating. You may recognise these in yourself and if you do make sure you get the help to treat it. It may not stop all of your symptoms, but any improvement is a win right?! We’ve got a life to get back!!

Hyperventilation (HVS)

Simply put this is when you breathe too much. And this breathing too much can present itself in different ways.

The first is that super fast respiratory rate. We should breathe at about 8-12 breaths per minute – higher could indicate a problem. I’m seeing rates of about 18-30 most commonly. This is going to cause a lower than optimal CO2 level and you are going to have symptoms as a result of it.

The others are the sighers, yawners, catch up breath kinda people. You know that feeling when you just can’t seem to get enough air in? You end up just heaving in as much as possible and it never seems enough to scratch the itch? Yeah, those people. Big breath in equals big breath out which equals a lower CO2. Same result just different action.

This is being supported by clinical trials who use exercise tests and people with LC are hyperventilating on exercise. If you’re doing it on exercise you’re probably breathing poorly at rest too.

Can we fix this………yep!

Inspiratory muscle weakness

Barring three exceptions, everyone I’ve seen have been upper chest breathers. Leaving your poor diaphragm in a state of underuse. It’s a muscle. If you don’t use it, it will get weak.

I will say now that the majority of people tell me they tummy breathe when we start working together. Then I shatter their world – no, take a look in the mirror (or the zoom camera), how are you breathing??? Ooohhhhhhh, it’s all in my chest. Yes. Yes it is. Now we’ve noticed it, lets fix it.

I’m seeing significant weakness in this group – more than I would normally see. Not everyone gets their inspiratory muscle strength tested when they do their lung function tests but those who do who I have seen have low maximum inspiratory pressures (MIP’s). This demonstrates a weakness in the inspiratory muscles.

This is a problem in the LC cohort and this is why….

Using your accessory muscles – the ones which lift your chest – to breathe is a waste of energy. They aren’t meant to breathe all day. They are only meant to kick in when we really need them, like when we exercise. The diaphragm is meant for breathing all day. It’s efficient. It uses way less energy. And let’s be honest, you guys don’t have the energy to waste on breathing. We need to save what we can.

It’s also really important for those with dysautonomia symptoms. I hear a lot of people saying I have “POTS’y type symptoms” or they have a diagnosis of orthostatic hypotension, postural orthostatic tachycardia syndrome (POTS) or inappropriate tachycardia syndrome (ITS).

You guys need a strong diaphragm. It’s a pump. It helps pump blood round your body. It affects abdominal and thoracic pressures which affects how your body functions. It also calms your system and can help reduce that heart rate.

I’ve been using inspiratory muscle training with the right people and seen some great improvements – it’s slow but as I said any improvement is a win!

Can we fix this………yep!

Dynamic hyperinflation

A lot of people have ‘air hunger’ and this can be caused by having too much air in your chest. You’re not breathing out enough. I’ve had loads of people say to me “my exhale feels short” or “I can’t breathe out”.

You’re breathing at higher lung volumes (technical term is an increased functional residual capacity). The lungs have millions of receptors measuring all sorts of things and sending information for your brain to interpret and respond to. In this case the information is interpreted as a need to increase tidal volume (size of breath), and this gives the sensation of shortness of breath (dyspnoea).

I know it sounds mad but instead of breathing in, try and gently breathe out, once, through pursed lips. And return to slow, calm nasal breathing. It will help way more.

Can we fix this………yep!

Those are the big three. Of course, there’s the odd mouth breather and the people who require cough suppression to stop that irritable dry cough, but they are relatively easy fixes.

Once we address the breathing pattern issue we can see what symptoms are left. For some sorting the breathing pattern issues is the missing piece of the whole puzzle and for others it’s just a corner piece or an edge. But you can’t complete the puzzle without all of the pieces!

It’s really important to remember that the underlying driver of the breathing pattern disorder must be identified and no longer present. We can’t fight it and it may be detrimental to do so. This is why it’s so important that you seek guidance from somebody who can take a medical history and provide a diagnosis. I have sent people back to their GP to have certain medical checks if I’m concerned – there are hundreds of differential diagnoses for a BPD, and you need to be medically trained to identify when something isn’t right. A bit of Wim Hof is not the answer here.

Final thoughts…….

Breathing pattern disorders are extremely common in those with Long Covid. Even if you don’t have breathing symptoms you could still have a problem. And if you do have ongoing breathing symptoms I would 100% have your breathing properly assessed.

Will sorting your breathing make LC go away? Maybe for some, yay! But being realistic, for most, it’s a tool to reduce symptom set by giving you something practical to do to help recovery. A way of taking some control of your body again! But either way it is such an important part of the recovery puzzle.

Please do contact me if you have any questions or just want to discuss your personal concerns – I love meeting you all and helping where I can! Contact details on website or socials @thebreathingpt.

Breathe well,


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Hello . Thank you for explaining things. I have had LC NOW FOR OVER 15 months. I got pericarditis as a consequence of my long covid. Shortness of breath was one of my main symptoms ( apart from te chest pain ) the pain has now gone, but I’m still sob particularly on exertion , or in hot weather., sometimes just walking. I note that you have Mentioned mouth breathing. I am a mouth breather and always have been as I have very narrow nasal passages which are now stuffy ( post covid) and I just don’t feel I get enough air. I also have to take an extra breath every now and then as I feel I’m Not getting…

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