James Nestor. (Photo: Mark Mahaney)

Nestor’s book is a fascinating take on the science and philosophy of breathing that combines modern respiratory research and the ancient breath-work doctrines of yoga, Taoism and more. His take is that prayer is another word for slow breathing. The Buddhist mantra Om Mani Padme Hum, which needs six seconds of inhalation and exhalation each, follows the same pattern of Om chanting and Kundalini yoga’s sa ta na ma mantra. He cites a research study at the University of Pavia in Italy, conducted in 2001, where two dozen people chanted a Buddhist mantra and the original Latin version of the Catholic prayer Ave Maria. There were sensors to measure their blood flow, heart rate and nervous system feedback. The cycle of inhalation and exhalation, while reciting the prayers, averaged at 5.5 breaths a minute. They found this breathing pattern increased blood flow to the brain while the body reached a state of coherence “when the functions of heart, circulation, and nervous system are coordinated to peak efficiency”. It almost matches the three-increasing-up-to-six counts inhale-exhale cycle adopted by Kamath. Prayer and therapy can heal.

In his quest to study breathing, Nestor casts his net wide. He analyses record-breaking athletic performances that were made possible solely by improved breathing techniques. There are case studies of people who reversed autoimmune disease and others who healed from incurable conditions like scoliosis, where the spine curves sideways. His book traces the remarkable journey of Katharina Schroth, who had a distinctive sidewards curved spine. Doctors had written her off as someone who would be in a wheelchair for life. But she trained herself to breathe right and after several years of this practice, she “breathed her spine straight again”. She went on to open a rehabilitation centre for scoliosis patients in Germany and helped hundreds. Now, the Schroth Method for scoliosis is offered as a physical therapy at The Johns Hopkins University in the US.

It is this university that contacted Nestor after the book was published in May 2020. He has received calls from Harvard and Stanford too. Each has the same intention—to introduce breathing studies. Nestor took about 10 years to research and write his book. “The nose is the silent warrior: the gatekeeper of our bodies, pharmacist to our minds, and weather vane to our emotions,” reads a poetic line. Perhaps it wouldn’t be too farfetched to link it to a medical practice, the Breathing Thinking Functioning model, which is used to manage breathlessness.

The Breathing Thinking Functioning (BTF) approach was pioneered by the UK’s Cambridge Breathlessness Intervention Service (Cbis) in 2012 as a palliative measure to tackle breathlessness. Cbis doctors found that breathlessness stems from maladaptive patterns that involve inefficient breathing, anxious thinking and declining lung function. For example, people with conditions like chronic obstructive pulmonary disease (COPD) are often vulnerable to worrying thoughts about breathlessness, such as “I can’t breathe and I will die”. Debilitating thoughts, unfortunately, beget breathlessness. It is a vicious cycle and is the Thinking aspect of the Cambridge model. The Functioning aspect implies the deconditioning or decline of lungs and related muscles due to breathlessness. It prevents people from being active, often leading to isolation. The third aspect of breathlessness is straightforward: breathing. In other words, a cycle of bad habits like fast inhalation and exhalation causes insufficient intake of oxygen and expulsion of carbon dioxide, and therefore breathlessness, which leads to anxiety and further breathing difficulty. The BTF approach, Cambridge experts claim, breaks each of these vicious cycles. For better breathing, patients are trained in efficient inhalation and exhalation techniques with therapies that include singing—a practice that combines fun with correcting breathing patterns. For spiralling thoughts, patients are taught mindfulness and relaxation. For better lung function, patients are encouraged to exercise. It is, overall, palliative care that goes hand in hand with COPD drugs.

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Rajani Bhat, a Bengaluru-based interventional pulmonologist, has adopted the Breathing Thinking Functioning model as part of her work. As an interventional pulmonologist, she does procedures in people’s airways. “It involves palliative pulmonology to help people release the symptoms of breathlessness and cough,” she explains. “Breathlessness occurs when I am not able to increase the supply of oxygen as per the demand.” For instance, when you run up a flight of stairs, the respiration would in most cases settle into a regular pattern after a period of heavy breathing—but if it doesn’t, it could signal trouble. “It means the lungs are trying their best but their effort goes unrewarded,” says Dr Bhat.

Healthy lungs respond to the body’s demands for oxygen and restore it to a normal state where you are unconscious of your breathing, says Dr Bhat. So, what happens to the lungs during covid-19? To answer this question, Dr Bhat narrates an engaging story filled with analogies of soap bubbles: The lungs contain the main breathing tube, divided into the right and left. Within the lungs, the tube forks out into smaller and smaller branches to end up as tiny, microscopic air sacs known as alveoli. Imagine them as delicate soap bubbles. The air that’s inside the soap bubbles is what you have breathed in. There are tiny little networks of blood vessels around the air sacs and the oxygen diffuses from the sacs into the blood cells. When you are exposed to covid-19, the virus comes in through the nasal passage, travels down the respiratory tract and eventually reaches the air sacs. It causes inflammation in their fine lining. These fine soap-bubble-like structures start thickening and the oxygen molecules find it harder to move into the blood vessels. When this happens, there is a feeling of breathlessness. Doctors try to remedy the situation before the thickening causes the air sacs to close and collapse.

Apart from medication, one way to ease the situation is by proning, where the doctor lays the patient on the stomach with a pillow beneath. This position opens up more surface area for breathing. “You have a larger part of the lung engaged in oxygen exchange, which will keep your oxygen levels up. We are just using simple physics. Proning is standard medical practice. It is recommended for cases that are on the cusp of going from mild to moderate,” she explains.

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Dr Bhat believes that the pandemic has made people more aware of their health and breathing. She says people have become more committed to tracking vitals like blood pressure, pulse rate, oxygen levels and sugar levels more closely. Many of her patients have focused on improving their health during the pandemic.

Does anything else impact breathing? She responds, “Air pollution.”

Different government programmes have been rolled out to address air pollution but it’s hard to measure their outcomes. (Image: Reuters)

Different government programmes have been rolled out to address air pollution but it’s hard to measure their outcomes. (Image: Reuters)


India has some of the world’s most polluted cities. More than 120 cities, including Delhi, Bengaluru and Ahmedabad, do not meet the National Ambient Air Quality Standards. Different government programmes have been rolled out to address air pollution but it’s hard to measure their outcomes.

Tanushree Ganguly, programme associate at the Council on Energy, Environment and Water, a Delhi-based think tank, is an air quality researcher who is developing a data-driven approach to clean air policymaking in India.

Between March-September last year, Ganguly says, restrictions on activity and mobility ensured a significant reduction in carbon dioxide emissions, whether from vehicles, industrial operations or construction. Air quality improved. It led to the realisation that if there are significant cuts in emissions, India can achieve the National Ambient Air Quality Standards. “There is a consensus across the board but has it translated into any significant air quality policy at the national level? Not so much. But some cities are becoming more particular about planning their mobility strategies,” says Ganguly. She cites the example of Bengaluru, which is planning its mobility infrastructure in such a way that it can cut down the need for personalised motorised transit.

Ajay Nagpure, the Delhi-based head of Air Quality and Sustainable Cities at the World Resources Institute, says that while vehicular pollutants may have reduced during the pandemic, emissions caused from cooking with biomass, like cow dung, firewood and crop residue, have not. This is the main contributor to indoor air pollution in urban and rural homes. “People are not talking about indoor air pollution because they are not aware that 30-40% of outdoor air pollution too is contributed by the biomass used for cooking,” he says. Job losses over the past year have forced more people to shift from expensive LPG to cheaper biomass. Nagpure suggests ways to tackle this problem: Reintroduce subsidies for cooking gas targeting income groups below the poverty line and create awareness programmes. “We have observed in low-income households where a woman is the decision maker, they tend to use more LPG compared to those where men take decisions. So we need to target the awareness campaign to women,” he says.

Also read | Track air pollution with these handy online tools

Breathing is the most intimate connection that we have with our surroundings, writes Nestor—an alarming idea for city dwellers breathing in polluted air. His advice for those living in a polluted cities is to breathe very slowly and deeply, through the nose.

For those wondering how to breathe with a mask on, Nestor again recommends nasal breathing with the mouth shut. Yoga has some answers too. “Breathing practices become even more pertinent when you wear a mask,” says Uttarakhand-based yoga teacher Vishnu Joshi. He has been conducting online yoga sessions for students around the world during the pandemic. He teaches practices like bhastrika, which involves forceful exhalation, and alternate nostril breathing, with a focus on breathing out. “One needs to exhale completely to expel all the stale air. When you are breathing with a mask on, you are taking in stale air too,” he explains.

Breathing practices become even more pertinent when you wear a mask—says yoga teacher, Vishnu Joshi. (Image: Getty)

Breathing practices become even more pertinent when you wear a mask—says yoga teacher, Vishnu Joshi. (Image: Getty)

Improving exhalation is key for those with asthma. It is impossible to take in a large generous breath until the lungs have been emptied. “In asthma, the exhalation is short, which does not give room for fresh air to come in. The cycle worsens when the attack happens. Until you breathe out fully, how will you pump in fresh air? That’s why all asthma exercises are primarily about breathing out and how to strengthen your lung capacity to do so efficiently,” explains Vijay Nallawala, author and founder of the mental health support group Bipolar India. He was diagnosed with asthma at the age of 14 and bipolar disorder at the age of 40. Now, at 59, he says he feels fitter than ever.

Nallawala’s asthma was severe. He had to be rushed to the ICU twice as a young man and was on 24 inhaler doses a day in his 20s. But his life transformed when he met the late Mumbai-based pulmonologist Pramod Niphadkar, who told him, “My medicines will not heal you, your discipline will.” Apart from medical treatment, Dr Niphadkar encouraged him to do cardio exercises like brisk walking for 45 minutes daily and pranayama. Nallawala changed his diet, staying away from sour and cold foods.

“But now I am stronger and once in a while, I sneak in an ice cream.”

He says that the discipline to manage asthma—he has never missed his daily pranayama since the age of 29—offered him a model to deal with bipolar disorder. His condition makes him vulnerable to stress triggers. When he starts feeling upset, an emotion that manifests in his body as a pounding heart and his mind as racing thoughts, he consciously slows down his breathing. “When I can sense that an experience like this can lead to an episode, I completely cut myself off from it. It is done by slow breathing, which slows down my thoughts too.”

Also read | World Asthma Day: A diagnosis doesn’t have to take your breath away

Medicines are essential to manage symptoms for many but following a routine with exercise and diet is a more rounded approach to better health. “Our lungs are elastic, like balloons. But asthma makes them stiff. To keep them elastic and functioning at their optimum, you need to do breath work and cardio. One can rewire the body. This applies to everyone,” he says.

In July, Nallawala had covid-19 with traces of pneumonia infection. He recovered in home isolation. “My pulmonologist said my fitness ensured healing. My oximeter readings are the best in my family,” he says. His joy in his healing through breathing right is infectious.

Resonant breathing.

Resonant breathing.

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