How Breathing Through Your Nose Will Change Your Life with Patrick McKeown

Dr. Rangan Chatterjee 0:00 [upbeat music]

Dr. Rangan Chatterjee 0:04 Patrick, welcome to the Feel Better, Live More podcast.

Patrick McKeown 0:08 Thanks very much, Rangan.

Dr. Rangan Chatterjee 0:09 So Patrick, just a bit of context. We have been spending the last few hours together. Um, you've been giving my kids a bit of one-on-one. Um, we've gone through all kinds of stuff and shot a few videos, which I think are gonna be really helpful for people who listen and get inspired, I hope, by what's in the podcast today. I read your book, The Oxygen Advantage, um, [lips smack] I dunno, maybe 18 months ago, something like that. And first of all, I love it. It's absolutely incredible. And the more I think about it, the more I've been trying to introduce its concepts into my life, the more I wanted to get you on the show and talk about it. Because I think breathing or breathing in the correct manner, which we'll no doubt, you know, touch upon during this conversation, is something that most of us are not really thinking about. And even if we are thinking about it, we're only looking at one piece of the puzzle.

Patrick McKeown 1:07 Yes.

Dr. Rangan Chatterjee 1:08 So there's so much to get through today. I have been looking forward to this for months now. Um, so let's just go back to basics. Breathing. You know, breathing is fundamental to life, right? We're all breathing.

Patrick McKeown 1:19 Yes.

Dr. Rangan Chatterjee 1:20 So why have you written a book on breathing?

Patrick McKeown 1:23 I wrote a book because I was a mouth breather for about 20 years, and my asthma was getting progressively worse, my sleep was getting progressively worse, I was waking up tired every morning, and also my ability to handle stress. And I came across an article in an Irish newspaper, it was back in 1998, and it said two things. It said, "Breathe through your nose," and to, "Breathe lightly." Now, when I read it, it struck a chord because I was constantly caught for breath. People could hear my breathing in the room, my nose was stuffy, and I was breathing through an open mouth. And you kinda learn to live with these things. And I took on board what the article was saying. I used an exercise to open up my nose, which was simply holding the breath, and within two to three days I felt a tremendous quality-of-life improvement. Sleep was better, I was feeling calmer, and my need for rescue medication for asthma had reduced by about 50% in one week.

Dr. Rangan Chatterjee 2:26 In one week?

Patrick McKeown 2:27 Yes, yes. And that was for years. Like, progressively, my asthma was getting worse. Breathing was a problem. I was breathing fast and shallow. And if you're breathing fast and shallow, what is it doing to oxygen uptake, oxygen delivery, your blood circulation, your sleep, and your emotions?

Dr. Rangan Chatterjee 2:46 How many people across the population would you say have some element of dysfunctional breathing at the moment?

Patrick McKeown 2:54 A Cochrane review shows about 9.5% of the general population. But if we target specific pockets, individuals with anxiety, panic disorder, depression, et cetera, it can be as high as 80%. Individuals with asthma, I would say pretty much most asthmatics. Most individuals with asthma, whether it's childhood, um, if they had childhood asthma and they grew out of it, or if they have asthma to this current day, they would have a breathing issue. If we were looking at sleep, 30% of the sleep apnea population have a phenotype that is conducive to poor breathing. Now, if I was just to take a group of individuals, most of the people who come into me, they have room for improvement.

Dr. Rangan Chatterjee 3:40 Yeah.

Patrick McKeown 3:41 So it's a lot.

Dr. Rangan Chatterjee 3:43 It is a lot, and I think room for improvement, I think, is an interesting concept to think about because, you know, breath is universal.

Patrick McKeown 3:54 Yes.

Dr. Rangan Chatterjee 3:54 Without, without breath there's no life, right? And how well we breathe can really determine, in a huge way, the quality of our life, the quality of our performance, the quality of our relationships even. And the more I th- I've been thinking about breathing and, you know, I have a daily breathing practice which has evolved somewhat, um, influenced by your work, uh, some of the, the practice I do for sure. It's amazing to think that breathing correctly and efficiently is something that I think very few people are doing.

Patrick McKeown 4:28 Yes.

Dr. Rangan Chatterjee 4:29 And that therefore means with the application of some very simple and cheap techniques-

Patrick McKeown 4:36 Yes, yes

Dr. Rangan Chatterjee 4:36 ... we all stand to gain benefit.

Patrick McKeown 4:38 Yeah, totally. Like, even if you were to look at just people who are sleeping, how many people wake up with a dry mouth in the morning? Very understudied. Um, we know that between 25% to 50% of studied children persistently mouth breathe. For adults, we know that individuals over 40 years of age, they are more than six times likely to have their mouth open during sleep. So it can be an age-related thing, but it's not just related to, to a specific age. It really comes back to it in terms of quality of life. People will say, "Well, you breathe." Yes, but we are br- we are living now in times, uh, much different to what our ancestors were evolving then.

Dr. Rangan Chatterjee 5:17 Yeah.

Patrick McKeown 5:17 There's higher stress levels. Stress will impact your breathing, and if you have long-term stress, your breathing changes, and even when the stress removed, your breathing, that dysfunctional breathing pattern will remain, and that will feed back into stress. And this is not new information. The first doctor who discovered this was back in the 1870s with soldiers returning from the American Civil War, and it was called Dacosta syndrome. And these soldiers who returned from the front line, from the front line, they exhibited symptoms of breathlessness, fatigue, and what's more, it took these soldiers a long time to recover.

Dr. Rangan Chatterjee 5:55 That is... I- it's just incredible to think that we've thought about this and known about this for a long period of time- I would say that in the media, in just I guess the wellness world in general-

Patrick McKeown 6:10 Yes

Dr. Rangan Chatterjee 6:11 ... I think sleep is something that has gained a lot of traction over the last five years certainly. There's, there's a growing awareness now of how important sleep is. But I don't think there has been as much awareness of how important the breath is. I think that's increasing. I think there's a few big names out there, yourself one of them, uh, Wim Hof another one, um, Brian McKenzie, all kinds of people who are talking about the importance of breath, um, and breath control in changing our states and changing our physiology. But I think breathing has got a long way to go to catch up with sleep, which had a long way to go to catch up with diets and movement, right? So it's all these little things. But then, you know, breathing and sleep are linked. They're hugely linked, aren't they?

Patrick McKeown 6:57 Totally, totally. Um, Dr. Christian Guilleminault, he's a French doctor, and he was based at Stanford Medical School, and sadly he passed during the summer of 2019. But for the last four to five years, he has been writing about, I quote, "The critical importance of restoring nasal breathing both during wakefulness and sleep." Here we have a doctor who coined the phrase obstructive sleep apnea, who developed the Apnea-Hypopnea Index, who is regarded as one of the founders, um, the fathers of sleep medicine, and he's talking about the critical importance of restoring nasal breathing. It's only in the last four years he's talking about it. It's going to take many more years-

Dr. Rangan Chatterjee 7:39 Yeah

Patrick McKeown 7:39 ... for that to trickle down. All I will say is this, Rangan, if anybody is waking up with a dry mouth in the morning, they are not having the deep and refreshing sleep that they need.

Dr. Rangan Chatterjee 7:51 Yeah. I mean, that is a very profound statement, and there will be people watching this on YouTube, listening through their headphones thinking, "Wait a minute, I wake up every morning with a dry mouth."

Patrick McKeown 8:01 Yes.

Dr. Rangan Chatterjee 8:02 And one of the possible causes might be the way that they're breathing at night. So let's just break this down. Okay. We're talking about nasal breathing versus mouth breathing.

Patrick McKeown 8:12 Mm-hmm.

Dr. Rangan Chatterjee 8:12 And I think for many people, that's a brand-new concept. W- you know, I breathe. W- w- what do you mean I need to breathe through my nose rather than my mouth? So let's take it down to its absolute basics. Why is it so important where you breathe?

Patrick McKeown 8:26 Well, number one is the mouth performs absolutely zero functions in terms of breathing. If you opened up any medical textbook, and if you look at the function of the mouth, you will never see breathing listed as a function of the mouth, because breathing is not a function of the mouth. Dr. Morris Cottle, he was an ear, nose, and throat surgeon from the United States back in the 1970s. He said the human nose is responsible for 30 functions in the human body. Now, many people will think about the nose, and they think, okay, it's a filtration mechanism. It warms the air. It moistens the air. But your nose is doing so much more than this. When you breathe through your nose, you're actively targeting the diaphragm breathing muscle. Your diaphragm breathing muscle is not just the main muscle for respiration. It's also linked with your emotions. When you breathe through the mouth, you're putting yourself more into that fight or flight response. Mouth breathing is shallower breathing. Nose breathing is slower breathing, and you're more likely to be breathing using the diaphragm. Straight away, oxygen uptake in the blood increases. It was discovered back in 1988 that the PO2, which is the pressure of oxygen in the blood, it increases by 10% when individuals were forced to continuously breathe through their nose. Not only is the oxygen uptake in the blood improved, but oxygen delivery to the cells is increased. The individual is more likely to be relaxed. The individual has much more efficient and economical breathing. It's not just enough to get oxygen into our blood. We also need to get oxygen delivered to the cells. How does that happen? And if we are breathing fast and shallow through an open mouth, we are not achieving optimum quality of life in terms of probably the biggest things, the mind. How can you calm the mind if your body physiological is in a state of fight or flight, if you're breathing fast and shallow? How can you if you're breathing fast, because that, that in turn is going to agitate the mind. Um, sleep, so the emotions, your sleep, and your breathing are all interlinked, and if one is off, it affects the other. If your emotions are off and if you've had a very stressful day, you will find when you go to bed that night, you cannot sleep because you're twisting and turning. When the mind is agitated, our sleep is hampered. When our sleep is hampered, our mind is agitated. When the mind is stressed, it affects our breathing. When our breathing is fast and shallow, it affects our stress. When our breathing is fast and shallow, it affects our sleep. That's why we say true one thing is look at your breath. How do you breathe? Do you breathe through the open mouth? Can you hear your breathing? Are you running out of air? Do you feel that you're not getting enough breath? Do you have nasal congestion? Are you breathing fast, and are you breathing shallow? And if you answer yes to a couple of those questions, you will get plenty out of putting this into practice.

Dr. Rangan Chatterjee 11:26 Yeah. I mean, I've noticed all kinds of changes since I moved, um, to more nasal breathing. And, and I should, I should clarify what I mean by that. I, I'm not sure I was a mouth breather before.

Patrick McKeown 11:40 Sure.

Dr. Rangan Chatterjee 11:40 Um, but I'm always looking to, you know, small percentage gains wherever I can.

Patrick McKeown 11:45 Yes.

Dr. Rangan Chatterjee 11:46 And I was reading that book, and I thought, well, I don't think I'm optimizing my breath network as much as I could do.

Patrick McKeown 11:52 Sure.

Dr. Rangan Chatterjee 11:53 And there were some really simple and very practical exercises in your book. We'll talk through some of them today no doubt. Um, but it gave me a lot of awareness of how much am I breathing through my nose-

Patrick McKeown 12:06 Mm-hmm

Dr. Rangan Chatterjee 12:06 ... as opposed to my mouth. And I've noticed a few things, because- I think awareness is really key, right? Because a lot of us, we go through life, we, we don't even think about our breath.

Patrick McKeown 12:16 Mm-hmm.

Dr. Rangan Chatterjee 12:16 We're just sailing through life. You know, our breathing's just going on in the background. Without any thought at all, our breathing is keeping us alive. But how are we living? That's a completely-

Patrick McKeown 12:24 Yes

Dr. Rangan Chatterjee 12:24 ... different, uh, different conversation. I've noticed sometimes, like, if I ha- if I do wake up at night, and I'm s- and I'm trying to keep my mouth closed, I've noticed a couple of times, well, more than a couple of times actually, if I've eaten late, I find it harder to keep my mouth closed at night. It's just, you know, that's just anecdotal.

Patrick McKeown 12:46 Mm-hmm, mm-hmm.

Dr. Rangan Chatterjee 12:46 That's not a study. That's just something I'm starting to observe with myself. When I finish my dinner earlier, two, three hours before I go to sleep, and don't snack afterwards, it's, it seems to be a lot easier, um, which is something... Ha- have you, have you had people who you've trained or clients, have you had anyone report that back to you at all?

Patrick McKeown 13:04 I think it's, it's something to take into consideration. If we look at the word breakfast, it means break fast. And if we are eating late into the night, when we wake up in the morning, we won't have an appetite, because the body is still digesting or processing the food. Um, so I think it's really important that when we do wake up in the morning that we have an appetite, and in order to have an appetite in the morning time, we must make sure that we are not eating late the night before. Now, how could eating a big meal at night affect your breathing? Possibly you could eat it, possibly you could affect it because of the stress, or not the stress, but the, the effect it's having on the diaphragm. As men, for example, when we hit 40 years of age, there's a tendency to put on a bit of weight. Where do we put the weight on? We put it on the belly. When we put weight on the belly, it impairs diaphragmatic movement, and when our diaphragm doesn't work as effectively, which is, our diaphragm is the main breathing muscle located at the base of the ribs. When our diaphragm doesn't work as effectively as it should do, we have a reduction in lung volume. We're not using our lungs the way we should be doing, and as a result, the upper airway dilator muscles in the throat don't maintain an open airway. So if we consider sleep disorder breathing, which is really getting attention nowadays, we need nasal breathing with the tongue resting in the roof of the mouth to m- help make, maintain an open airway. Our tongue has got two places to be. If your mouth is open, your tongue is not in the roof of the mouth, because you're breathing in and out through the mouth. When the tongue is not in the roof of the mouth, your tongue is more likely to be on the floor of the mouth and more likely to fall back into the throat. So if you have an individual, they're breathing heavy, and all of a sudden then they stop breathing. Well, that could be a condition called obstructive sleep apnea. That's getting a lot of attention, and by changing your breathing patterns, you will reduce the risk of having obstructive sleep apnea. We can never address, I will say this, this is okay, I can back it up with papers from Dr. Christian Guilleminault. I can back it up with the phenotypes of sleep apnea, because it's changed. If we want to really improve sleep, we need to have a few things. One is nose breathing. Number two is slow breathing, regular breathing by the diaphragm. And if we're eating late at night, I think that's going to impact it.

Dr. Rangan Chatterjee 15:32 If you look at babies-

Patrick McKeown 15:33 Yes

Dr. Rangan Chatterjee 15:34 ... and watch them breathe when they're sleeping, it's quite something really. It seems very calm, very relaxed. I think, although it's been [laughs] a while since my kids were that age, I think they're breathing through their nose.

Patrick McKeown 15:49 Yes.

Dr. Rangan Chatterjee 15:50 Or lots of them are. Um, and actually it's very different watching a child or a, or a baby sleep compared to an adult, when it can be a, a bit more forced, a bit noisier sometimes. And I guess this plays into what you said at the start, which is there's many factors in these modern, busy 21st century lives-

Patrick McKeown 16:09 Mm-hmm

Dr. Rangan Chatterjee 16:09 ... that are affecting something as basic as our breathing apparatus. You mentioned chronic stress, which, you know, listeners of my podcast will [laughs] will know very well. I've spoken about this on many, many occasions. The World Health Organization are calling stress the health epidemic of the 21st century, and stress directly affects our breathing. Um, but I think it's many things. I think it's also potentially, you know, looking over a, you know, bending down over a laptop, putting us in a very, um, un- anatomically efficient posture. And of course, we're gonna be breathing in that posture, because we can't go more than, what, a few seconds without breathing, right? Um, I don't know, is there anything about highly processed food potentially, and how that can affect our breathing? Do you know much about that at all?

Patrick McKeown 16:53 I think there's a connection there. Um, Dr. John Mew is an orthodontist who is based in Purley here in London, and he's, has been studying the effect of mouth breathing and malocclusion, which is basically crooked teeth from an orthodontic perspective. But in his book, I remember reading that he looked at skulls from individuals w- who were buried back about 400 years ago, and these were individuals from high, upper middle class backgrounds. They had access to sugar, and when he looked at the shape of the skulls, he seen the first cases of c- crooked teeth. Now, again, we can ask, "Well, why are the teeth crooked?" The teeth are crooked because the tongue isn't in the roof of the mouth, because it's the pressures exerted by the tongue which are helping to develop the maxilla, which is the top jaw. We want a really wide shaped maxilla, and when the maxilla develops correctly, and there's forward growth of the jaws, the airway is good. But he put it down to possibly it was a change in diet, that upper middle class people at the time had access to food that was different to what the lower classes had. And it was this processed food or more sugar type food that was contributing, having some negative impact on breathing, but more- Having an impact on the development of the face and jaws, we have to consider here there's something about the survival of the species. Airway is absolutely king. If we have kids growing up with their mouths open and their, their tongue is in a low resting position, these children don't get the, the adequate development of the face, and it's not just about the face, but it's about the airway. If you look at the book written by Dr. Weston Price back in 1938, it's called Nutrition and Physical Degeneration.

Dr. Rangan Chatterjee 18:45 Yeah.

Patrick McKeown 18:45 On page 55 of that book, he looked at individuals living off the Hebridean Islands in the coast of Scotland. These individuals, when they switched from their traditional diet of, um, their traditional diet was fish and oats, and when they switched to chocolate and marmalade and all the foods we have today, first generation children became mouth breathers. Now, my parents had really well-developed facial structures, and they didn't have crooked teeth. They had six kids, I'm one of them, and all of us had overcrowding of teeth.

Dr. Rangan Chatterjee 19:21 Yeah.

Patrick McKeown 19:21 We have to bear in mind what is causing crooked teeth, and crooked teeth is not just about the teeth. It means that the jaw is too small for the tongue, and if the jaw is too small for the tongue, the tongue then is more likely to go back into the airway, and then it's increasing the risk of obstructive sleep apnea for the rest of their life.

Dr. Rangan Chatterjee 19:42 I, I've been thinking about this a lot, um, both from, you know, my own personal experience, but also professional experience, and from an understanding of the science, particularly with respect to inflammation. And we know that highly processed foods, which many of us are consuming in excess these days, drive inflammation in the body because they go down into your gut, uh, a large part of your immune system sits in and around your gut, and actually, the messages from those foods can absolutely drive, um, the di- the creation and the, and the sort of propagation of what we call inflammatory mediators, so interleukins, cytokines, all these kind of things which basically drive up inflammation. So highly processed food can cause inflammation in our body, whereas minimally processed foods, uh, helps to switch that off and doesn't drive that process, which, you know, that's a, that's a, a discussion for another day. But bringing it back to our breathing, if you've got inflammation going on in your gut, well, the whole body's connected. It seems reasonable to me that that inflammation may not just stay in your gut and may be there in your airways, potentially in your brain. And we know this from, uh, things like depression and, and other sort of conditions. A lot of the inflammation comes from the gut, but it causes symptoms in other parts of the body. So it could be that the processed food is increasing inflammation per se in the body.

Patrick McKeown 21:03 Mm-hmm.

Dr. Rangan Chatterjee 21:03 And if that's happening in your airway, that's gonna affect your ability to sleep and breathe through your nose. For me, I'm absolutely convinced that's what's happening with me, 'cause I've always been a bit reactive-

Patrick McKeown 21:14 Mm-hmm

Dr. Rangan Chatterjee 21:14 ... to certain foods. And often if I've eaten out or, uh, where I, you know, I'm not in as much control over what's going into my mouth, often, I don't know if it's the vegetable oil that things get fried in, I don't know what it is, but I can often get a bit of mucus afterwards, and I'm pretty sure occasionally when I've been up in the night and I thought, "Oh, no, no, you just shut your mouth. Make sure your nose are breathing," and I'm struggling, yes, I think it's that I ate a bit late, but it could also be that I was having, uh, food that was driving inflammation in my body. So I find that quite interesting. Um, going back to the jaw development and children, I think, I think a lot of parents listen to this podcast and will probably be quite interested in that. So just let's go through that. Jaw development, you know, what happens with the jaw? What age do these things happen by, and how does the way we breathe impact that process?

Patrick McKeown 22:09 It's absolutely vitally important that we're breathing through the nose. Um, there's a number of aspects. You could ask, well, is it genetically that the child is born with a narrow maxilla, a narrow top jaw? There's not enough room for the tongue. If the jaws are narrow, the nasal cavity is impacted. If individuals or kids, if they have a small nose, they may feel air hunger when they try to breathe through the nose, and as a result, they automatically breathe through the mouth. So we need to look at breathing from a combination of a number of different perspectives. Number one, if a child is tongue-tied, and if the tongue is held, if the frenum, which is the string attaching the tongue to the floor of the mouth, if the s- if the string is too tight, that child can't elevate the tongue from the bottom, from the floor of their mouth. They then have difficulty breastfeeding. The child is not able to adequately express the milk from the mother, and breastfeeding is not just about the nutrition from the mother, but it's also about manipulation of the muscles of the face necessary for craniofacial growth. It takes effort to take milk from the mother. If, on the other hand, the child is not thriving because of a tongue tie, they're not able to breastfeed, the child isn't thriving, the mom gets sore, a bottle is introduced. We introduce a bottle. It takes no effort whatsoever to take milk from the bottle. Then we put the baby onto soft foods. Everything is mulched up. There's no effort by the baby because they're on soft food. Again, you know, it's impacting the development of the face. So we have to consider muscle tone. Secondly, the environment in terms of the child. Is the house, for exa- for example, excessively heated? Um, is there adequate fresh air coming into the room? Like, I sleep with the window open all the time, and even last night, staying in a hotel in a busy c- in a busy s- city, and of course you hear noise, but at least I'm getting some fresh air in. Because it's really vitally important that the quality of the air that we are taking in is adequate. If we are in very, very stuffy air environments that there's no exchange of air, that's going to affect our breathing. Is there other factors? Well, if I was to look at my own child, my own child was born with genetically a narrow maxilla, and congenitally, she's missing teeth. Now, this already is an alarm bell, not the fact that she's missing teeth, but the fact that she has got a small jaw. We need to make sure that the jaw, again, coming back to the point, we have enough room in the mouth for the tongue, as again, the two- the tongue has got two places to be. It's either in the roof of the mouth or it's falling into the throat. I embarked on functional orthodontics with her because I wanted to ensure that we have forward growth of the jaws, because it's not just about straight teeth. It's about the development of the face, and if the face has developed the way it should develop, it follows that the teeth are straight. I'm going to give you an example. If you look at a photograph of Prince, um, Prince William and Kate Middleton, and if you compare when you see a photograph of the two of them together, count when William is smiling, how many teeth can you see? And when Kate Middleton is smiling, how many teeth can you see? With William, you will probably count about six or seven teeth. With Kate, you will count about 12 teeth. She has a beautifully developed maxilla. She is a stunning-looking woman, but it's not just the aesthetics, it's function. And we choose our mate, we choose our partners based on good looks, but good looks is not just good looks. Good looks is the function, good looks is the airway, and good looks is the development of the face. And good-looking people naturally will have more straighter teeth because the face has developed the way it should do. So,

Patrick McKeown 26:13 you know-

Dr. Rangan Chatterjee 26:13 Are, are you basically saying that if in early childhood we get the appropriate, um, stimuli to our bodies, whether it's with the right foods, the right-

Patrick McKeown 26:25 Breastfeeding

Dr. Rangan Chatterjee 26:25 ... atmosphere, you know, breastfeeding where possible-

Patrick McKeown 26:27 Yes

Dr. Rangan Chatterjee 26:28 ... um, you know, sort of not s- too much mushy food-

Patrick McKeown 26:32 Yes

Dr. Rangan Chatterjee 26:32 ... things that require effort. Are you saying that if those appropriate signals come in and nasal breathing, which will probably result as a consequence of that, that the jaw will develop in a different way-

Patrick McKeown 26:45 Yes

Dr. Rangan Chatterjee 26:45 ... than if you don't get them? And also, the follow-up question is, if, are we saying on an evolutionary level that the way we would develop if our breathing mechanics were optimal would also make us more attractive to the species biologically? So is it, is, is ... I mean, this is really quite profound what you're saying here.

Patrick McKeown 27:06 The two go together, um, function and form, function and beauty. Look at beautiful-looking people. Look at the development of their jaws. Look at s- elite sports players. Like, I was a mouth breather for all my life up until about the age of 25. My nose is crooked. My maxilla is set back in my face. My mandible is set back. I've had scans. I've had cone beams. My airways are totally compromised. I would never be an elite athlete. I don't have the airway to be an elite athlete. I wouldn't be able to handle that volume of air.

Dr. Rangan Chatterjee 27:40 So you, you say you don't have the airway to be an elite athlete.

Patrick McKeown 27:43 Yes.

Dr. Rangan Chatterjee 27:43 So let's back up. Is this because of your childhood and your upbringing? So the point I'm getting at is when Patrick is a little baby, if things had gone slightly differently, was it possible that Patrick could then have become an elite athlete? Are you saying that your jaw and maxilla developed as a consequence of what happened to you as a child?

Patrick McKeown 28:10 Every photo that I look at, we can never say exactly what was-

Dr. Rangan Chatterjee 28:13 Sure

Patrick McKeown 28:13 ... the cause and effect, but every photo that I looked at as a child, my mouth was open. And I remember going to school, I would be constantly wheezing. I was caught for breath. I had asthma, and if you have asthma, it's not just isolated to the lungs. So my nose was stuffy, and if you have a stuffy nose, your sleep is impacted. You're twice as likely to have a sleep problem. You know, this is, there's so many things coming into play here, but all I'm saying is this. We know that if a child has the mouth open during critical growth periods in that child's life, that is going to have a negative impact on the development of the face, and I'm not just saying this. In 1981, papers were published in the American Journal of Orthodontics, and they looked at, this is Harvold's famous papers. He literally got groups of young monkeys. He was an orthodontist in the United States. He was saying, "Why are mouth-breathing children more at risk of malocclusion?" And this is not new information. I have the papers going back to 1909 at the time, published in the journal which was called The Dental Cosmos, and they talk about mouth breathing and malocclusion, but not just about malocclusion. The child is unattentive in school. The teacher will accuse the child of daydreaming. The bones on the face are expressionless. In other words, it's not just about the teeth, but let's, let's look at the knock-on effect to that. Now, I'm gonna come back to Harvold's papers. He got groups of young rhesus monkeys. He blocked the noses in one group with silicone nose plugs, forcing the monkeys to breathe through the mouth. In another group, he put something into the roof of the mouth so they couldn't get their tongue up there. And then the control group were just allowed to develop as normally. All of the experimental animals gradually acquired a facial appearance different to those of the control animals. By simply blocking the monkeys' noses, he was able to alter the growth of the face. When he removed the silicone nose plugs, the monkeys' faces started growing towards normal. Now, people say to me, "That's a dreadful study. It's cruelty on animals." Well, I'm gonna tell you there is a dreadful study happening every moment in this country and in many countries throughout the Western world because there is no attention paid On how the child is breathing or how the adult is breathing. Can you imagine 5.6 million people with asthma in this country? How many of those have been told, "Breathe through your nose. Your nose is the first point of defense of air coming into the lungs"? Why are we letting these people breathe through the mouth? Why are we ignoring it?

Dr. Rangan Chatterjee 30:54 Yeah, it's very, very powerful, Patrick. Um, I have been a practicing doctor now for, you know, getting close to 20 years, and have seen thousands of patients with asthma in my career. And I can tell you that no part of our training ever discusses how that patient should breathe, you know, whether it should be through the nose or their mouth. And this is potentially a very... Uh, I should not really use the word potential. This is an untapped resource, an untapped, um, tank, basically, to help everyone pretty much, but especially the asthmatic population. I guess in your own story, you have been asthmatic. I mean, just, just take us through that. So how bad were things, and how are things now?

Patrick McKeown 31:40 Sure.

Dr. Rangan Chatterjee 31:40 And what do you put the improvement down to?

Patrick McKeown 31:43 Sure. So when I was a young kid, at first, I wasn't diagnosed with asthma. I think the doctor was afraid to, to frighten my mom. Um, so it was called bronchitis at the time, and I think I was about three or four years of age. I remember being prescribed a, a medication called Intal. It was yellow, and it was gray. And I felt at the time it never real- really did anything to me. And then I was on a medication called Uniphylin, which was a tablet that I took every night as a kid, and certainly that helped. I was on then, um, Ventolin, and that was to give me relief if my airways were narrowing. I was then on steroids, and I was on different medications all the way through. I've had three hospitalizations. One bout was for about 15 days. But it wasn't just the asthma that was affected. It was my sleep. It was my concentration. When I used to go into school, I would be in secondary school, and we are required as students to have 100% of our attention on the curriculum, on what, you know, in the textbook. But how can you have that if you're not having quality sleep, and you don't have a quality sleep because of nasal obstruction? So, you know, I really was driven. Um, I studied very, very hard. I studied in my university years from 9:00 in the morning till 9:00 at night. I sacrificed everything to get my grades. I got my grades. I went into the corporate world, and I was highly stressed. And in hindsight, okay, the job didn't suit me anyway, but I wasn't suited to the job. I was highly strung. Emotionally, I wasn't able to deal with stress because, of course, stress is perceived, but if you're already in a state of agitation of the mind, and if you don't have the capacity to concentrate, your job, you're not going to be as productive. And as a result, you don't have the quality of attention to detail, and now there's increased stress levels because you're not reaching those demands. So this newspaper article, just by reading it, that completely changed my life. Um, when I read it, I went back into Trinity College 'cause I had access, of course, to, to, you know, the, the internet was in its infancy at the time, and I simply used one exercise to open up my nose, and I kept on doing it. And yeah, it was a struggle when I switched from mouth to nose breathing. I was feeling air hunger. That night, I got Breathe Right strips in the chemist. I wore them, and I got paper tape from the chemist, and I put it across my lips. And I struggled the first night a little bit, and then I went again to sleep the second night with the tape on. I woke up the second morning with an alertness that I had never experienced in my life, and that was a moment that, you know, sometimes things stay with you. Now, my use for reliever medication went down by about 50%, certainly within the first week. Do I get asthma symptoms now? There's times that I will get some symptoms. I can feel chest tightness. Um, uh, my work is very, very busy at the moment. Um, but in terms of asthma medication, I'm not on medication. If I have got symptoms, I will do my own techniques, and I'm not saying that this is a replacement for medication.

Dr. Rangan Chatterjee 34:58 Yeah.

Patrick McKeown 34:58 But what I am saying is we need to improve asthma control, but it's not just, you don't just have asthma. You have sleep issues, and you have more anxiety. So, you know, there's been the odd time that I've had to take steroid. Um, if I find that my wheezing or whatever gets a little bit too worse, I will take a steroid. So, you know, it's, we are, like, I'm not here, if I had to take a little bit of steroid to manage my control, that's fine.

Dr. Rangan Chatterjee 35:27 Yeah.

Patrick McKeown 35:28 But I want to be doing something to help myself.

Dr. Rangan Chatterjee 35:30 And I think that's very empowering, right? It's, it's not about saying the medication for asthma doesn't work. It does work.

Patrick McKeown 35:36 It, of course.

Dr. Rangan Chatterjee 35:37 [laughs] It works very well.

Patrick McKeown 35:38 Yes, yes.

Dr. Rangan Chatterjee 35:39 Um, but with all these things, you wanna try and see, well, what else can you do? Can you make some changes in your lifestyle, in your sleep, in your breathing that may improve the condition?

Patrick McKeown 35:49 Yes.

Dr. Rangan Chatterjee 35:49 And in some people, it's gonna be a dramatic improvement. In others, it's maybe gonna be a 30, 40% improvement that might reduce how many inhalers they need to take.

Patrick McKeown 35:58 Yes.

Dr. Rangan Chatterjee 35:59 I, I've got to add, you know, asthma's a very serious life-threatening condition. Um, you know, we are not advocating that people stop their inhalers-

Patrick McKeown 36:06 Of course not

Dr. Rangan Chatterjee 36:06 ... or do anything without, uh, the correct medical advice.

Patrick McKeown 36:09 Yes.

Dr. Rangan Chatterjee 36:09 I think that's super important to say. But this may well be an untapped resource for people. Um, you know, when you woke up with that sort of energy that you'd never felt before-

Patrick McKeown 36:19 Mm-hmm

Dr. Rangan Chatterjee 36:19 ... how old were you?

Patrick McKeown 36:20 I was 25 or 26 years of age. It was in around 1998, 1999.

Dr. Rangan Chatterjee 36:25 But, but let's think about that. You're basically saying that at the age of 26-

Patrick McKeown 36:31 Mm-hmm

Dr. Rangan Chatterjee 36:32 ... you woke up with a feeling of clarity and energy that you had never felt before.

Patrick McKeown 36:40 Yes

Dr. Rangan Chatterjee 36:40 But that's quite profound because that, in some ways, really indicates that for the first 26 years of your life, you may well have been functioning with one hand tied behind your back.

Patrick McKeown 36:56 Well, you have nothing to-

Dr. Rangan Chatterjee 36:57 Would you agree with that?

Patrick McKeown 36:58 You have... Well, I would absolutely agree with it, but I had nothing to compare it to.

Dr. Rangan Chatterjee 37:02 No, no, sure. But, but make-

Patrick McKeown 37:03 You know? So you kind of, you live with how you feel at that moment, and it's only when you have something so striking the difference that you can make a comparison, and then you start to realize.

Dr. Rangan Chatterjee 37:13 It's, it... I mean, is it... I mean, it, it's not quite the same thing, but when some people go on these sort of 21 or 30-day, um, uh, um... I'm not gonna use the word diets, 'cause I don't think that's the right thing. When they, when they unprocess their diet for 30 days, when they literally-

Patrick McKeown 37:29 Mm

Dr. Rangan Chatterjee 37:29 ... cut out all the processed food-

Patrick McKeown 37:30 Yes

Dr. Rangan Chatterjee 37:30 ... and just eat whole foods, it is amazing how some people feel at the end of it. They feel, "Oh my God. I can, I can go for hours. I've got so much energy, so much concentration. Some of my joint pains aren't there anymore. My sleep has improved." It is amazing, and, and I guess that really reflects what you're saying, which is many of us are walking around day to day in a certain state of what we consider to be our norm, and we think that's it for us. We don't know how good we could feel, right?

Patrick McKeown 38:03 Mm-hmm.

Dr. Rangan Chatterjee 38:03 And I guess that's what happened to you when you woke up that morning. You're like, "Wait a minute. I like feeling like this. I'd like to feel like this every day."

Patrick McKeown 38:09 Mm-hmm. Mm-hmm. Yes. And to the point, I have taped my mouth literally every night since, pretty much, with the exception maybe one or two nights, even last night, staying in a hotel. And you could say, well, why is he still taping his mouth? Surely now he's adopted nasal breathing. Yes, I have, but I suppose if you do something for a period of time, it's like my own little ritual.

Dr. Rangan Chatterjee 38:31 Yeah.

Patrick McKeown 38:31 Most people get into bed, they'll bend the pillow over the, you know, they'll-

Dr. Rangan Chatterjee 38:34 They'll do that thing

Patrick McKeown 38:34 ... tuck in the duvet. Mine is tape up. And I can... You know, and there's something there that, yes, I wake up 46 years of age, my concent- my workload is very, very heavy. Um, my travel is, I have about 60... no, sorry, about 26 trips booked in advance, all international trips. So it's full on, and I need the concentration, but not just the concentration. I need the calmness of the mind that I don't get stressed. And as you said, stress makes people sick, and on the basis that stress makes people sick, relaxation will help to make them better. How can we negate the effects of stress? How do we breathe when we get stressed? We breathe faster, we breathe shallow, we breathe irregular, and this is keeping the body in that state of fight or flight. So what are we doing? I'm saying to people, "I need you to breathe through your nose. I need you to gently slow down your breathing. I need you to use your diaphragm, and I need you to adopt a cadence of the breath."

Patrick McKeown 39:41 Because when we're looking at the breathing, we need to consider that it's not just about diaphragmatic breathing, or it's not just about breathing in through the nose-

Dr. Rangan Chatterjee 39:49 No

Patrick McKeown 39:49 ... and out through the mouth. Or it's not just about take a deep breath when you're stressed. The information take a deep breath when you're stressed is absolute nonsense. It is based on nothing, and it helps nobody, because if we have a belief that it's good to be taking in that huge, big breath, are we really making any positive change in the body? And what I would say to people is, start just gently slowing down your breath, even to the point of a slight air hunger, by just relaxing your breathing, breathing through the nose, and, you know, just even concentrate on that. Does it change your body temperature? Does it increase the amount of saliva in the mouth? Do you feel different?

Dr. Rangan Chatterjee 40:35 Yeah. I mean, there is so much to talk about with respect to how we breathe and those three elements or those three pillars of breathing. It's, I don't know, it's one of those things. Take a deep breath. As we've already discussed, we made a little video-

Patrick McKeown 40:50 Yes

Dr. Rangan Chatterjee 40:50 ... for people on that. But that whole idea of taking a deep breath, you're not actually against it. You're just against the way most people interpret that-

Patrick McKeown 40:58 Yes

Dr. Rangan Chatterjee 40:58 ... and what they do.

Patrick McKeown 40:59 Yes, yes.

Dr. Rangan Chatterjee 41:00 So what we would demonstrate is that if, to most people, you say, "Hey, take a deep breath," what do they do? They sort of open the mouth, lift the chest up, you know, breathing from the chest-

Patrick McKeown 41:09 Yes, yes

Dr. Rangan Chatterjee 41:10 ... breathing through the mouth.

Patrick McKeown 41:11 Yep.

Dr. Rangan Chatterjee 41:11 And you're saying there is another way to take a deep breath, which is-

Patrick McKeown 41:15 Well-

Dr. Rangan Chatterjee 41:15 ... using your diaphragm through the nose-

Patrick McKeown 41:17 Slow

Dr. Rangan Chatterjee 41:18 ... slow and quiet.

Patrick McKeown 41:19 I'm saying to do the absolute opposite to how you breathe when you are stressed.

Dr. Rangan Chatterjee 41:23 Yeah.

Patrick McKeown 41:24 When we breathe when we are stressed, we sigh more, we breathe faster, we breathe shallow. Instead of sighing, we want to achieve regular breathing. Instead of breathing faster, we want to slow down the breath. Instead of breathing using the chest, we want to breathe using the diaphragm. And the pillar or the crux or the foundation of this is breathe in and out through your nose. And also, it's not just about concentrating on the biomechanics of the breath. You know, we often hear people, "I want you now to breathe using the diaphragm," and this individual is instructed on breathing using their diaphragm, but there is no mention of breathing using your nose. Your nose is connected with the diaphragm. Your mouth is connected with the upper chest. How can you restore diaphragmatic breathing-

Dr. Rangan Chatterjee 42:12 Yeah

Patrick McKeown 42:13 ... unless you restore nasal breathing?

Dr. Rangan Chatterjee 42:15 Yeah. I mean, you've obviously covered this in your book. I, in my last book, The Stress Solution, I wrote a whole chapter on breathing, and I covered how the nose is linked to the diaphragm as well, because it's something that I don't think people are aware of, or certainly not as many people as should be are aware of. Before we go into some of these solutions, some of these exercises, which I think are really, really important, I just wanna back up, because, you know, we mentioned breastfeeding before, how important that can be, and we've also mentioned the early years and how important it is to set the jaw up and the mandible up for life. And there's no doubt that a lot of parents will be listening to this feeling quite panicky when they heard that or thinking, you know, "I wasn't able to breastfeed." You know, m- maybe the child had a tongue tie or there was some sort of problem which meant that they couldn't do it, or they might feel as though, "Oh, it's too late now. Like, my child is 11, and they're mouth breathing, and they've got asthma. Oh, my God, should I have done something different?" So I just want to address this because this in- m- you know, this podcast is about giving out information-

Patrick McKeown 43:18 Mm-hmm, mm-hmm

Dr. Rangan Chatterjee 43:19 ... to empower people and inspire them to start taking control of their health. And I know as a parent myself, when I hear things that, you know, are important at three, four, five, and I think, "Oh, I didn't really do that, and now my kids are past that," there is a bit of parental guilt sometimes. But I, I would like to say from my perspective, there's no need to feel guilty, right? People, everyone's doing the, the best that they can with the knowledge that they know at that time. But if someone is listening to that thinking, "Well, have I screwed up my child's future?" What would you say to them?

Patrick McKeown 43:53 There's, anytime we switch, I switched to nose breathing at 26 years of age. It changed my life. We have people, I have s- clients coming in. They could be 60, 70. We had one woman last week, um, Bridge, and she did the Boston City Marathon exclusively nasal breathing, and she is heading for 70 years of age.

Dr. Rangan Chatterjee 44:14 Oh, my gosh. [laughs]

Patrick McKeown 44:14 There's never a time, there's never a time not to put it into practice. What I would say is, as a parent looking at your child, just pay particular attention. If your child is snoring, if they are twisting and turning, we have to consider could that be impa- impacting the child's cognitive ability during the day. Um, what could you do to address it? Well, number one is sit the child down, and there are simple exercises that you can do with gentle breath-hold exercise to help open up the nose. And even, you know, if the child is watching TV, always encourage nasal breathing-

Dr. Rangan Chatterjee 44:53 Yeah

Patrick McKeown 44:53 ... walking, et cetera, and start bringing it into your way of life. Now, the child at first may feel a little bit of air hunger. We will have all of the videos that we recorded before Christmas-

Dr. Rangan Chatterjee 45:04 We'll, we'll link to everything-

Patrick McKeown 45:05 Yes

Dr. Rangan Chatterjee 45:05 ... all these resources that you've got, Patrick-

Patrick McKeown 45:07 And we'll-

Dr. Rangan Chatterjee 45:07 Which, uh, we'll link to them in the show notes page so that everyone can tune in and actually see them if they wanna do it with their kids

Patrick McKeown 45:13 And you'll see all of the exercises there, and it's completely free of charge. So what I want to do is I would love to see an awareness happening, that we can show kids how to decongest the nose even if they've got a head cold. And as we were working with your two, two youngsters earlier on, you know, I, I... Can you imagine a child going into school? There's gonna be a few kids in there with colds, with coughs, et cetera. There's, of course, the child is coughing. There's germs going into the air. Well, all of the other children, it's vital that they breathe through the nose because it's the nose that helps to sterilize the air on the way in. Nitric oxide is a gas which was first identified on the exhale breath of the human being in 1991, so it's a relatively recent, um, discovery. And nitric oxide plays a number of really important roles in terms of the physiology of breathing. As you breathe through your nose, you carry nitric oxide into your lungs. Nitric oxide is a natural bronchodilator. It helps to open up the airways. Nitric oxide redistributes the blood throughout the lungs to inc- to improve, um, the transfer, the gas exchange of oxygen from the lungs into the blood. And nitric oxide sterilizes the air. Now, we're talking about we hear the first cases of the coronavirus. Well, I'm not saying that nasal breathing is going to prevent the inhalation of a virus, but what I am saying is that you have a better likelihood. Because if you have your mouth open, you are breathing hard, you are breathing fast, and you have no defense.

Dr. Rangan Chatterjee 46:46 Yeah, I mean, that's, that's pretty empowering, Patrick, because, you know, the nose is the filter.

Patrick McKeown 46:51 Yes.

Dr. Rangan Chatterjee 46:51 Right? It's, and a practice that I have been engaging with in the last couple of years, and I don't know why, I don't know where this has come, whether if this is directly from reading your book or just my general understanding of how important nasal breathing is, is that if I'm, like, I was in London last week, and, you know, I was walking somewhere, and this big truck or something went past, and you could smell the smoke.

Patrick McKeown 47:14 Yes.

Dr. Rangan Chatterjee 47:14 I was, init- initially, I was very cautious to s- keep my mouth closed. I thought at least if my mouth is closed, and everything's coming in and out through my nose, at least it's doing some sort of filtration, um, process. Look, I don't have a study to prove that, okay?

Patrick McKeown 47:31 [laughs]

Dr. Rangan Chatterjee 47:31 But it, it makes logical sense to me given the function of the nose. I also, and what comes to this, by practicing a lot of breath holds, which I've been doing anyway, which, uh, you talk about in your book, um, you know, I sometimes will try and hold my breath while I'm going through that for 10, 15 seconds until I'm through, and then I think, "Oh, you know, I didn't breathe out." And so it's a, it's a very simple strategy that we can use to help protect us in this quite toxic modern environment. But generally, what you're saying is it's never too late.

Patrick McKeown 48:01 Oh, absolutely. Absolutely.

Dr. Rangan Chatterjee 48:02 Wherever you are now-

Patrick McKeown 48:03 Yes

Dr. Rangan Chatterjee 48:03 ... if you've never come across the concept of nasal breathing before-

Patrick McKeown 48:07 Mm-hmm

Dr. Rangan Chatterjee 48:07 ... you can still start straight after this podcast. You can start whilst listening to this podcast. Guys, if you're listening to this, if you're walking, if you're sitting at home, if you're doing the housework, why don't you just try right now to keep your mouth closed as you're doing it-

Patrick McKeown 48:21 Yes

Dr. Rangan Chatterjee 48:21 ... and see what happens? And even that awareness could be quite profound for people.

Patrick McKeown 48:25 And, Rangan, we have to bear in mind that people will say, "Well, I have my mouth closed all the time. It's during rest. But when I go to a gym, how am I going to breathe?" You should alw- also breathe through your nose when you're doing physical exercise. I will tell you the reasons why. When you breathe through your nose, you've got increased oxygen uptake, you've got increased oxygen delivery. It's less trauma to the airways. If you are breathing hard and fast through an open mouth, moisture is sucked out of the airways, both out of the throat, out of the lungs, and especially if you're prone to exercise-induced bronchial constriction. Your nose is targeting the diaphragm. Diaphragmatic breathing helps generate intra-abdominal pressure. Intra-abdominal pressure is basically that as you are breathing in, your diaphragm is moving down. That's almost that it's bracing the abdomen like a pneumatic balloon, that your abdomen is, you know, changing to provide stabilization or support for the spine. So why would you breathe through an open mouth when you have got less oxygen uptake and less, less oxygen delivery to the tissues? Now, I get it. People switch to nose breathing when they are doing exercise. The air hunger is too much, so they go back to mouth breathing. But if you persist with nose breathing for a period of time, six, eight weeks, your exercise intensity will improve to the same par, but your ventilation will be a lot less. If you look at a paper by George Dahlem, he was a well-known triathlete in the United States. He's also an academic, and he switched to nose breathing during his physical performance back many, maybe six, seven years ago. But most recently, he published a paper in 2018. He asked, "What happens when we get a group of recreational athletes and we have them switch from mouth to nose breathing for a period of six months? What adaptations take place?" Okay. When the individuals switched to nose breathing for six months, then when they were tested using a graded exercise test, they had, with nasal breathing, 39 breaths per minute, with mouth breathing, 49 breaths per minute. With nose breathing, the CO2, or the carbon dioxide, in their blood, which is not just a waste gas, even though we breathe to get rid of excess CO2, we have to bear in mind that we need a certain amount of concentration of carbon dioxide in our lungs, in our blood. The CO2 in our, in the blood through, uh, as measured by end-tidal CO2, was 44 millimeters of mercury pressure by nasal breathing versus 40. But the individuals, they were able to achieve 100% work rate intensity with 22% less ventilation. Now, can you imagine doing all of your physical exercise with 22% less breathing? And if you think it's good to breathe hard, if you see somebody walking down that street and that individual is breathing hard with noticeable breathing and they are running out of air, you are hardly going to say that that's a recipe of fitness. If you were going for a run with an elite athlete, that athlete will have light breathing, relatively, for the intensity and duration of physical exercise. How hard do you breathe? How economical are you with your breathing? Can you change it? Yes, you can.

Dr. Rangan Chatterjee 51:52 Yeah, amazing. I mean, 22% less ventilation, that's like you're doing the same intensity of work-

Patrick McKeown 52:00 Yes

Dr. Rangan Chatterjee 52:00 ... and exercise-

Patrick McKeown 52:02 Yes

Dr. Rangan Chatterjee 52:02 ... but with a much more efficient engine.

Patrick McKeown 52:04 Totally.

Dr. Rangan Chatterjee 52:05 Thinking about it in terms of cars, right?

Patrick McKeown 52:06 Yeah.

Dr. Rangan Chatterjee 52:06 It's just like getting a, a much more, a much bigger and more efficient engine.

Patrick McKeown 52:10 Yep.

Dr. Rangan Chatterjee 52:10 And who wouldn't want that, right?

Patrick McKeown 52:12 Yeah.

Dr. Rangan Chatterjee 52:12 And what's super fascinating is that, I don't know if you, um, follow Eliud Kipchoge or not. You may not. Okay, so you're shaking your head. So he's the, um, Kenyan athlete. He's the best marathon runner in the world at the moment, and he recently ran a sub-two-hour marathon with some pacers and with some, um... He was wearing some Nike, I think they're called Vaporfly shoes. I mean, there's, there's, it's, it was, irrespective of what was used to achieve that, it was an incredible human achievement. And the pace of, he needed to run, I mean, I can't even imagine running that pace for one kilometer, let alone for 40-plus kilometers. It's utterly incredible. But I have watched some of that video footage back, not all of it, but what I can see, and I've looked at pictures of Eliud Kipchoge online as he's running that, and it looks to me as though his mouth is always closed. It looks as though he's always nasal breathing, and what was really remarkable for me at the end of the race is that he looked as though he was just starting, right? There was no panting. He just looked... There was no shoulders elevated. There was no change in posture. It was just complete relaxation. It wa- Certainly, that's how it appeared to me, and he is probably one of the most ef- has probably one of the most efficient human engines probably in the world, given what he's achieved. But it's remarkable to me that he looks as though he's breathing through his nose, and he doesn't look as though he's actually trying that hard.

Patrick McKeown 53:44 So when we consider the factors which are essential to sustain nasal breathing during physical exercise, one of those is going to be the size of the nasal cavity. Obviously, if you have a better developed nose, you can handle a larger amount of air. There's less resistance to breathing, so you're not gonna feel air hunger. Another factor is the length of time that you can hold your breath for comfortably. And yeah-

Dr. Rangan Chatterjee 54:07 Is, is, is this what you, you have in your book that's called the Bolt-

Patrick McKeown 54:10 Yes

Dr. Rangan Chatterjee 54:11 ... Test or the Bolt Score?

Patrick McKeown 54:12 Yes. Yeah, yeah. And-

Dr. Rangan Chatterjee 54:13 Okay, can you talk us through that? 'Cause I think that is something I try and do regularly.

Patrick McKeown 54:17 Mm-hmm.

Dr. Rangan Chatterjee 54:17 Um, possibly not as regularly as I could do it, but I have done it, and I think it's potentially easy to misinterpret, so I wonder if you could take people through that Bolt Score, 'cause I think many of the listeners can actually do it at home straight after this show, right?

Patrick McKeown 54:33 Yeah, of course. Totally. So all you need is a watch or you need a, your phone with a, with a timer. Take-- You sit down for first about five minutes. Rest. Just have normal breathing. Don't make any changes to your breathing.

Dr. Rangan Chatterjee 54:44 Through your nose?

Patrick McKeown 54:45 In and out through your nose.

Dr. Rangan Chatterjee 54:46 So, okay, so you're sitting down for five minutes-

Patrick McKeown 54:47 Mm-hmm

Dr. Rangan Chatterjee 54:48 ... with the mouth shut.

Patrick McKeown 54:49 Yes.

Dr. Rangan Chatterjee 54:49 Breathing in and out through your nose. You might be reading. You might be chilling out, but y- anyway, nothing strenuous

Patrick McKeown 54:55 Then take a normal breath in through your nose, a normal breath out through your nose, pinch your nose, and time it in seconds the length of time it takes for you to feel the first definite desire to breathe. Now, accompanied by that, you might feel that your diaphragm muscle involuntary moves, or you might feel that the throat muscles are involuntary contracting. When you resume breathing, your breath should be fairly normal. So this isn't a test of the maximum length of time you can hold your breath for. This is a test after you exhale normally, how long does it take for your brain to react to the point that you have stopped breathing? So it's a more physiological, you know, more objective measurement because I don't want necessarily individuals holding their breath for as long as they can, because if they've got good willpower and determination, some of the athletes will hold their breath until they go, go blue. So it's not really an objective measurement. Now, what does the Bolt Score measure? The Bolt Score measures the degree of dyspnea or breathlessness. It's a measure of exercise tolerance. If you have a low Bolt Score, you can imagine somebody coming in, they have asthma. This individual gets breathless when they're going for a walk. I sit them down. I look at their breathing. Their breathing is fast and shallow. You know, there's no natural pauses following exhalation. And I measure their Bolt Score, it's 10 seconds. I know from their Bolt Score that I can predict how they breathe, and also by watching their breathing, I can predict their Bolt Score because-

Dr. Rangan Chatterjee 56:29 What, what should their Bolt Score be?

Patrick McKeown 56:31 A minimum for that individual is 25 seconds, and a minimum for any of us is 25 seconds. The International Journal of Sports Physical Therapy, they did some research. It was published in 2017. They wanted to have a screening tool of dysfunctional breathing patterns in athletes. Now, they looked at the breath from a number of different perspectives, but they concluded that breath-hold time of 25 seconds was key. If you have a Bolt Score of at least 25 seconds, and they measured it exactly according to the instructions of the Bolt Score. They didn't call it Bolt Score. They just call it breath-hold time. If the breath-hold time, if the breath-hold time was 25 seconds, there is an 89% chance that dysfunctional breathing isn't present. Now-

Dr. Rangan Chatterjee 57:20 89% chance that dysfunctional breathing is-

Patrick McKeown 57:21 Is not present

Dr. Rangan Chatterjee 57:23 ... not present-

Patrick McKeown 57:23 Yes

Dr. Rangan Chatterjee 57:23 ... if you hit a Bolt Score of 25.

Patrick McKeown 57:25 A minimum of 25, yes.

Dr. Rangan Chatterjee 57:26 Minimum of 25.

Patrick McKeown 57:27 Yes.

Dr. Rangan Chatterjee 57:27 Can, can I just clarify? Because you mentioned that it is a measure of exercise tolerance.

Patrick McKeown 57:33 Yes.

Dr. Rangan Chatterjee 57:33 But you don't mean it's just for athletes who wanna exercise, right? That exercise tolerance is relevant for even someone who is inactive and just wants to get on with their life.

Patrick McKeown 57:43 Well, just look at this with people with sleep apnea. We have been measuring breath-hold time for the last 20 years, and we, you know, the science seems to be catching up. One Dr. Messineo, he looked at one of the phenotypes of sleep apnea, and it's called loop gain. Loop gain affects, high loop gain affects about 30% of the population with obstructive sleep apnea. They either have a restriction or, or a reduction to the flow of their breathing during sleep, or they stop breathing altogether, which would be an apnea. So 30% of that population have high loop gain. And he wrote a paper that was published, and he asked, "How can we measure high loop gain in obstructive sleep apnea?" We can measure it by using breath-hold time during wakefulness. So if I have a client coming in, and that client is telling me they have obstructive sleep apnea, of course, I want to look at that person's breathing because their breathing is going to influence the flow and also the upper airway dilator muscle in the airway. In other words, if we think of obstructive sleep apnea, it's almost that it's a battle going on. The negative pressure created during inspiration as air is drawn into the lungs is bringing the airway inwards, and we are dependent on the upper airway dilator muscles. We have a set of muscles in the throat which are designed to help maintain an open airway. So we need to look at two aspects. We want to open up the airway, but we also want to reduce the flow. But by using breath-hold time, you can predict one of those phenotypes, loop gain. And by improving breath-hold time, you're, you are reducing the chemosensitivity of the body to carbon dioxide. In very simple terms, every breath that you take in your regular breathing is not driven by oxygen. What is driving your breathing is that you have cells in the medulla, the central chemoreceptors in the brain, in the most primitive part of the brain, and those cells are monitoring the change to blood pH as a result of the changes to carbon dioxide. If you slow down your breathing, carbon dioxide increases in the blood, and the brain reacts by sending the stimulus to breathe. If you stop breathing, the same thing happens. If you have a reduced sensitivity to carbon dioxide buildup, you have lighter breathing. You have lighter breathing during physical exercise. You naturally breathe slower. You will naturally breathe more likely to using your diaphragm, breathe through your nose, and you have lighter breathing during sleep. Now, I think it may be time to talk even about snoring and about obstructive sleep apnea because it's not just about the airway. We have to consider the flow. If you were an engineer, and if you were considering a pipe, you would never consider the pipe in isolation. You would always ask the question, what is supposed to go through that pipe? Now, in terms of sleep medicine, most of the emphasis is on looking at the airway. Most emphasis is on looking at the pipe. Nobody is looking at the flow. I want to, you know, when I'm working with somebody, I want to change their breathing pattern during wakefulness, which will translate into lighter breathing during sleep. When there's lighter breathing through the nose driven by the diaphragm, there is less turbulence in the nose, snoring reduces, there's less turbulence and resistance to breathing in the throat. We can help obstructive sleep apnea.

Dr. Rangan Chatterjee 1:01:21 Yeah. There's so many thoughts going on in my head at the moment. Um, the Bolt Score, I think everyone should try and do that themselves.

Patrick McKeown 1:01:32 Yes. Yes.

Dr. Rangan Chatterjee 1:01:32 Um, common mistakes that I've seen, and certainly I've made myself, is you hold on for a bit too long. It's when, it's when you get that first urge to breathe. And I think when you watched me do it, and we made a video of that, which will be on the YouTube channel, um, I went on probably a couple of seconds longer than I should have done.

Patrick McKeown 1:01:52 Mm-hmm.

Dr. Rangan Chatterjee 1:01:52 Because, and, and you detected that because I needed to take quite a medium-

Patrick McKeown 1:01:57 Mm-hmm, mm-hmm

Dr. Rangan Chatterjee 1:01:57 ... sized breath afterwards, and it, that means I've gone on a bit too long, doesn't it? It should be-

Patrick McKeown 1:02:01 Yeah

Dr. Rangan Chatterjee 1:02:01 ... a very smooth breath at the end of it.

Patrick McKeown 1:02:02 Yeah. Your breathing should be fairly regular. Now, I wouldn't get too hung up about it because even if the individual, if they hold their breath for a little bit too long, just be consistent with the breath hold.

Dr. Rangan Chatterjee 1:02:12 Yeah.

Patrick McKeown 1:02:12 Because sometimes people have difficulty, well, is it this point or is it that point? Don't worry about it. You know, all you're doing is you're let- you're measuring the length of time that you can hold your breath for comfortably. Now, I see people coming in with panic disorder and anxiety, and if you are prone to panic disorder, you can have a very strong fear response to the feeling of suffocation. So just be careful when you're measuring the Bolt Score, because as you hold your breath, carbon dioxide increases in the blood, and you just may have an exaggerated response to the buildup of CO2. However, if you are prone to panic disorder, it is vitally important that you address your breathing patterns. Because we know traditionally, if an individual had a panic attack, what was the first thing that was often told? Get a bag.

Dr. Rangan Chatterjee 1:03:01 A paper bag.

Patrick McKeown 1:03:02 Breathe in and out of the bag. And then what's the purpose of the bag? The bag was there that you're breathing into the bag, you're breathing in t- from the bag, and you're bringing carbon dioxide back into the lungs to increase it in the blood. As carbon dioxide increases in the blood, the blood vessels open, they dilate, and also you have what's called the right shift of the oxyhemoglobin dissociation curve. In other words, red blood cells release oxygen in the presence of carbon dioxide. Now, if I have somebody prone to panic disorder coming in, they can often have a very exaggerated alarm response to the feeling of suffocation. So when I'm working with them, I want to give them a teaspoon of suffocation. So I give them a teaspoon of suffocation, a teaspoon of air hunger, and I gently build it up over a period of time, and this way their Bolt Score improves. And w- it's almost that we are dic- deconditioning. Not only are we helping to change the breathing pattern disorder, but there has to be a psychological thing happening that we are deconditioning them towards the feeling of suffocation. So when they do experience suffocation in their ordinary everyday life, it doesn't put them into the same panic mode as it would have done before.

Dr. Rangan Chatterjee 1:04:17 Yeah. You know, when someone's having a panic attack or they're suffering from anxiety, almost certainly their breathing will also have changed.

Patrick McKeown 1:04:26 Yes.

Dr. Rangan Chatterjee 1:04:26 Not almost certainly, it will have. And unless that's addressed, you know, you can take medication, you can see a therapist and do CBT or whatever, you know, is recommended for you, which can all have value.

Patrick McKeown 1:04:38 Mm-hmm.

Dr. Rangan Chatterjee 1:04:39 But none of that is directly looking at your physiology and the way you are breathing. And actually, if you're gonna sort of tackle something in a 360-degree fashion and really try and get, give a rounded approach to health, then it almost seems like madness that we don't address the breath.

Patrick McKeown 1:04:57 Yes.

Dr. Rangan Chatterjee 1:04:57 And, and obviously that's what you do with, with, with your clients. And, you know, Patrick, you, you're a very humble man, but you, you are working with some top people, aren't you? Olympic athletes, Navy SEALs, top CEOs. I mean-

Patrick McKeown 1:05:10 Yes

Dr. Rangan Chatterjee 1:05:10 ... you know, you work with a lot of people who want to be performing at their best.

Patrick McKeown 1:05:15 Mm-hmm.

Dr. Rangan Chatterjee 1:05:15 And nasal breathing is a fundamental part of what you do with people. I, I want to go into some more exercises. Um, I would love people to do that Bolt Score themselves, see what it is. Obviously we're looking for 25 as a minimum.

Patrick McKeown 1:05:30 Mm-hmm.

Dr. Rangan Chatterjee 1:05:30 Many people will clearly get a 10 or a 15.

Patrick McKeown 1:05:34 Yes.

Dr. Rangan Chatterjee 1:05:34 But you would tell them not to panic, right? There's plenty that they can do.

Patrick McKeown 1:05:37 Yes, totally. So what we want to do is we want to improve their Bolt Score. It's just a measurement. How do you do it? The foundation is switching to nose breathing.

Dr. Rangan Chatterjee 1:05:46 And on that-

Patrick McKeown 1:05:47 Yes

Dr. Rangan Chatterjee 1:05:47 ... before we go any further, and I want to ask this so I don't forget, a lot of people will say, "That's fine, but my nose is blocked," right?

Patrick McKeown 1:05:57 Yes.

Dr. Rangan Chatterjee 1:05:57 That is a very, very common thing for people to say. I put it out on my Instagram this morning that I was, uh, talking to you, and I think that question came up quite a lot. It's like, you know, "But how can I breathe through my nose because it's blocked?"

Patrick McKeown 1:06:08 Okay. To un- to decongest your nose, to unblock the nose, you hold your breath. The only thing I'll say is, if you have high blood pressure, don't hold your breath if it's unstable. If you're pregnant, don't do this breath hold exercise, or if you have any kind of serious medical complaints, don't hold your breath. But if you're in general good health and your nose is stuffy and you want to decongest the nose, take a normal breath in through your nose, a normal breath out through your nose, pinch your nose, and you could just gently nod your head up and down as you hold your breath, and keep on holding your breath for as long as you can to generate a strong air hunger. When you generate a strong air hunger, let go of your nose, breathe through it, and calm your breathing immediately. Wait about a minute or so, do it again, and repeat it six times. Your nose, you should feel that your nose is opening up. But you will container, you will continue to have nasal obstruction until your Bolt Score is 25 seconds. So don't be surprised If your nose gets stuffy again thereafter, like when I first switched from mouth to nose breathing, of course I was feeling an air hunger. Because if you've been going around with your mouth open for so many years, we develop a habit of breathing hard and heavy. And now all of a sudden when you're breathing through your nose, you feel that you're not getting enough air. I would say continue to maintain nasal breathing. Even if you feel a little bit of air hunger, continue with it because ultimately that's what it's about. Now, there's breath-hold exercises you could do as well. You can take a normal breath in through your nose, a normal breath out through your nose, pinch your nose, and just walk around holding your breath. And continue walking and holding your breath until you have a moderate to strong air hunger. Then let go, breathe in through your nose, breathe normal for about a minute or so, and repeat that six times, and you will find that your nose is starting to open up. But I'm gonna come back to the slow breathing. It's amazing sometimes that science is catching up with this. If you go into Google and if you type in slow breathing, Stanford Medical School, in March of 2017, researchers, they first identified this structure in the brain of mice, and they said that this structure is different because it's spying on your breathing. And if you breathe fast, this structure is relaying signals of agitation to the rest of the brain. But it's more, also more likely to waken you from sleep. And if you breathe slow, this structure is relaying signals of calm to the rest of the brain.

Dr. Rangan Chatterjee 1:08:50 Yeah.

Patrick McKeown 1:08:51 You know, there is such a feedback loop here. Stress and anxiety is causing our breathing to be faster, but faster breathing is feeding back into stress-

Dr. Rangan Chatterjee 1:09:02 Yeah

Patrick McKeown 1:09:02 ... and anxiety.

Dr. Rangan Chatterjee 1:09:02 I mean, absolutely. Uh, I mean, I always talk to people about this idea that breathing is information.

Patrick McKeown 1:09:08 Yes.

Dr. Rangan Chatterjee 1:09:08 Right? And I say to people that, look, if you're rushing around, if you've got a work deadline, if you're trying to get all your emails done and you're not aware, almost certainly your breathing will change, right?

Patrick McKeown 1:09:19 Yes.

Dr. Rangan Chatterjee 1:09:19 You're gonna be breathing faster. You're gonna be breathing more from your chest, your upper chest, than from your, your, your diaphragm.

Patrick McKeown 1:09:25 Yes.

Dr. Rangan Chatterjee 1:09:26 And that's gonna send signals to your brain on a, on a very primal level that there is danger in my environment. Things aren't going well. Which then the brain will send signals back down to your breathing, and you'll be in this feed forward cycle-

Patrick McKeown 1:09:39 Yes

Dr. Rangan Chatterjee 1:09:40 ... where you start to breathe faster and faster and faster.

Patrick McKeown 1:09:42 Yes, yes.

Dr. Rangan Chatterjee 1:09:42 But the beautiful thing about that is you can hack that, for want of a better term, straight away by changing the way you breathe.

Patrick McKeown 1:09:50 Yes.

Dr. Rangan Chatterjee 1:09:50 Because if you change the way you breathe, if you slow it down-

Patrick McKeown 1:09:52 Yes

Dr. Rangan Chatterjee 1:09:53 ... if it's more diaphragmatic than from the chest, well, you're sending calm signals up to the brain.

Patrick McKeown 1:09:58 Yes.

Dr. Rangan Chatterjee 1:09:58 And the brain is then sending those calm signals back down.

Patrick McKeown 1:10:00 Yes.

Dr. Rangan Chatterjee 1:10:00 So it's a very simple way for people to understand breathing is information. The way you breathe is the way you live.

Patrick McKeown 1:10:08 And by gently slowing down your breath, and a lot of the research is centering around six breaths per minute. So when I'm working with a client, the first time w- what we'll do is we work in the biochemistry of breathing, so we generate a air hunger. Then I will spend so much time working on the biomechanics of breathing. Then I will work on the cadence of the breath, and I have the client simply breathe in two, three, four, and out three, four, five, six. And I continue with that. And we are changing the respiratory rate from their normal spontaneous breathing down to six breaths per minute. Why? Because the research shows that you can influence the autonomic nervous system. Bodily systems which have been disturbed by stress, especially long-term stress, and the research is looking at post-traumatic stress disorder, um, irritable bowel syndrome, anxiety, and also depression has been featured, that when you slow down the respiratory rate to six breaths per minute, it's stimulating the vagus nerve, it's increasing heart rate variability, it's increasing the synchronicity between your respiration and the timing of your heartbeat, and it's also exercising or increasing the sensitivity of baroreceptors. Now, I'll just talk about those for just one moment.

Dr. Rangan Chatterjee 1:11:34 Yeah, sure.

Patrick McKeown 1:11:35 Our body has an innate capability and a need to be able to respond well to the environment. We need to have a balance between the parasympathetic and the sympathetic. If a challenge comes our way, we should be able to adapt to it. Life is always going to throw us a curved ball. How does our body react to it? This is about resilience, and people with really good functioning of the autonomic nervous system, they can cope better with what life is throwing at them. Now, in terms of can you improve that, if you read the paper or, or an article by Mark Russo, it's called Slow Breathing, you will see that they have done quite a lot of research looking at the, the application of slow breathing to general health. When you slow down the breath to six breaths per minute, you stimulate baroreceptors, which are pressure receptors in the major blood vessels in the aorta and in the carotid arteries, and they become more sensitive. So when there's an increase of your blood pressure, the baroreceptors send an immediate message to cause your blood vessels to dilate and your heart rate to slow down so that it brings down your blood pressure. But conversely, if your blood pressure is low, the baroreceptors immediately react that, by causing your blood vessels to constrict and your heart rate to increase to normalize your blood pressure. But the sensitivity of your baroreceptors are a very good marker of your resilience in life. Now, it's not just about slow breathing. As you pointed out, we do breath-holding as well. Now, why would we do breath-holding? We want You know, to stress the body a little bit because we can cause adaptations to happen there. Like modern life now, it's all about comfort.

Dr. Rangan Chatterjee 1:13:25 Yeah.

Patrick McKeown 1:13:25 But throughout our evolution, we were always exposed to little stressors, and I think it's good. You know, physical exercise is a stress. Um, going into a cold environment is a stress. We can improve our ability to cope by doing stressors, and breath-holding is a stressor.

Dr. Rangan Chatterjee 1:13:43 Yeah. The breath-holds you recommend, Patrick, are exhale breath-holds.

Patrick McKeown 1:13:48 Yes.

Dr. Rangan Chatterjee 1:13:49 And there's a lot of, um, techniques out there where they do inhale breath-holds. I wonder what is the difference in doing an inhale breath-hold? And for people who are new to these terms, I'm just basically talking about when you take a breath in, before you breathe out, I'm talking about a hold there where you sort of hold your breath as long as you can potentially, as a inhale breath-hold, as opposed to when you've, you know, you breathe in, you breathe out, and then you hold. I'm calling that an exhale hold.

Patrick McKeown 1:14:19 Yes.

Dr. Rangan Chatterjee 1:14:19 So is there a difference?

Patrick McKeown 1:14:21 Yes, there's quite a difference. If you breathe in, you know, this became popular, breath-holding in sports became popular in the 1980s. Um, there was a very famous swimming coach, his name was James Counsilman, and he introduced what he called hypoxic training for swimmers. His whole technique was breathe in and hold the breath. But if you breathe in a lung full of air, you have so much more oxygen in the lungs to transfer into the blood and for the cells to use that oxygen before your blood oxygen saturation drops. So if you breathe in and hold your breath, it's very difficult or it's more difficult to lower your blood oxygen saturation.

Dr. Rangan Chatterjee 1:14:59 And why, and that's-- Why is it important to lower your blood oxygen saturation? 'Cause a lot of people will think, "Hold on a minute, I don't wanna lower it, I wanna, I wanna increase it."

Patrick McKeown 1:15:08 Yes.

Dr. Rangan Chatterjee 1:15:08 So why is that a good thing?

Patrick McKeown 1:15:10 We use it mainly for sports performance because what I want to do is, you know, athletes are aware of the importance of training to stimulate anaerobic glycolysis, and generally what they do is high-intensity interval training. However, if an athlete repeatedly does high-intensity interval training, it's traumatic, and it increases their risk of injury. What we want to do is, I want to disturb the blood acid-base balance by lowering blood oxygen saturation. Because if you take a normal breath in through your nose and a normal breath out, and if you hold your breath, during that time, your cells continue to extract oxygen from the blood, but you are not replenishing it through breathing because you have stopped breathing. But also during that time, carbon dioxide cannot leave the blood through the lungs, and as a result, carbon dioxide is increasing and blood oxygen saturation is dropping. This combination of the two effects is increasing hydrogen ions, and it's forcing, in some way, it's not known exactly where it is happening, but it's thought that the buffering capacity inside in the muscle compartment is, is increased. And what this in turn then, it delays lactic acid and fatigue. So basically, the runner, the, the person who is doing sports can push themselves without-- They can delay fatigue, so they can continue going on for longer. Now, I'll give you an example of a, a paper that was used. It was published in 2018 by Woorons, W-O-O-R-O-N-S, and he was wor- working with 21 elite rugby union players from Australia. Now, these are professional athletes during peak season. He trained them with exhale hold breath-holds, the same as what we do. He had two groups. He had 10, 10 athletes in one group, the experimental group, and 11 athletes in the control group. He was measuring their repeated sprint ability. For four weeks, he got the athletes in the experimental group to breathe in through the nose, breathe out, pinch their nose, and sprint for 40 meters on a breath-hold. He got them to do eight repetitions twice a week for four weeks. With the control group, they did 40-meter sprinting with normal breathing. Then he measured them four weeks later. The repeated sprint ability in the experimental group increased from nine to 14.7, and the repeated sprint ability, which I will explain what it is in a second, increased in the control group from nine to about 10.4. Now, here we have a remarkable gain with an elite group of athletes, and usually when you're talking about elite athletes, if you could have a fraction of a percentage improvement, that's a gain. But to increase repeated sprint ability from nine to 14.7 in just four weeks. And what's more, the experimental group who were doing breath-holding, they dropped two sessions of anaerobic training because they didn't want the athletes to get to overdo it. Now, what is repeated sprint ability? Repeated sprint ability is a performance indicator in any team sports. You can imagine you're watching a soccer game. You have the soccer player, they're sprinting at an all-out effort, and then they have a very brief recovery before they sprint again, and a very brief recovery before they sprint again. So it's almost that it's a marker of the performance ability in team sports, and as a measurement to be able to increase it quite considerably in four weeks, that's the testament to using breath-holding. But what's more, I think most athletes, they're not aware of it.

Dr. Rangan Chatterjee 1:18:57 Yeah.

Patrick McKeown 1:18:57 You know, they're not aware of, like, it's not just about your breathing on a football field or whatever game you play. It's about your everyday breathing, and it's also about tapping in, incorporating breath-hold exercises. Because if I'm giving-- To give you an example, if I get a, give a presentation, and I talk quite a lot and I, you know, I'm giving presentations to different groups of people, and I used to get a little bit anxious of it becau- of course, you g- you're going out.

Dr. Rangan Chatterjee 1:19:25 Yeah.

Patrick McKeown 1:19:25 And I don't like using PowerPoint, so I'll often talk off the cuff. And you can be talking for an hour, and you've no backup Um, and the reason that I don't like PowerPoints is because people get hypnotized by this white light, and they're not looking at me at all. I want to connect directly with the audience in front of me. So what would I do? Before the event, I would go into a separate room, and I would really slow down my breathing and take my attention out of the mind, onto the breath, and bring a quietness to the mind and bring myself into the zone. But then I'm too relaxed. I have, I have focus, but I'm too relaxed. Then I do five strong breath holds because this increases blood flow to the brain. It opens up my nose. It opens up my lungs. It puts me into that state of pr- preparedness.

Dr. Rangan Chatterjee 1:20:15 And how do you-

Patrick McKeown 1:20:16 And then I go out

Dr. Rangan Chatterjee 1:20:17 ... and how do you do those breath holds?

Patrick McKeown 1:20:18 So I simply, I will be in the room. I know I'm about to talk in, say, five or 10 minutes. I'll take a breath in through my nose, a breath out through my nose. I pinch my nose, and I simply walk around, holding my breath until I feel a medium to strong air hunger, then I let go. I breathe through my nose. I calm my breathing. I wait a minute. I do it again. I do about five of them. Um, we also have athletes do it pre-competition.

Dr. Rangan Chatterjee 1:20:42 Yeah.

Patrick McKeown 1:20:42 And it's really good for alertness because you want to be going. If you're making a presentation, you don't... You want to be relaxed and focused, but you don't want to be too relaxed. I want to have absolute stillness of the mind, whereby I can focus 100% of my attention on the delivery, and I want, I want my attention to move simultaneously with time. I spent 20 years living in my head, stuck in my head, and with all of my attention, pretty much, thinking all the time. And, you know, this is another topic for conversation because Western education, it has gave us a great ability to think. We can decipher. We can break information into tiny pieces. We can reason. We have been trained how to think, but we have not been trained how to stop thinking.

Dr. Rangan Chatterjee 1:21:37 Yeah.

Patrick McKeown 1:21:37 We need also to be able to bring a solitude to the mind. How can you create gaps between thoughts? And it's not that we want to turn the individual into vegetable, but we want to have choice. We don't even hardly pay attention to what we're thinking about. We're talking about lack of awareness of the breath. How about lack of awareness of the mind?

Dr. Rangan Chatterjee 1:21:59 But, but it, it's, it's such a big problem that I think it's such a great topic to talk about, Patrick, that everything in our society is about getting into our heads, thinking more-

Patrick McKeown 1:22:10 Yes

Dr. Rangan Chatterjee 1:22:10 ... reading more online, getting more information and knowledge. I've been absolutely guilty of this, and it's just head, head, head.

Patrick McKeown 1:22:16 Yes.

Dr. Rangan Chatterjee 1:22:16 And the big thing I'm really becoming aware of in the last, probably the last three or four years is how to switch that head off and how to-

Patrick McKeown 1:22:24 Yes

Dr. Rangan Chatterjee 1:22:24 ... come back into your body-

Patrick McKeown 1:22:26 Yes

Dr. Rangan Chatterjee 1:22:27 ... and how to start trusting your feelings and your intuition. You said what you do just before going in to give a talk-

Patrick McKeown 1:22:34 Mm-hmm

Dr. Rangan Chatterjee 1:22:34 ... and I think that has real take-home value for people. A lot of people will be thinking, oh, I might do that before I give a presentation at work, or I have to talk in front of people, or, you know, whatever they have to do.

Patrick McKeown 1:22:44 Yes.

Dr. Rangan Chatterjee 1:22:45 What I have found when I do breath holds, Patrick, uh, apart from the benefits you're talking about, it automatically switches your mind... Sorry. It switches your head off. Your thoughts stop. Why?

Patrick McKeown 1:22:57 Right.

Dr. Rangan Chatterjee 1:22:58 Because when you feel a medium air hunger, that's one of those life-threatening... On, on that sort of deep, primal level, that, if that continues for another minute or two, that's a threat to life, right? So you start to shut off everything else, and you come right into your body. So I find it one of the most, one of the simplest ways to come into your body. And I guess if people have tried meditation and struggled, right, I would say try some of the breath holds that Patrick's mentioned already in this talk or that are in your book, and just see what happens because it's almost, it's default mindfulness. Like, you can't do it without being mindful.

Patrick McKeown 1:23:38 Yes. Yeah.

Dr. Rangan Chatterjee 1:23:38 So I, I really enjoy doing those breath holds, and, you know, the, the, the take-home here for people is just incredible. That's to increase performance, right, and reduce stress. Um, you mention about that exercise how you can unblock your nose. Now, guys, just a few hours ago, Patrick taught my wife that exercise. She struggles with her nose. She says that she breathes through her mouth because she finds her nose is blocked all the time. Literally, after a few rounds, she's got a smile on her face. She can, you know, she's, she can definitely feel it's a lot easier to breathe through her nose.

Patrick McKeown 1:24:12 Mm-hmm.

Dr. Rangan Chatterjee 1:24:12 And I know feels very motivated now to do the exercises that you recommend in your book. And I've got to say, Patrick, on a side note, I'm so delighted that you did it with her because I have been trying my best for [laughs] probably a year-

Patrick McKeown 1:24:26 Sure. Of course

Dr. Rangan Chatterjee 1:24:26 ... to talk to her about this stuff. And you know what? It, I get it. It's just human nature. It's very hard to talk to the people you love about stuff. Um, but I think she really connected with the way you described it.

Patrick McKeown 1:24:35 Mm-hmm.

Dr. Rangan Chatterjee 1:24:35 And so for people who are listening to this and people who ask me on Instagram, what do you do if your nose is blocked, well, you, there is something you can do for that. It's one of those-

Patrick McKeown 1:24:45 Yes

Dr. Rangan Chatterjee 1:24:45 ... those exercises.

Patrick McKeown 1:24:46 Yeah, even if you have a head cold. And I'll just point out that when you do, when you take the normal breath in, out, pinch nose, walk, hold your breath, and when you resume breathing, maybe half an hour later, an hour later, your nose gets stuffy. Do it again. You also have to maintain nasal breathing, and you have to practice slowing down the breath. And as your Bolt Score increases, then, in the long term, your nose is more open. But give it two weeks. Sustain it for two weeks, even if you feel a little bit of air hunger. And I'm just gonna point on one thing before you come back. The emotions of the mind, meditation is wonderful, you know, the focus of the, of the attention from the mind onto the breath. However, if the mind is in an emotional turmoil, it's impossible to meditate. Because how can you have your attention on your breathing when your mind is all over the place? The last thing you want to do is focus on your breath. Instead, do breath holding. And that was a great point that you mentioned. When we stop breathing and the mind stops thinking. So what I would say is, don't do extreme breath holding when you're in a state of major stress or anxiety. Start off with small breath holds, the ones that we started off when we were working with your kids. Take a normal breath in and out through the nose, pinch the nose, hold the breath for five seconds, then let go. Breathe in through your nose, breathe normal for 10 seconds, and again, take a normal breath in and out, pinch the nose, hold for five seconds, then breathe normal for 10, and continue to do that way. We've used it with many people with anxiety and stress, and the feedback has been very good.

Dr. Rangan Chatterjee 1:26:33 Yeah. A- and just to sort of further that theme of kids, um, a few weekends ago, we all went out for a walk at the weekends, and I thought, "You know, why don't I try that walking breath hold exercise with the kids?"

Patrick McKeown 1:26:48 Yes.

Dr. Rangan Chatterjee 1:26:48 I've never done it with them. It's ... I normally do most things with them, but I, for some reason, it never come up, and I'd been practicing it by myself. So we were out, you know, in some nice countryside walking, and I explained it to them. You know, I didn't make a big deal about it, and we started doing it and they loved it. We had a bit of competition-

Patrick McKeown 1:27:03 Yes

Dr. Rangan Chatterjee 1:27:03 ... between each other. Now I think there was a bit of, um, nose sort of breathing out going on when they were-

Patrick McKeown 1:27:09 Sure

Dr. Rangan Chatterjee 1:27:09 ... meant to be, like, holding their breath. But nonetheless, it was super fun, actually.

Patrick McKeown 1:27:14 Yeah.

Dr. Rangan Chatterjee 1:27:14 And it's something I think I'm gonna do more and more-

Patrick McKeown 1:27:16 Yes

Dr. Rangan Chatterjee 1:27:16 ... like every couple of weeks when we're out at the weekend walking. Just making it fun rather than, "Oh, there's this thing you've got to do-

Patrick McKeown 1:27:22 Absolutely

Dr. Rangan Chatterjee 1:27:22 ... and can you do this breathing? I want... You know, Daddy wants you to do more of that." It's more, it's just a fun thing to do.

Patrick McKeown 1:27:28 Yes, yes.

Dr. Rangan Chatterjee 1:27:28 And I think it will have... It's something the whole family can do together, right?

Patrick McKeown 1:27:31 Yeah. It's, it's not a technique. It's literally, you know, nobody is going to continue doing exercises for the rest of their life. But let's look at how you are breathing now. Are you breathing fast, shallow, and have, and having the mouth open? That's going to impact you in some way. Just make it a concerted effort to bring your attention onto the breath, to slow it down, and make that your everyday ritual. And as you pointed out, all of our attention is going outwards, and seldom do we bring our attention inwards. And there is an intelligence in the human body. Can you imagine a machine that for 75, 80 years was conducting all of the functions of the human body? There's an intelligence in the human body which is so far going to outweigh anything that mankind can achieve. We can tap into that intelligence, and I'm hoping this is not new agey stuff. You know, I was living in my head for 25 years. I would walk into a beautiful park. I wouldn't see the park because I wasn't there. I, all of my attention was in my head. Now, when I go into the park, yes, of course, thoughts come into the mind, but less. There's gaps between the thoughts. I can bring my attention into the present moment. I can see, I can listen, I can feel, I can smell, and I can taste. And that's how we are relating to life. But you don't relate to life if you're stuck in your head. And as Oscar Wilde, he said that, "Thinking is a disease and people die of it just like any other disease." So, you know, there's that link between the emotions, the sleep, and the breath, and that's what we want to tie into.

Dr. Rangan Chatterjee 1:29:21 Yeah, yeah. Very, very profound. Um, a good mate of mine who has read your book, actually, he was recommended your book by his dentist-

Patrick McKeown 1:29:30 Mm-hmm

Dr. Rangan Chatterjee 1:29:31 ... which is super interesting.

Patrick McKeown 1:29:33 Yes.

Dr. Rangan Chatterjee 1:29:33 Um, so obviously a lot of dentists are aware of the importance of nasal breathing for oral health.

Patrick McKeown 1:29:38 Yes.

Dr. Rangan Chatterjee 1:29:39 And he's a keen runner, and he's started introducing nasal breathing into his runs, over a period of months. But he's found, 'cause he's, he sort of tracks everything with his-

Patrick McKeown 1:29:48 Mm

Dr. Rangan Chatterjee 1:29:48 ... I think it's his Fitbit. He sort of tracks heart rate and all that kind of stuff, and he has seen huge improvements. So he's seen his, um, his speed go up on these kind of 5, 7, 9K, 10K runs or whatever. He's also seen that his heart rate stays lower during those runs. So not only is he going faster, his heart rate's not elevating as much, which goes back to what you were saying maybe half an hour ago about efficiency.

Patrick McKeown 1:30:12 Yes.

Dr. Rangan Chatterjee 1:30:12 So he has now got a much more efficient engine.

Patrick McKeown 1:30:14 Yes.

Dr. Rangan Chatterjee 1:30:14 So my question is, a lot of people who listen to this podcast enjoy doing parkrun at the weekends. And parkrun, I'm sure you are familiar, but for those of you who are not, is a 5K run that is done on Saturday mornings in your local community. Now some people walk it, some people run walk it. So if they are already doing a 5K and they enjoy it, and they do it with their mouth open, which I'm sure the majority of people are doing. In fact, when I go to my parkrun and watch, pretty much everyone-

Patrick McKeown 1:30:46 Mm-hmm

Dr. Rangan Chatterjee 1:30:46 ... is doing it with their mouth open. Why should they think about going through the process of training themselves to be able to do it with their mouth closed?

Patrick McKeown 1:30:56 Well, it's about, it's about efficiency. It's about improving the economics. It's easier to sustain. There's less trauma. To give you an example, if you breathe out through the mouth, there's a 42% greater water loss. And historically, I've often heard of it, that primitive tribes, when a boy was becoming a man, one of the tasks or the rituals that they would put the boy through was to take a mouthful of water and to go for a run in the desert and to reach a destination and to spit out the mouthful of water. And you could say, "Well, why would they have that ritual?" Well, it's like this. If the boy got strander- stranded in the desert, and if the boy was persistently mouth breathing- That boy is going to dehydrate. The nose is not just for moistening the air on the way into the lungs, but the nose is also for trapping the moisture on the way out. So there is a 42% greater water loss breathing through the mouth. Dental health. You talked about the dentist. When we have a dry mouth, and many of your, you know, if they're just recreational athletes, they may be breathing very hard, and they are feeling an intense feeling of breathlessness, and often that can put people off doing physical exercise. But I will give you, first of all, I will point out, I'm gonna talk about two different things here. When you breathe hard through the mouth, the mouth gets dry. It's not good for your dental health. Um, bacteria is more rampant. You're more prone to gum disease. You're more prone to dental cavities. You're more prone to chapped lips. The lips don't chap unless you breathe through the mouth. Because what's happening is that as you're breathing that dry air across the lips, you're drying them out. Then you lick the lips, and it's that vicious circle. But the second aspect of it is Luciano Bernardi, he's got about 500 papers published in PubMed, which is a database of medical papers, and he's an Italian doctor. He was working with his patients with chronic heart failure. And he asked a question, "My patients with chronic heart failure, they have exercise intolerance. They walk, but they get very breathless." Of course, this is going to put you off doing physical exercise. But he asked, was it their chronic heart failure that was causing their exercise intolerance, or was it their poor breathing? So he worked with his patients. He slowed down their breathing to six breaths per minute. By doing that, he modified the baroreflexes, which I talked about earlier on, the pressure receptors in the blood vessels, and that in turn reduced the chemosensitivity to carbon dioxide, so the individual was less sensitive to carbon dioxide. In other words, they could do physical exercise with less breathlessness. Many of the people doing the parkrun, they, they are walking. This is a great opportunity to get out and do physical exercise. Don't be worried about having to go fast. Continue sustaining nasal breathing.

Dr. Rangan Chatterjee 1:34:01 Yeah.

Patrick McKeown 1:34:01 In time, your breathing becomes lighter. And also measure your breath-hold time. If you find that your Bolt Score is 10 seconds, of course you are going to be breathless during physical exercise. But when you get home, sit down on a chair, turn off your phone, bring your attention inwards, slow down your breathing, and gently soften the breath until the point of a light air hunger. This way, you can change your body's reaction to the gas, carbon dioxide, that comes into the blood during physical exercise, which will translate into lighter breathing. Again, the group of people who really need to do physical exercise, they don't want to do it because they get too breathless.

Dr. Rangan Chatterjee 1:34:44 Yeah.

Patrick McKeown 1:34:44 And because they do get too breathless, they don't do exercise. And because they don't do exercise, they get too breathless. Well, you could use-

Dr. Rangan Chatterjee 1:34:52 It's a vicious cycle

Patrick McKeown 1:34:52 It's a vicious cycle.

Dr. Rangan Chatterjee 1:34:53 They're stu-

Patrick McKeown 1:34:54 Yes

Dr. Rangan Chatterjee 1:34:54 ... stuck in a loop.

Patrick McKeown 1:34:55 Yes. And you could be doing slow breathing. And any of the papers that I've cited, I will give you the references of it because I think it's very important. Don't just listen to me. All I've been doing is trying to ju- do- join the dots and, you know, if there's science available on this, this is not just a breathing technique. This is just looking into the functioning of the human body. How best can we make subtle changes to incorporate-

Dr. Rangan Chatterjee 1:35:21 Yeah

Patrick McKeown 1:35:21 ... them into our life to get some benefits?

Dr. Rangan Chatterjee 1:35:24 Yeah, it's incredible. And we will, as many papers as we can-

Patrick McKeown 1:35:26 Yes

Dr. Rangan Chatterjee 1:35:26 ... and the links to them, we will put in the show notes page for this episode because-

Patrick McKeown 1:35:30 Great

Dr. Rangan Chatterjee 1:35:31 ... there's a lot of people who will be listening and want to learn more. I know there's loads of healthcare professionals who listen to this podcast who will probably wanna go and actually dive a bit deeper.

Patrick McKeown 1:35:38 Yes.

Dr. Rangan Chatterjee 1:35:38 And if you guys wanna do that-

Patrick McKeown 1:35:40 Yes

Dr. Rangan Chatterjee 1:35:40 ... it will all be there. If you don't, that is completely fine as well. Just on that parkrun note, I am, you know, I've been working on my nasal breathing for a little while now, and I'm being quite disciplined at the moment. And the parkrun, w- I've not been for a few weeks, but when I go, um, I've been quite disciplined because I'm letting my ability to nasal breathe dictate my pace.

Patrick McKeown 1:36:02 Yes.

Dr. Rangan Chatterjee 1:36:03 Now, you gotta let go of your ego a little bit for that to happen because you're going slower initially.

Patrick McKeown 1:36:09 Yes.

Dr. Rangan Chatterjee 1:36:09 And I'm still in that phase where I'm going slower than I could if I was to mouth breathe, but I'm doing it to improve my efficiency. And I know, I've also spoken to Brian Mackenzie about this, who I know you know Brian. Brian is also a big proponent of nasal breathing. I interviewed him a few months ago. I've not put it out yet. It comes out, it will come out a few weeks after this one, uh, because I really wanna raise, um, the attention given to breathing. I think it is something that we just take for granted. But, you know, I'm... It's really interesting. As soon as I feel the need on the run to open my mouth, I'm us- I'm slowing down because I'm trying to train my efficiency. 'Cause I know if I do that, that-

Patrick McKeown 1:36:47 Yes

Dr. Rangan Chatterjee 1:36:47 ... within months, I'll suddenly start to beat the times I had before-

Patrick McKeown 1:36:49 Yes

Dr. Rangan Chatterjee 1:36:49 ... because I'll be running, uh, a lot more efficiently.

Patrick McKeown 1:36:52 Yes, yes.

Dr. Rangan Chatterjee 1:36:52 But-

Patrick McKeown 1:36:52 Air hunger diminishes over time.

Dr. Rangan Chatterjee 1:36:54 Yeah, but a lot of people don't wanna go through that. They feel, you know, I d- I can't let that person go past me 'cause I normally beat them.

Patrick McKeown 1:37:00 [laughs]

Dr. Rangan Chatterjee 1:37:00 And I think, guys, you gotta just let, let go of the ego a little bit-

Patrick McKeown 1:37:03 That's right

Dr. Rangan Chatterjee 1:37:03 ... and go. And if that's you, if you love doing as fast as you can on a Saturday morning, go for your life. I'm not here to tell you how to do it. But this is a opportunity, potentially, for people who are interested, to start using it as a way of actually training themselves, which is gonna help them be more efficient during their run, but it's gonna also translate into every other aspect of their life. And that's the thing about this for me. It's not just about exercise or focus or sleep. Breath links them all, right? So you get your breathing right, and you improve any aspect of your life that's dependent on your breathing. You also have the potential to improve that as well.

Patrick McKeown 1:37:44 So it's, it's a case this is quality versus quantity. So if you're going for your walk, say, and, um, you're bringing your attention inwards, don't breathe fast and shallow because I will show you how it's very, very inefficient. When we take a breath of air in through our nose or through the mouth, a certain amount of that air remains in what's called dead space. It remains in your nasal cavity, it remains in your throat, in your trachea, in the bronchi, in the bronchioles. So a certain amount of air that you breathe never gets into the small little air sacs in the lungs where oxygen transfers from the lungs into the blood. Now, if you are breathing fast, if you are breathing a lot of breaths per minute, you are wasting a lot of air in dead space. So when you go for your walk, make a concerted effort to take less breaths but to take fuller breaths. That way, breath for breath, you're improving the efficiency of your breathing. So it's possible that you won't run out of air-

Dr. Rangan Chatterjee 1:38:47 Yeah

Patrick McKeown 1:38:47 ... so easily. It's like the woman coming in with chronic heart failure, and I took it from Luciana Bernardi. I had this woman coming in. She was breathing fast and shallow, and her complaint was coming into me, "I'm always feeling breathless." I watched her do a physical exercise. She was running out of air. She was breathing disproportionately for the given level of physical exercise. It was just walking, but she was breathing hard for that walk. I said to her, "Okay. I want you to put your hands either side of your lower two ribs. And as you breathe in, I want your lower two ribs to move outwards. And as you breathe out, I want your lower two ribs to move inwards." Now, I had pulse oximeter on her, which is measuring the fraction of your hemoglobin, your red blood cells occupied by oxygen. When she walked breathing fast and shallow, her blood oxygen saturation dropped to 92%. When we did slow but deep breathing, we increased the blood oxygen saturation to 96%-

Dr. Rangan Chatterjee 1:39:48 Yeah

Patrick McKeown 1:39:48 ... which is just bordering on normal. So here's a case that you can make subtle changes to your breathing. So if you are running out of air, look at your breathing pattern, and don't worry. Listen. Don't worry about people passing you out. They will have dry mouths. They're totally inefficient, and there's no point in adding trauma to the body.

Dr. Rangan Chatterjee 1:40:11 Yeah.

Patrick McKeown 1:40:11 And let your nose dictate the pace at which you do physical exercise because at the very least, you are not going to overtrain.

Dr. Rangan Chatterjee 1:40:19 Yeah. And, you know, I spoke to Brian about this, and I've looked in some of the research on this. It, it very much looks as though if you breathe through your nose throughout exercise, that you recover quicker as well.

Patrick McKeown 1:40:29 Yes, for sure.

Dr. Rangan Chatterjee 1:40:29 Which is incredible because-

Patrick McKeown 1:40:30 Yes

Dr. Rangan Chatterjee 1:40:31 ... for those athletes, uh, amongst the, the audience, and even if you're not an athlete, you know, even if you go out for a walk, a long walk, or you do the park run or whatever, everyone wants to recover quickly. You know?

Patrick McKeown 1:40:42 Yes.

Dr. Rangan Chatterjee 1:40:42 We've all got lots of things we need to get on with-

Patrick McKeown 1:40:44 Yes

Dr. Rangan Chatterjee 1:40:44 ... with our lives, right?

Patrick McKeown 1:40:45 Yes. Yes.

Dr. Rangan Chatterjee 1:40:45 So who doesn't want enhanced recovery?

Patrick McKeown 1:40:47 Yes.

Dr. Rangan Chatterjee 1:40:47 So I think that's really, really, um, I think it's a really important point to remember for people is how quick your recovery can be.

Patrick McKeown 1:40:55 Mm-hmm.

Dr. Rangan Chatterjee 1:40:56 You know,

Dr. Rangan Chatterjee 1:40:56 it strikes me, Patrick, that sometimes modern science teaches us what we've already known for years. And when you talk about the breath and nasal breathing, I'm, I'm intrigued about yoga.

Patrick McKeown 1:41:12 Yes.

Dr. Rangan Chatterjee 1:41:12 And, you know, I've heard you talk before about some of the early yoga texts and what they said because I tell you the, the thing, you know, there's lots of people writing about breathing and in different ways, and I, I as I say, I really, I think your book is brilliant. Really, there's a lot of interesting concepts in there which I hadn't read anywhere else. Uh, so I definitely encourage people to pick up a copy. Um, but the one thing that was really, really new for me in there was this idea of breathing light. Breath holds, fine. I was aware of that. Um, diaphragmatic breathing, again, aware of that, but I certainly was not aware of the importance of breathing light. And you have that exercise, breathe light, breathe right-

Patrick McKeown 1:41:53 Yes. Yes

Dr. Rangan Chatterjee 1:41:53 ... uh, which is brilliant. How does that fit into, let's say, yoga, for example? Is that something that has ever been spoken about in those ancient texts?

Patrick McKeown 1:42:03 Yes, now it is. Um, when-- I will give you a story. There's a woman called Robin Rothenberg, and she's been teaching yoga for about 30 years. And, uh, she was trained in India, and she works from Fall City in Seattle. She developed chronic fatigue, and, uh, she had sleep issues, and she had asthma. Her yoga was helping. But then she came across these exercises, and she started putting them into practice, and it made quite a difference. So she came down to Ireland, and she trained with me for two weeks, and then she went back to Seattle. And she got-- she started writing a book. During the research of her writing the book, she went back as far as she could to the sutras. And when yogi were talking about breathing, they never talked about breathing hard. They always talked about breathing subtle, conservation of the breath, conservation of prana. And she asked a question, how is it that if we go into a yoga studio today, many of them, we will hear people intentionally taking more air? Because that is the complete opposite to how yoga was originally developed. So she has written a book. It's called Restoring Prana, and it was published just before Christmas. And this book documents as best as she could do the transition, how yoga, how breathing during yoga should have been taught, and what has happened today. All of the yoga postures are conducive to breathing light. All of the yoga breath holds, if you had a yoga master They could stop breathing for 180 seconds. They could slow down their breath to one light breath per minute. They could achieve enormous feats of human endurance. But how could they do that? They had light breathing. But this seems to have got lost, so whatever way that the information was transferred throughout the generation, I think it's going to be time to go back to basics. So I suppose if you want, it's because I don't know very much about yoga. Um, my field is, is kind of breathing, and maybe I should know more about yoga, but Robin's book, Restoring Prana, it could be a very interesting, you know-

Dr. Rangan Chatterjee 1:44:26 Yeah

Patrick McKeown 1:44:26 ... um, insight for people who are working with yoga. And the one thing, and sometimes people have said it to me, Rangan, and they've, they've said this, is they, they couldn't have all got it wrong. And I said, "No, they haven't all got it wrong, but, but most of them have." Because if we go into a yoga studio, we are hearing this breathing. Why are, why are the students breathing hard during gentle practice, you know? And you could ask the question, well, when we do physical exercise, we want to breathe more air. Okay, but how much more air are you breathing for a given level of physical exercise? There is no need to intentionally breathe more. No animal does it. And also, back to nose breathing, with the exception of a dog, all of the animal kingdom are innate nasal breathers, and it's only if farm animals are stressed or sick that they switch to mouth breathing. So physiologic, why is it that the human-

Dr. Rangan Chatterjee 1:45:22 That says it all, right?

Patrick McKeown 1:45:23 The human-

Dr. Rangan Chatterjee 1:45:24 That says it all

Patrick McKeown 1:45:25 ... the human is the only animal that doesn't know what their nose is for.

Dr. Rangan Chatterjee 1:45:29 Yeah. That, I mean, for me, that is so profound, that the animals only breathe through their mouth when they're sick or stressed. And then you think about how many of us are mouth breathers, and you flip that and go, well, are we not in a sick and stressed out society? You know, which comes first?

Patrick McKeown 1:45:48 Yes.

Dr. Rangan Chatterjee 1:45:48 It's, you know, they, it goes both ways, right? But that is-

Patrick McKeown 1:45:51 Yes

Dr. Rangan Chatterjee 1:45:51 ... so profound that... Yeah. And I wonder why dogs do that. Any, is there a-

Patrick McKeown 1:45:55 Well, I s- I suppose because dogs are regulating their body temperature.

Dr. Rangan Chatterjee 1:45:59 Right.

Patrick McKeown 1:45:59 Um, because they don't have sweat glands. But also coming back to yoga, there's a few different sayings that, that I've taken that I incorporate in because one is that your breathing should be so smooth that the fine hairs within the nostrils do not move. Okay, that's breathe light. Number two, man's life is not measured by the number of his years, but by the number of his breaths. That's all about slow breathing. So all of this is really coming from yoga.

Dr. Rangan Chatterjee 1:46:31 Yeah.

Patrick McKeown 1:46:31 And I think it's time to go back and uncover what did the original yogi say? What was their message?

Dr. Rangan Chatterjee 1:46:40 Breathing quietly, breathing slowly appears to be the opposite of what one of the most well-known proponents of breathing-

Patrick McKeown 1:46:52 Yes

Dr. Rangan Chatterjee 1:46:52 ... or breathwork out there at the moment is Wim Hof.

Patrick McKeown 1:46:55 Yes.

Dr. Rangan Chatterjee 1:46:56 So a lot of people are following Wim. A lot of people are going on his courses. I saw him lecture a few years ago in California, and, you know, I think he said at the start of the talk that, "Within 20 minutes, I'll have everyone in the room holding their breath for three minutes."

Patrick McKeown 1:47:10 Yes.

Dr. Rangan Chatterjee 1:47:11 I thought, "No chance." But nonetheless, 20 minutes later, there I was [laughs] with-

Patrick McKeown 1:47:16 Yes

Dr. Rangan Chatterjee 1:47:16 ... everyone else, and I had also held my breath for three minutes, something that I thought frankly wasn't gonna be possible.

Patrick McKeown 1:47:22 Yes.

Dr. Rangan Chatterjee 1:47:23 But he's got a very different technique.

Patrick McKeown 1:47:24 Mm-hmm.

Dr. Rangan Chatterjee 1:47:24 So I'm interested into your view on that and how that fits in with your philosophy.

Patrick McKeown 1:47:30 I think it's, it's a very interesting technique. Um, it's, it's a stressor. It's, technically it's intermittent hypoxic, lowering blood oxygen saturation to a very low level. Hypocapnic, lowering also CO2.

Dr. Rangan Chatterjee 1:47:46 Oh, yours is about increasing CO2-

Patrick McKeown 1:47:48 Yes

Dr. Rangan Chatterjee 1:47:49 ... and increasing-

Patrick McKeown 1:47:49 And that's the difference

Dr. Rangan Chatterjee 1:47:50 ... our tolerance to CO2.

Patrick McKeown 1:47:51 Yes, yes. So if you think of the Wim Hof technique, it's typically that you would breathe hard for 30 breaths. Now, if you breathe hard for 30 breaths, you remove a lot of carbon dioxide from the blood through the lungs. Carbon dioxide is the alarm to breathe. If you get rid of so much carbon dioxide, then when you stop breathing, it takes quite a long time for the breathing center to react because you have to wait for carbon dioxide to climb back up to the threshold that it stimulates your breathing.

Dr. Rangan Chatterjee 1:48:24 Is, is that why you can hold your breath for so long?

Patrick McKeown 1:48:26 That's why you hold your breath.

Dr. Rangan Chatterjee 1:48:27 I got it.

Patrick McKeown 1:48:27 It's not because of oxygen. It's because of the depletion of carbon dioxide.

Dr. Rangan Chatterjee 1:48:30 Yeah, so the, the drive to breathe is carbon dioxide-

Patrick McKeown 1:48:33 Yes

Dr. Rangan Chatterjee 1:48:33 ... not oxygen-

Patrick McKeown 1:48:34 Yes

Dr. Rangan Chatterjee 1:48:34 ... as you, you, you've already explained. So you're blowing out a ton of carbon dioxide. So when you then do the breath holds, you can go on for a lot longer-

Patrick McKeown 1:48:43 Yes

Dr. Rangan Chatterjee 1:48:43 ... because you're not getting that signal saying, "Hey, you need to breathe."

Patrick McKeown 1:48:46 Yes. So because you can then hold your breath for so much longer, you're giving the body so much time for your blood oxygen saturation to drop. So during the retention phase, your, when you stop breathing, your blood oxygen saturation drops. And I think on the first cycle, after about 30 breaths and a breath hold, the SpO2, which is the, you know, the measure of how fully loaded are your red blood cells with oxygen, it drops down to about 80%. Then you do, then you breathe in, you hold your breath, just, uh... So basically, it's 30 breaths. Okay, 30 hard breaths, exhale hold, breathe in and hold your breath for 10 seconds, and then 30 more hard breaths, which is getting rid of even more CO2. Then you can hold again for so much longer. You breathe in, you hold, and then you do a third cycle. Now, the carbon dioxide levels never recover. From start to finish. If you look at Mateusz Koks's paper, he's included data here, and the CO2 level drops, so it causes respiratory alkalosis, and blood pH increases quite significantly to 7.75. It's very, very alkaline. So it's really a stressor to the body. Now, the SpO2 doesn't increase, so we have to bear in mind that in the blood, 98% of our oxygen is carried bound by hemoglobin. That's already almost fully saturated at the beginning of the study. Because if we were to measure the vast majority of people, their SpO2, it's normal. And if you start breathing hard, if your blood is already fully saturated or almost fully saturated, you're not going to add any more oxygen in.

Dr. Rangan Chatterjee 1:50:27 Okay.

Patrick McKeown 1:50:27 However, the PO2 increases. This reflects the amount of oxygen that's dissolved directly in the blood. So the Wim Hof technique is an interesting one. Now, ultimately, what is the question here? Does it increase oxygen delivery to the tissues? And here is a question I don't have an answer for, but let's look at it a little bit detail. When you breathe hard, you don't increase the blood oxygen saturation, and you get rid of so much carbon dioxide. This causes a left shift of the oxyhemoglobin dissociation curve, so hemoglobin holds onto oxygen more readily. Hard breathing is reducing the oxygen delivery from the red blood cells to the cells. That's causing a net loss of oxygen delivery. However, on the other hand, hard breathing is increasing the oxygen that's dissolved directly in the blood. That will increase the diffusion of oxygen from the blood to the tissues, but we have to bear in mind that oxygen is relatively insoluble in plasma, in water. So is it a net effect or not? I would possibly think, if I was to put my money on it, I would say that the Wim Hof technique is causing a deprivation of oxygen delivery. It is not, it is not causing an increased oxygen delivery to the tissues. The benefits of the Wim Hof technique is it's activating a real sympathetic response. This, in turn, is increasing the release of adrenaline, epinephrine, et cetera, and this is forcing the body to make adaptations. This coming, this is coming back to the, the whole thing. Don't be living in a comfort society. Stress your body a little bit to get your body to make adaptations-

Dr. Rangan Chatterjee 1:52:12 Yeah

Patrick McKeown 1:52:12 ... so that your immune, immune functioning is better.

Dr. Rangan Chatterjee 1:52:15 Yes.

Patrick McKeown 1:52:15 And I think that's what the... It's a really wonderful technique. Um, it's, and I don't have all the answers on it, but what I would say to people is read Mateusz Koks's paper, and he, they go a little bit fairly detailed into it, just what I spoke about.

Dr. Rangan Chatterjee 1:52:28 No, I, I appreciate you, you answering that and trying to sort of, um, work through those mechanisms to try-

Patrick McKeown 1:52:34 Yes

Dr. Rangan Chatterjee 1:52:34 ... and make a, a reasonable, educated guess on what might be happening.

Patrick McKeown 1:52:38 Mm-hmm.

Dr. Rangan Chatterjee 1:52:38 'Cause a lot of people like doing it. They feel good afterwards.

Patrick McKeown 1:52:41 Yes.

Dr. Rangan Chatterjee 1:52:41 I guess if you're talking that we're, generally we're a breath illiterate society. We don't understand the power of the breath. Certainly, if you do the Wim Hof technique, you are aware of the power of the breath, right? You certainly-

Patrick McKeown 1:52:54 For sure [laughs]

Dr. Rangan Chatterjee 1:52:54 ... you know, you're certainly tuned in. And I guess-

Patrick McKeown 1:52:56 Yes

Dr. Rangan Chatterjee 1:52:56 ... taking it one step further, with all these things, it's not about saying good or bad, is it? It's about understanding what role they serve.

Patrick McKeown 1:53:04 Yes, yes.

Dr. Rangan Chatterjee 1:53:04 And we can have many different breathing techniques that are-

Patrick McKeown 1:53:08 Mm-hmm

Dr. Rangan Chatterjee 1:53:08 ... available to us.

Patrick McKeown 1:53:08 Yes.

Dr. Rangan Chatterjee 1:53:08 So we can choose to do the ones that we want to give us-

Patrick McKeown 1:53:12 Yes

Dr. Rangan Chatterjee 1:53:12 ... the outcome we want. I guess if you, you know, use exercise as a comparison, you've got resistance strength training, you've got cardio, you've got high-intensity interval training, you've got yoga restorative flows. You, you know, there's a whole variety of different, uh, options for you if you want to be physically active.

Patrick McKeown 1:53:31 Yes. Totally.

Dr. Rangan Chatterjee 1:53:31 And I guess the more breathing, the bigger the breathing menu out there-

Patrick McKeown 1:53:35 Mm-hmm

Dr. Rangan Chatterjee 1:53:35 ... the more that, you know, people are gonna tune into the ones that they like. But I think it's, it's really useful that, to understand what it's doing. And for me, I guess, it sounds like there's huge benefit there. And I, I was meant to interview Wim last year, but we, we, we couldn't make that date work, and I, I hope to get him on this year, 'cause I would like to explore that a bit further. Um, but it is interesting that if we are fundamentally living in a carbon dioxide intolerant society, so which we are, which you passionately talk about, Brian McKenzie talks about, is very clear that we are, um, which is where these breath holds come in so beautifully, don't they? They train us to actually be able to tolerate a increased concentration of carbon dioxide-

Patrick McKeown 1:54:20 Yes

Dr. Rangan Chatterjee 1:54:20 ... which then leads to more oxygen going-

Patrick McKeown 1:54:21 Nasal breathing, yes

Dr. Rangan Chatterjee 1:54:22 ... into our tissues, which is fantastic.

Patrick McKeown 1:54:24 Yes.

Dr. Rangan Chatterjee 1:54:24 But I guess the Wim Hof method won't be addressing that. I can't see physiologically how it would be addressing that particular aspect of breathing. It could be addressing other aspects, but I can't see how it would address that one. Although I, again, I, I could be misplaced on that. Um, d- does that sound like a reasonable sort of-

Patrick McKeown 1:54:44 Well, like the only data that I've looked at is, well, I've, I know the technique in terms of what they're doing, and when I look at Mateusz Koks's data, um, I have to consider does it, and this, does it cause what's called a Bohr effect, B-O-H-R. In 1904, Danish physiologist Christian Bohr, he said that the carbon dioxide pressure in the blood is very important because as carbon dioxide increases in the blood, the red blood cells, which are carrying oxygen, release oxygen to the tissues. Now, if during the Wim Hof technique, from reading Koks's paper, the carbon dioxide drops at the start due to hyperventilation, and even during every breath hold thereafter, it never recovers. So you have a net loss of carbon dioxide, which would imply a left shift of the oxyhemoglobin dissociation curve. And just on that topic, never do breath holding underwater.

Dr. Rangan Chatterjee 1:55:40 Yeah.

Patrick McKeown 1:55:40 And the reason being is because If you hyperventilate and you get rid of so much CO2, and swimmers unfortunately have done this, they s- they stand or sit at the s- the side of the pool, they hyperventilate, they get rid of their alarm to breathe because they get rid of carbon dioxide. Then they get into the water, they don't feel any sensation to breathe because you've depleted your carbon dioxide levels, but in the meantime, your blood oxygen saturation is dropping, and they have underwater blackout. There is no warning. That's it. You are out.

Dr. Rangan Chatterjee 1:56:14 People have died doing this.

Patrick McKeown 1:56:15 They have died.

Dr. Rangan Chatterjee 1:56:15 People have died doing this.

Patrick McKeown 1:56:16 They've died.

Dr. Rangan Chatterjee 1:56:16 So-

Patrick McKeown 1:56:16 So never do breath holding.

Dr. Rangan Chatterjee 1:56:18 Just before swimming or-

Patrick McKeown 1:56:19 Yes

Dr. Rangan Chatterjee 1:56:19 ... or get to the water.

Patrick McKeown 1:56:21 Yes.

Dr. Rangan Chatterjee 1:56:21 Okay. That's really, really important.

Dr. Rangan Chatterjee 1:56:24 Patrick, look, I've got a million more questions to ask you.

Patrick McKeown 1:56:27 [laughs]

Dr. Rangan Chatterjee 1:56:27 But I can see we've been chatting for two hours already, and I guess this is a topic that I find incredibly fascinating. I just want to talk to you about mouth tape. You know, a lot of people do use, um, mouth tape, tape up their mouths at night to help encourage them to breathe through their noses. I've got a couple of patients who've done it, and it has literally transformed them. Again, we've got to be careful what we recommend on a podcast, um, but you have used mouth taping with clients, haven't you-

Patrick McKeown 1:56:54 Yes

Dr. Rangan Chatterjee 1:56:54 ... to good effect?

Patrick McKeown 1:56:55 Thousands. Every client. Um, if a client comes in to me, well, first of all, I want to establish that the client can breathe through the nose, and I want to change their breathing pattern because even if the client is feeling air hunger, my role is to give exercise to diminish that feeling of air hunger, to make it comfortable to breathe through the nose. Yeah, in a few occasions, we can't. If the, if the nasal polyps are so extreme, of course, the client then goes back to the doctor, their nose is, is fixed, and then the client comes back to me. And I will make this point. In 1994, I had an operation on my nose, and my nose was fixed, but I was never encouraged to breathe through my nose post-surgery. So if any of you, if you are having an intervention of your nose, if you're on nasal steroids, et cetera, also, it's very important to change the behavior. It's not just enough to fix the nose. And if you have children, if they've had an adenoidectomy and tonsillectomy, the relapse in the worsening of their sleep is a 65% relapse within three years unless nasal breathing is restored. So make sure that if you are fixing your nose, make sure that you actually breathe through it. We need to change the behavior. So my role is change the behavior, and where possible, we help open up the nose in the vast majority of cases. And taping is key, because if the mouth is open for six or eight hours, you're going to slow down your progress.

Dr. Rangan Chatterjee 1:58:20 Yeah.

Patrick McKeown 1:58:20 Now, we have a tape that I was always kind of wondering for children, how can we ensure nasal breathing? And one of the best things with kids was, which, because it was getting so frustrated with me. I'd be working with children, opening up their noses. Child comes in the week later, mouth open. How do we fix this? I said, "Okay. When the child is sitting down during the day watching television, doing their homework, playing with toys, I want that child to wear a half an hour, to wear tape across their lips during wakefulness, because I want the brain to associate-

Dr. Rangan Chatterjee 1:58:54 Yeah

Patrick McKeown 1:58:54 ... their nose with breathing," because we're trying to change a habit, and we don't change a habit in 21 days. That's baloney. It takes 60 to 70 days for the brain to change, that there's new neural connections there, neuroplasticity, that we're unconsciously changing a habit. We change structures in the brain to make sure that this becomes involuntary, that we don't have to think about it.

Dr. Rangan Chatterjee 1:59:18 Yeah, absolutely. And, and you showed me those, those orange, um-

Patrick McKeown 1:59:23 Yes

Dr. Rangan Chatterjee 1:59:23 ... sort of mouth tapes that, that are for kids.

Patrick McKeown 1:59:26 Yeah.

Dr. Rangan Chatterjee 1:59:26 And I can see the incredible value. I tried them on, and they're brilliant because they sort of encourage you to keep your mouth closed.

Patrick McKeown 1:59:32 Yes.

Dr. Rangan Chatterjee 1:59:32 But if you actually do need to open it-

Patrick McKeown 1:59:34 Yes

Dr. Rangan Chatterjee 1:59:34 ... it opens very easily.

Patrick McKeown 1:59:36 Yes, yes.

Dr. Rangan Chatterjee 1:59:36 And so I think if people are a bit anxious. Are those, um, tapes, which you've had created, are they available to buy somewhere for people?

Patrick McKeown 1:59:43 In about four weeks.

Dr. Rangan Chatterjee 1:59:44 In about four weeks.

Patrick McKeown 1:59:45 Yeah.

Dr. Rangan Chatterjee 1:59:45 And where would people go if they're interested?

Patrick McKeown 1:59:47 Um, we, we have a website. It would be myotape.com.

Dr. Rangan Chatterjee 1:59:50 How do you spell that?

Patrick McKeown 1:59:51 M-Y, myo-tape.com.

Dr. Rangan Chatterjee 1:59:54 Myotape.com.

Patrick McKeown 1:59:54 Yeah, because it's after, there's a therapy called myofunctional therapy.

Dr. Rangan Chatterjee 1:59:58 Yeah.

Patrick McKeown 1:59:58 Um, there are some therapists here, but it's a therapy that's often used in dentistry.

Dr. Rangan Chatterjee 2:00:02 Yeah.

Patrick McKeown 2:00:02 So a lot of my work would be with dentists in that if a child is undergoing orthodontics, it's really important that the child learns to breathe through the nose because the tongue is the scaffolding for the teeth.

Dr. Rangan Chatterjee 2:00:15 Yeah.

Patrick McKeown 2:00:16 So you don't want a child to do orthodontics, but by the time that child is 20 years of age, the teeth have gone back inwards. So to ensure a long-term success, nasal breathing is paramount.

Dr. Rangan Chatterjee 2:00:28 Patrick, I think that's a pretty good place to try and close this conversation down. Um, as I say, so much more we could talk about, but I think we should probably start wrapping it up.

Patrick McKeown 2:00:37 [laughs]

Dr. Rangan Chatterjee 2:00:37 Or, or not start wrapping it up. Wrap this conversation up. Um, if there is interest, um, as I say, we can either do an Instagram Live, uh, you know, um, to, to, to answer those questions-

Patrick McKeown 2:00:48 Mm-hmm

Dr. Rangan Chatterjee 2:00:48 ... or we can just do a follow-up podcast [laughs]

Patrick McKeown 2:00:49 Sure, sure

Dr. Rangan Chatterjee 2:00:50 ... 'cause I think there'll probably be that much to talk about. You know, really I think about what you've spoken about today, I think about what's in your book, I think about all the research that's out there, and it really does seem apparent that we have, you know, quite literally under our nose one of the most powerful performance-enhancing drugs available that is completely free.

Patrick McKeown 2:01:14 Mm-hmm.

Dr. Rangan Chatterjee 2:01:15 Right? It's that profound, guys. Getting your breathing improved, starting to breathe more through your nose than your mouth is gonna improve the way that you feel, your energy, your sleep, your breathing, your, um, ability to exercise efficiently. You know, there's so many benefits. Your focus, your performance at work, your performance in life, full stop, right? And for me, that's really why I wanted to get you on this show, to really explain a lot of those benefits to my audience, and my hope is that everyone who listens to this goes away at least trying to do a Bolt Score to see where they sit. But also think about just being more aware. How much are you breathing through your mouth? How much are you breathing through your nose? You know, if your nose is already blocked, Patrick has already covered that, how you can unblock it. We'll link to more videos that he's created. Um, you know, there's so many links out there that you have created so many videos. We'll try and link to as many as possible because people wanna get this information. Of course, you've written step-by-step guides in the book The Oxygen Advantage. But Patrick, just to finish off, this podcast is called Feel Better, Live More. When we feel better in ourselves, we get more out of our life.

Patrick McKeown 2:02:25 Mm-hmm.

Dr. Rangan Chatterjee 2:02:26 And for you, I guess we, we take that a little bit further, and when we breathe better, we live better.

Patrick McKeown 2:02:32 Yes.

Dr. Rangan Chatterjee 2:02:33 Do you have some of your very, very top tips to finish off this podcast? It's probably stuff you've already covered, um, but your very top take-home tips to inspire listeners of my show to go away from this and actually start making changes in their life.

Patrick McKeown 2:02:48 Sure. I think the first one is to observe your breathing, and not just observing the breath, but ob- obviously observe your mind as well. You know, there's an interconnectivity there that we want to start paying attention to ourselves, and awareness is all about giving ourselves some attention. If you notice that you are doing a habit such as mouth breathing or fast upper chest breathing, if you find that you're running out of air, start making changes to address that. And it is about the foundation, it is about nose breathing, but it's also about slow breathing. It's also about light breathing, and it's about breathing using the diaphragm. And if you also want to get that edge, start thinking about bringing breath holding into your way of life. So from a functional breathing perspective, we want to address your everyday breathing, but also as a performance resilience, um, hacking way, you know, to tap into that often untapped edge, breath holding. So I, you know, I would say explore it. You could say, "Well, I've done breathing exercises, and I didn't really feel much of a difference." And I'm saying try this for two weeks.

Dr. Rangan Chatterjee 2:04:06 Yeah. Love it. Patrick, thank you so much for flying over today. Thank you for coming over to my house. Thank you for spending the day with us, teaching us some of your techniques, you know, one on one. Incredibly powerful. If people wanna connect with you online, where can they find you?

Patrick McKeown 2:04:21 Sure. Um, for health reasons, go to buteykoclinic.com, and for sports and focus and performance, oxygenadvantage.com.

Dr. Rangan Chatterjee 2:04:32 And are you on social media?

Patrick McKeown 2:04:34 Yes, we're on YouTube, we're on Instagram, um, we're on Facebook. So-

Dr. Rangan Chatterjee 2:04:38 And on Instagram, what is it? Is it, uh, because it's-

Patrick McKeown 2:04:41 One is think Buteyko Clinic or Patrick McKeown, and the other is Oxygen Advantage.

Dr. Rangan Chatterjee 2:04:45 Sure, and we'll link to all of those, uh, in the show notes.

Patrick McKeown 2:04:47 Thanks.

Dr. Rangan Chatterjee 2:04:47 Patrick, thank you so much. Look forward to the next time when we have this conversation again.

Patrick McKeown 2:04:52 Thank you, Rangan. [upbeat music]