Author: Samantha Holtzhausen, a Cardiopulmonary Physiotherapist at the NHH Pulmonary Rehabilitation Clinic, Cape Town, South Africa.

“It isn’t the mountains ahead to climb that wear you out; it’s the pebble in your shoe.” – MUHAMMAD ALI

What if I told you that the “pebble in the shoe” could be the way you breathe?

Let me explain.

We enter the world with a breath, and the process of breathing continues automatically for the rest of our lives. Although breathing is an involuntary action and we don’t usually give it much thought, the way we breathe has an enormous impact on our overall health. While “correct breathing” should be everyone’s birth right, it has become extremely challenged by our modern society. Over centuries we have altered our environment so dramatically that many of us have forgotten our innate way of breathing. As a result, our “everyday” breathing has become sub-optimal. This presents a problem during physical activity, especially when that physical activity increases in intensity, as it is the quality of your everyday breathing that determines your “performance breath.” So, how efficient is your everyday breathing?

My guess, is that it could use a bit of work. Answer the questions below to see if I’m right:

  1. Do you sometimes breathe through your mouth as you perform basic, daily activities?
  2. Are you breathing through your mouth right now?
  3. Do you wake up in the morning with a dry mouth?
  4. Do you snore?
  5. Can you visibly notice your breathing at rest?

TO FIND OUT: Place one hand on your chest and one hand on your upper abdomen (above the belly button). The more movement you see, the heavier you breathe. The aim is to breathe light

  1. Keep your hands as described above, do you notice more movement from the chest (top hand moving more) or from the abdomen (bottom hand moving more)?
  2. Can you hear yourself breathing?
  3. Do you suffer nasal congestion, fatigue, light-headedness, frequent sighing, tightening of the chest, tingling in the fingers, an inability to take a deep breath etc.?

If you answered “yes” to some or all of the questions above, then your baseline breathing deserves some attention.


Of the three body systems contributing most to athletic performance – cardiovascular, respiratory and musculoskeletal – the respiratory system is, without a doubt, the least appreciated. “Respiratory health in athletes still remains overlooked,” says Dr James Hull, “despite the fact that one in four endurance athletes experience asthma or asthma-type symptoms. Many athletes and their coaches often attribute their respiratory symptoms to deconditioning or assume it is 'just the way you breathe' and yet it is our experience that many of these individuals will ultimately turn out to have evidence of under-treated asthma or breathing pattern problems.”

A conditioned respiratory system is a fundamental building block to enhancing sports performance. In my opinion, it’s the most important block of them all – just hold your breath for a few minutes if you don’t agree. You are likely ticking all the other boxes, such as strength training, optimal nutrition, interval sessions, hill repeats, recovery workouts etc., but if you are not optimizing the way you breathe, you are significantly limiting your performance potential. If you can’t breathe optimally, you can’t perform optimally. And it’s honestly as simple as that. You’re breathing anyway, so why not learn to harness it as a tool to become a more efficient athlete – on and off the trails.

First things first, it’s important to know what normal breathing at rest should look like:

  • Quiet and relaxed
  • Smooth and rhythmic
  • Through the nose and not the mouth (Nose in, nose out)
  • Shoulders and upper chest should stay still, with no accessory muscle use
  • Abdominal ribcage movements, using the lower intercostal muscles and the diaphragm
  • Exhalation passive and relaxed (the abdomen should be relaxed here)
  • Rate of 8–12 breaths per minute

Is this you? If not – what can you change to make your breathing more efficient at rest? Usually the best place to start for most is to use the nose to breathe in and out. Make sure your breath is quiet, slow and into the lower ribs, not the upper chest. Can you do this?

Try this flow after your next work out. If it’s not practical to lie down, you can perform it in any position that feels comfortable:


After exercise, lie on your back, hands behind your head. Close your mouth. Focus on breathing nose (in and out), low (use the diaphragm, 360 degree breathing) and slow (slow down your breath rate). Count four seconds in, four seconds out, or five seconds in, five seconds out - any duration that feels comfortable.


Following 10 x cycles (inhales, exhales) of the 5 x 5's on the left, add in a 10s inhale hold.

e.g. Inhale 5's, hold your breath for 10's, exhale 5's (Repeat x 10)

  • If 5:10:5 is too difficult, drop down to 4's in, 8's hold, 4's out OR 3's in, 6's hold, 3's out. 


During strenuous physical exercise, oxygen consumption increases, leading to a slightly reduced concentration of oxygen in the blood. At the same time, increased muscle activity and metabolic rate produce more carbon dioxide, causing an increased concentration of carbon dioxide in the blood. When there is an increase in carbon dioxide and a decrease in oxygen, breathing is stimulated. In other words – you want to breathe faster because you are sensitive to the build-up of carbon dioxide in the system and therefore want to get rid of it. This is a natural response. However, it results in less delivery of oxygen to the working muscles. Which means, you get tired. Having a greater tolerance to carbon dioxide allows for a more effective delivery of oxygen to your working muscles during exercise. You will also experience a reduction in breathlessness, as your body is able to work harder with far less effort. The result? Enhanced performance.

What is your tolerance of carbon dioxide?

Follow the steps below to test your tolerance, by measuring your exhale breath hold time:

1. Take a small, silent breath in and out through the nose

2. Pinch your nose closed after the breath out

3. Count the seconds until you feel the first definite desire to breathe (Not until you turn blue)

4. At this point, you may also feel involuntary movements of your breathing muscles (i.e. jerking of the abdomen, contraction around the neck)

5. Release your nose and breathe in through it

What was your score?

10 seconds? 20 seconds? 30 seconds? More?

Your tolerance of carbon dioxide indicates how well your body can use oxygen to fuel cells while running

A common starting score for an individual who exercises regularly at moderate intensity is ±25s. If your score is less than 25s, you may experience disproportionate breathlessness during exercise, as well as disrupted sleep, fatigue, a blocked nose etc. By applying individualised breath work to improve your carbon dioxide tolerance, this score can be increased.

This type of breath work also aims to:

  • Lower sensitivity to carbon dioxide
  • Increase endurance
  • Reduce discomfort and fatigue from lactic acid build up
  • Increase oxygen carrying capacity of the blood
  • Improve breathing economy
  • Improve v02max


Located below the lungs, the diaphragm is the primary muscle used for breathing. It plays a role in everything - from oxygen utilisation, to the removal of waste, to core stabilisation when running. But due to the nature of our everyday tasks, with most of us spent hunched over a desk, we place the diaphragm at a mechanical disadvantage. We therefore don’t use this powerhouse of a muscle nearly as much as we should. Instead, we use the mouth to do the nose’s job, gulp large volumes of air into the upper chest and use the neck and shoulder muscles (accessory muscles of breathing) to do so.

Let’s change that. Try these 2 simple exercises at rest:


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There are a number of factors that may limit exercise tolerance in endurance-trained athletes. We’ve briefly discussed breathing efficiency and carbon dioxide tolerance, but what about the strength and endurance of the respiratory muscles? This is important to consider, because unlike any other skeletal muscle in the human body, the diaphragm must contract and relax continuously. That’s hard work. And it’s especially tough if that muscle is weak. Did you know the strength and endurance of the diaphragm can be measured, and trained too? Many endurance trained athletes present with diaphragm weakness, despite being strong in almost all other muscle groups. If your diaphragm is weak, it will struggle to meet the demands that the respiratory system places upon it during intense exercise. As a result, you may recruit the accessory muscles of breathing to help with the increased respiratory load, but you may also feel very breathless, easily fatigued and complain of heavy legs (specifically, the quadriceps).

Inspiratory muscle training (IMT), is a form of resistance training that strengthens the breathing muscles, specifically the diaphragm. The theoretical basis behind the use of IMT is to make respiratory muscles work harder by controlled, forced breathing against an adjustable resistance. The purpose is to make spontaneous breathing without this extra resistance feel easier. It improves function and performance, by decreasing the sensation of breathlessness, decreasing respiratory muscle fatigue, attenuating the metaboreflex (blood-stealing phenomenon) and reducing lactate build-up during exercise. IMT has been extensively researched in the cycling, rowing, rugby and running populations, showing significant improvement in time trial efforts and performance. 


  1. Perform exercise 1 or 2 of “wake up that diaphragm” daily, for 10 minutes. While performing this exercise, breathe only through your nose – think slow, quiet, light. Try do this before going to bed, especially if you struggle falling asleep, it may help
  2. Perform the “recovery breathing” exercise after every workout you do, in any position, with or without the breath hold progression
  3. Develop an increased awareness of your everyday breathing and try to use your nose to breathe, as much as possible
  4. During exercise, start with nasal breathing. If you’re running alone and the aim of the run is an easy, flush out – try to stick with nasal only breathing. Yes your pace will drop and yes its tough (initially) – but give it a try anyway. And no, it’s not impossible. It’s just a skill that requires practice
  5. Try to think of your breathing like the gears of a car:

GEAR 1 - Nose in, nose out

GEAR 2 - Nose in, mouth out

GEAR 3 - Mouth in, mouth out

Now while you’re running easy on the flat, why are you breathing in the same gear you would be in when running up an incline. Try to stay in gear 1 or gear 2 on the flats and the downs and keep gear 3 for when you really need it. If you arrive at a climb huffing and puffing in gear 3, dumping all your carbon dioxide that you need to deliver oxygen to the working muscles, you’ve got nowhere to go from there – you’re all maxed out. Try use the gear system in your next run and see how you go, attempting to down gear to gear 1 as quickly as possible when you’re done with your work out


Physiotherapists with a special interest in the field of cardiorespiratory and with the necessary post-graduate qualifications, are equipped to assess and treat dysfunctional breathing patterns, breathing pattern disorders, chronic respiratory conditions, nasal patency issues, respiratory muscle weakness, respiratory health in athletes etc. By improving breathing efficiency, strengthening the breathing muscles, improving carbon dioxide tolerance and learning to up-regulate the parasympathetic nervous system when appropriate, you could significantly enhance your performance and quality of life. Another advantage of learning to breathe more efficiently is the positive effect it has on post-training recovery, sleep, stress management, anxiety and pre-race nerves.

Following The COVID-19 pandemic, there are a lot of people who have taken an interest in the world of breathing. While the enhanced awareness is great, it is really important to seek out a qualified healthcare professional or cardiorespiratory physiotherapist if you feel you have an issue with your breathing. Changing the way you breathe can be a big deal and the experience is very different for everyone.


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