#30: Shut Your Mouth for Running and Health, with Patrick McKeown

So you have an athlete then that's tapping into something that's so new that his competitors or her competitors are not tapping into it. And it can give you a gain, and it can give you a gain above that 0.5% or, you know, even 1% of an increase to performance. And it's not just about how do you breathe during your physical exercise. How do you breathe during sleep? Because that can be a game changer.

Welcome to the Extra Mileage Show. My name is Floris Gierman. And in On this show, I talk with inspiring guests about ways to become a stronger, healthier, and happier athlete. Let's dive right in. Breathe in and breathe out. Sounds so simple, yet so many people don't know how to properly breathe. And that's what we're going to talk about in much detail this entire episode today. Very honored to have Patrick McCowan on my show. He's the author of The Oxygen Advantage book, which has been referred to me and recommended to me probably about 10 times in the last 6 months here. Tim Ferriss brought it up in his newsletter, the Five Bullet Friday. Um, Chief Running founder Danny Dreher mentioned Patrick McCowan being a big influence on his own breathing during running, um, on one of the last episodes that I recorded with him. And then I've heard about him The Ben Greenfield Podcast, Dave Asprey from Bulletproof Coffee has had him on his show. I saw an episode on London Real. He's been a really influential spokesperson about the right way of breathing. So we're going to take a deep dive into how can you breathe the right way? How can you implement this in your own running and in your own daily life as well? So very excited to, to talk more there. Patrick shares a tremendous amount of detail in this podcast, and some of it might be quite technical and it might go over some people's head. But I think when you listen to it carefully and you take in some of the different lessons that he mentions in there, there's a tremendous amount of value that can be taken out of this episode. And I'm actually sharing some of my own experiments with the breathing techniques that he describes as well. I've been posting quite a bit about this on my own Strava, so if you want to see some breakdowns there, I'll make sure to link to my my Strava account as well. Patrick has recorded many good videos on YouTube as well, so a few of the favorite ones, I'll make sure to include those in the show notes as well. They can be found at extramilest.com/30. So that's the number 30. I don't really have any sponsors for the Extramilest podcast, so I'm just going to be plugging my own thing over here. This podcast is brought to you by PATH Projects, which is the running clothing company that I'm one of the owners of, and we've only been around for about 2 years, but it has been an incredible ride so far, and we've learned a lot along the way. We just came back from Powder Mountain, Utah, where we had our first board meeting on top of a mountain at 9,000-foot elevation. And we went through all of the different things we've learned in the last 2 years and all of our plans for the next 2-3 years here as well. And there's a lot more new products coming out soon, which is exciting. So we're making running shorts, baseliners, shirts, and headwear, and it's only available on our website pathprojects.com. We ship worldwide, so we ship to all customers all over the place, from the UK to Australia to Asia and Europe. So if you want to find out more, take a look at the website there. I hope you enjoyed today's episode with Patrick McCowan. Well, welcome, welcome to the show.

Thank you very much, Phil.

Very nice to have you over here. It has absolutely been fascinating because I want to take a deep dive with you into the right breathing techniques for healthy living and optimal performance. And breathing sounds so simple and automatic, yet so many people are doing it wrong. So over the years, you've worked with thousands of people to improve their overall health and their sport performance. And I want to start out with, with asking you, like, what is the right way to breathe? And what are some of the differences that you have noticed between people breathing right and people breathing wrong?

What's the right way to breathe? Can you ever imagine having to ask that question? Yeah.

Right.

So, you know, it's, we develop many bad habits and there's much, much, much misinformation out there about breathing. When we consider breathing, we need to consider how to breathe to improve oxygen uptake in the blood, improve oxygen delivery to the cells, open up the airways and help to influence the automatic functioning of the body that's normally outside of our control. Many children, adults, persistent mouth breathers, they breathe fast, they breathe upper chest, they have their mouth open during sleep. So from a biochemistry point of view, they don't have optimal breathing, and this is resulting in their blood vessels constricting and less oxygen delivery. But from a biomechanical point of view, they're not generating sufficient intra-abdominal pressure. This is impeding their functional movement. Impeded functional movement increases their risk of injury. Their sleep, because of fast upper chest breathing and mouth breathing, is poorer quality. During physical exercise, their breathing can impact, causing disproportionate breathlessness, reduced oxygen delivery to the tissues, increased lactic acid and fatigue. And the list goes on. So when we talk about breathing, we need to be looking at the impact of breathing on the emotions, and the impact of emotions on breathing, the impact of our breathing on sleep, the impact of sleep on our emotions, and then tie that in with physical exercise. And let's, you know, let's talk about how can you breathe to open up the airways and to increase oxygen delivery? Because we're breathing Less is often more.

How did, how did you go down this rabbit hole of becoming a breathing expert? How did this happen for you?

It was just by accident. It was 20 years ago. I came across this, 1998. Um, and I had chronic asthma for 25 years at the time. I had terrible sleep. I had chronic nasal obstruction. I was in hospital a few times with asthma. I had nose surgery on my nose in 1994. So the surgeon fixed my nose and never told me to breathe through it. And it's still to this day, children and adults are getting nasal surgery. They're doing E&T interventions, they're taking nasal steroids, and they're not changing the behavior of breathing. I came across it by, by accident. I read a newspaper article, a Russian doctor, he said two things, breathe less, breathe through your nose. I started practicing both things and I woke up feeling alert as if I never had experienced such a good night's sleep. My wheezing reduced 50% in that first week. I knew I was onto something and that's, you know, it's absolutely unbelievable how so many people have got this wrong. So many people.

Yeah, it is fascinating. I'm not going to lie. Like I, I heard about you through many different angles actually. Like I saw Tim Ferriss wrote about you in the newsletter. I saw you on the Ben Greenfield Podcast. I ended up buying your book and listened to your audiobook as well. It's an exceptionally good book that goes into much detail called The Oxygen Advantage, and I'll make sure to link to that as well. And the one part that I noticed is once I started experimenting with some of the things that you describe in that book, all of a sudden I became much more conscious and much more aware of my breathing. And so I, I know that you have covered, like, you have been on several different podcasts covering different topics about the nasal breathing, the different benefits. What I would like to jump into a little bit further here is very specifically about running and a few different ways that we can apply this in training, in racing, and a few of the different things there. Because yeah, I started experimenting with this and I want to share a few of these experiments with you and I would love to hear some of your thoughts because I've started posting some of these experiments. Sure. As easy as it sounds, like breathe through your nose during exercise and during even a run at lower intensity, it definitely takes some getting used to. So can you talk to me a little bit more, like the first few times, for example, my nose got runny. Or started experimenting some lightheadedness. Like, what are some of these different experiments or some of these different symptoms? And how long is this happening? And why is this happening?

Well, I suppose if you look at a medical textbook, you will never see a function of the mouth. Breathing is never listed as a function of the mouth. So it's only the nose that's listed as a function of breathing. Now, when individuals go for a run with their mouth open, It's easier to breathe through an open mouth because the resistance is less. Your nose is a smaller entry into the body. And that can impose a resistance to breathing during wakefulness, which is 2 to 3 times that of the mouth. So it slows down your breathing. But this is where it's very beneficial. So what does mouth breathing do during exercise? Well, I suppose if runners realize that mouth breathing is going to cause a greater loss of hydration. There's 42% greater water loss from the mouth than through the nose. Mouth breathing is activating the upper chest. It's reducing oxygen uptake in the blood. It's reducing oxygen delivery to the tissues. It's traumatizing the airways. And during mouth breathing, the fraction of expired oxygen is more. In other words, that the body hasn't utilized that oxygen that has been brought in. So if you switch to nose breathing, it's tough at the start. And it's tough because you're breathing through it from a big space to a small space. Your airway, the nasal cavity, the nose, the nostrils, they impose a resistance and it will depend on person to person. Somebody like me is totally screwed because I've got one nostril which is small and the other nostril which is even smaller again. So I would have to have nasal dilator. To help open up the airway because I've got really structural issues.

What, sorry, I have to, I have to just ask for clarification there. Nasal dilator, please explain.

Yeah. So a nasal dilator is if you put one finger here, either side of your nostrils, put a finger and gently pry your nostrils apart and you will find that it's easier to breathe. Yeah. So a nasal dilator would be a plastic device that's inserted into the nose to help open up the, up the nose. It's based on a maneuver called the Cottle maneuver, after American ear, nose, and throat doctor from the 1970s. Now, some people and some races have really well-developed noses and nasal cavities. African people, they tend to have a better space in the nose. If you often see, we have some black guys coming into the courses. And I'm always, you know, kind of looking at their facial structure. And I'm always interested in from race to race. And it is written about in the literature that some people, some races do have better developed nasal cavities and nasal structure. And that will make running with the mouth closed easier. So Caucasians tend to have smaller noses. And that can make mouth running with the mouth closed a little bit more difficult. But here's the thing, Floris. It makes total sense for everybody, regardless of the size of the nose to breathe through the nose during physical exercise. And yes, initially it is tougher. However, if you continue doing all of your physical exercise with your mouth closed, in about 8 to 10 weeks, you should be able to achieve 100% of your work rate intensity, whether nasal breathing or mouth breathing. However, you will have a lot less ventilation. Because when you switch from mouth to nose breathing, it adds an extra load onto the body. And it's adding this extra load to force the body to make adaptations. What is this extra load? Well, number one is improving respiratory muscle strength. It's adding an extra load onto the diaphragm. The diaphragm breathing muscle becomes stronger, less likely to fatigue. And 50% of athletes are prone to respiratory muscle fatigue. If the diaphragm gets tired, blood is stolen from the legs to feed the diaphragm. And the athlete has to cease. So if you see an athlete, they're going for a run, and the next thing is their legs starting to go from under them, is that due to a buildup of hydrogen ion, which is causing fatigue, which also is impacted by mouth breathing? Or is that due to blood stealing by the diaphragm? The diaphragm is stealing blood from the legs. Second aspect, carbon dioxide increases in the blood with nose breathing. How do we know that? Well, during a run, you go for, if you go for a run with your mouth closed, you feel a greater sensation of air hunger. And the stimulus to cause that air hunger is carbon dioxide. So if you're feeling increased air hunger going for a run with your mouth closed, you know then that there's increased CO2 in the blood. Now, what does carbon dioxide do? Well, it's a catalyst for the release of oxygen from the red blood cells. So when you sustain nose breathing during physical exercise, your body gets more used to the higher partial pressure of carbon dioxide. And because carbon dioxide is the drive to breathe, if you're able to tolerate more CO2 in the blood, then your breathing is going to be less for a given intensity and duration of physical exercise. Now, as CO2 is increasing in the blood, the release of oxygen from the red blood cells to the tissues, to the working muscles, increases. So the working muscles are getting oxygen, better oxygenated. As a result of better oxygenation, the hydrogen ion coming from the muscle gets oxidized to form water. So there's less lactic acid. So there's much better recovery post-exercise, nose breathing versus mouth breathing. Even just think of runner's teeth. You know, runners tend to have bad teeth and it can be related to running time. And I know sometimes people will say, well, that they're drinking a lot of sugary drinks. That's fine. However, their mouth is often dry. And constant hard and mouth breathing is traumatic for the mouth, traumatic for the upper airways, and also traumatic for the lower airways. So how many athletes get frequent colds, chest infections, exercise-induced bronchoconstriction? Your mouth doesn't protect your lungs. Another aspect of your breathing, I'll just give you the last point. Breathing through the nose, you harness a gas called nitric oxide. Nitric oxide, as you're carrying that gas down from your nasal cavity, down your throat into your lungs, it helps to redistribute the blood throughout the lungs. So the oxygen, the pressure of oxygen increased in the blood is 10% higher. So it's not just about increased oxygen uptake in the blood, but it's also about increased oxygen delivery to the cells. It's about stronger breathing muscles. It's about more open airways. Um, no comparison. Mouth breathing during physical exercise, it doesn't make sense, but it's easy. And that's why people do it.

What you describe over there, that your body can get used to it more over time.

Yes.

So I read your book and finished it about 6 weeks ago. And initially at about 137 beats per minute heart rate was the crossover point where I got very air hungry and I felt the need to take deep breath in or start mouth breathing, right?

Yes.

That was about 6 weeks ago. And I've done quite a few different experiments over the last 6 weeks. And so right now I've noticed like all of a sudden that became 142 beats. That I started getting that point then at 145 beats. The other day I went on a 90-minute run and there were hills involved and everything, and even at 156, 157 beats per minute, I was still able to nose breathe. So that transition, I'm blown away how quickly that's actually happening.

Yes, yeah, the body gets used to it, and your air hunger that you're sustaining during physical exercise is going to be related to a number of factors. As I spoke about earlier, the size of the nose. The second thing is Bolt score, which is a measurement of your comfortable breath-hold time after an exhalation. And that's traditionally known as a measurement of breathlessness, dyspnea. So if one has a low Bolt score, they tend to breathe harder for a given intensity and duration of physical exercise. The other thing is about how efficient is our breathing, because if we are breathing fast and shallow, we're wasting a lot of air in dead space. You know, as we take a breath in through the nose or through the mouth, part of that breath is going to remain in the throat, in the trachea, in the bronchi, in the bronchioles, and it doesn't reach the small air sacs where the gas exchange takes place. So if we are breathing faster, it means that proportionately we're leaving more air in dead space. So it's much more efficient that if an athlete is doing physical exercise with the mouth closed, take less breaths, but breathe fuller breaths. And I'll give you an example if I give you the maths. If you take, say, 12 breaths per minute into the, into the nose, and the size of that breath is 500 ml, that gives you a tidal volume of 6 liters. Now when we subtract dead space, We know that it's not 6 liters of air that's reaching the small air sacs, because 1.8 liters remains in dead space. So 4.2 liters gets into the small air sacs. Now, if we switch from 12 breaths per minute down to 6 breaths, and if we double the size of each breath to 1000 from 500 ml, that's giving us 6 liters of air taking into the body. But when we subtract dead space, we are left with 5.1 liters of air reaching the small air sacs. So there's an improvement of breathing efficiency by 20%, just by changing the respiratory rate. So that would be another aspect. And, you know, it's been looked at with people going up into physical, physical, doing physical exercise at altitude. At altitude, their blood oxygen saturation can be dropping quite significantly.. And I know in one study, it was dropping down to 80% was the blood oxygen saturation. Just by slowing down the respiratory rate to 6 breaths per minute, increasing the tidal volume, it increased the blood oxygen saturation from severe hypoxia to mild hypoxia. And I've used the same approach with people coming in with chronic heart failure, because they had increased breathlessness during physical exercise, their blood oxygen was desaturation. So when we're, when we're looking at breathing, we want to see what's the optimum way to breathe to improve the efficiency of breathing. Nose breathing, slow breathing, deep breathing, light breathing. It's a combination of all. So breathing in and out through the nose, it doesn't make sense to breathe in through the nose and out through the mouth. The body has expended an energy when you're breathing in through the nose. The body has heated the incoming air, warmed it, moistened it, and on the breath out, the nose traps that energy, traps the heat, and traps moisture. So some runners who may have to stop off at a lot of water stops, there's a 42% greater water loss breathing out through the mouth. So if a runner is in a hot environment, you know, they need to be able to conserve as much water as possible, and nose breathing is going to do that. So it's, yeah, it's really about looking at the combination. So that was nose breathing. Slow breathing then is don't have so many respiratory rate. You're much better off having slower breaths, having reduced breaths per minute, you know, breathing slower, but breathing fuller. And of course, breathing using, you know, the lower breathing muscle, the diaphragm, breathing using the abdominal with lateral expansion and contraction of the lower ribs. So when we're teaching functional breathing, I don't want to just look at the biomechanics of the breath. I want to look at the biochemistry, the biomechanics, and the cadence of the breath. And by improving that, we can improve breathing during physical exercise.

Yeah. Wow. That's a, that's a lot to take in right there. It's simple enough. It is very simple, but you actually explain all the other elements of what's happening as well. So, so let me walk you through another experiment, right? Because I love doing these experiments. Like, I've been into low heart rate training, like methadone type of training, for the last 8 years. I'm running almost all of my runs with a heart rate monitor, but I've been bringing like the pulse oxygen meter as well. So, so for example, last night I went on to a 90-minute run And now I started experimenting with some more things, right? So at the beginning of the run, I was at 98% before I started.

So that's good.

So, so 98%, which seems to be normal, normal, like at the start, right? Yeah. Then 30 minutes in, after just nasal breathing, I was at 95%. So that dropped 3%. Yeah. Then 60 minutes in, I started like in between 30 and 60 minutes, I started doing some breath holds. And so if you like, my Bolt score is over 30 seconds at this point, so I'm able to start experimenting with some more of these breath holds. And so after 60 minutes, it dropped to 93% using breath holding. Uh, yeah, like using still some of the nasal breathing, some of the breath holding. And then after, after 90 minutes, at the end of my run, I was at 88%. And I'm not, I'm not gonna lie, it really started to get challenging at that point, not just the nasal breathing But sure, even when I'm looking at some of these, like, you inhale, you exhale, and then you hold your breath. Uh, like, those are not— those are not easy to do exercises. And I could tell that sometimes I pushed it a little bit too hard, and I noticed I got an air hunger and I couldn't comfortably breathe through my nose, almost like a panic mode. Then I noticed I overdid it a bit, and then after a few breaths, it came down again. But I would like to know, like, what you're seeing there, some of these numbers, is that in line with what you've been seeing in some of your experiments as well? And also, like, the blood oxygen saturation level you aim for in endurance athletes, what are some of these optimal numbers there that you're trying to go after with training?

Typically, at rest, you're looking for between 95 to 99%, so 97 or 98% is optimal. When you start doing light physical exercise, your tissues are producing more CO2. And if you are maintaining nose breathing, it will increase CO2 in the blood. And the increased CO2 in the blood will cause the hemoglobin, which is red blood cells carrying oxygen, will cause hemoglobin to release oxygen more readily to the tissues. So you will see the drop to the SpO2 due to the increase of carbon dioxide, which is a good thing. Your working muscles are getting more oxygen. If you do physical exercise with the mouth open, obviously the mouth, there's less resistance during physical exercise, so you can breathe more. And you'll tend to have higher blood oxygen saturation with mouth breathing. But we have to bear in mind that with nose breathing, part of the reason that you see a drop to blood oxygen saturation is because of the increase of carbon dioxide. So what's called the oxyhemoglobin dissociation curve, you're going for a run with your mouth closed, carbon dioxide is increasing in the blood, causes a right shift of the curve. And as a result, the affinity of hemoglobin for oxygen reduces, more oxygen is getting delivered. And I made that point already. And when you start doing breath holding, there's a couple of things happening there. Now we always do breath holding after an exhalation. Because we want to drop the blood oxygen saturation. If you breathe in and hold your breath, now you've got lung full of air, you've got two lungs full of air, and your body has to use all that oxygen from the lungs. Yeah, before you see a drop in your blood oxygen saturation. Now the circulation time is about 16 seconds. So for, from the gas to take place, from the gas to travel from the lungs to the fingertip, there's a 16-second. So when you do a breath holding, you're gonna see that you'll have normal blood oxygen saturation for a while. There's a time lag before you start to see the blood oxygen saturation drop. The reason that your blood oxygen saturation drops when you hold your breath is because your cells continue to extract oxygen, but you have stopped breathing. So you're not replenishing that oxygen. And this in turn then is dropping the, lowering the oxygen in the blood. Now at the same time, carbon dioxide is increasing in the blood. Because again, you've stopped breathing during a breath hold. And just as oxygen can't get into the body, carbon dioxide can't get out of the body. So carbon dioxide increases in the lungs, which in turn increases in the blood. And the increase of carbon dioxide will further cause a drop of blood oxygen saturation. So we have a much stronger effect when we do an exhale hold. Now, what does that do? That disturbs the blood acid-base balance. So because of the drop to blood oxygen saturation, the hydrogen ion coming from the cell doesn't get oxidized to form water. The hydrogen ion will form, will associate with pyruvic acid to form lactic acid. Lactic acid then will dissociate into hydrogen ion and lactate. But at the same time, the increased carbon dioxide in the blood forms carbonic acid, and this in turn dissociates into hydrogen ion and bicarbonate. So you're disturbing the blood acid-base balance by really increasing the acidity in the blood, but not just in the blood, but also in the muscle. Now, people talk about doing high-intensity interval training to stimulate anaerobic glycolysis. High-intensity interval training hardly stimulates anaerobic glycolysis at all. If you go for a sprint with your mouth closed, your blood oxygen saturation will go down to about 91%. That's barely hypoxia. But if you do breath-holding with your mouth closed, and you don't even have to sprint, you could just jog, you know, so there's less trauma involved. And we can drop the body into severe hypoxia, which is really stimulating anaerobic glycolysis. So it's less traumatic on the athlete. And what is the principle of this? Well, you know, there's some theories that we're increasing oxygen carrying capacity. I've seen some non-responders. And, you know, when you do breath holding, your spleen contracts to release more red blood cells into circulation. Your kidneys synthesize a hormone called erythropoietin or EPO, and EPO sends a message to the bone marrow to mature more red blood cells. But I think the big thing that we're able to do when we do breath holding is we're teaching the body that the body can go harder and faster without overdoing it. So it's almost that we're training the brain to be able to, you know, push the limits that bit more. We're able to tolerate increased levels of lactic acid or lactate. And we're also increasing the buffering capacity inside in the muscle compartment, which in turn is going to slow down the release of hydrogen ion coming from the muscle into the blood to delay lactic acid and fatigue. I think there's a lot going on with, with these exercises. And I'll give you an example. I'm not sure where you're based, Floris. Are you in Holland?

Are you? Um, I grew up in Holland, but I actually live in Los Angeles right now.

Okay. You're living in LA. Cool. I'm there in about 3 weeks. Ah, so there's a paper that was written by Warons. He's a, he's a researcher from France, from Paris 13 University. And he looked at repeated sprintability in rugby union. So in Australia, rugby union athletes, they were 21 years of age. He selected 21 athletes, 10, approximately 10 were in each group. So 10 were doing high-intensity interval training with normal breathing. And 10 were doing breath-holding for 40-meter sprints. So basically, he replaced normal breathing with breath-holding. Their repeated sprint ability before exhaustion before the trial was about 9 reps. So they could do 9 reps until they were exhausted. And then he had them train for 4 weeks. And it was only 2 sets per week, 8 reps per set. And on the last week, 8 reps, but there were 3 sets. Very easy, very simple to do. And the experimental group who were doing the breath-holding on the 40 meters, at the end of 4 weeks, the repeated sprintability came up from something like 9 to 14.8. And the control group hardly changed at all. It come up from 9.8 to 10.4, but you'll find more accurate figures if you Google Wurunds repeated sprint ability rugby. Yeah, you'll find the paper.

And I'll make sure to link to that as well.

So yeah, and this is just one experiment and there's a lot more that's, you know, looking at it with sports, um, to increase repeated sprint ability in elite professional athletes, And repeated sprintability is a great performance indicator in team sports because it's the ability of an athlete to do an all-out intense sprint followed by a very brief recovery before they can do it again. But to increase it from 9 to 14.8 in 4 weeks during their peak season, that's a great training effect. But, you know, it's really because athletes are not tapping into breathing, some are, and more are, but traditionally they weren't. So you have an athlete then that's tapping into something that's so new that his competitors or her competitors are not tapping into it. And it can give you a gain, and it can give you a gain above that 0.5% or, you know, even 1% of an increase to performance. And it's not just about how do you breathe during your physical exercise. How do you breathe during sleep? Because that can be a game changer.

Let's talk about that part for a little bit because my wife has been giving me some weird looks when I'm sleeping with tape over my mouth, which has been inspired by you and your book. Can you talk a little bit more about the mouth taping?

Yeah, well, it's more so don't breathe through your mouth during sleep. So whether you need tape or not, but if you have the mouth open, your tongue is more likely to fall into the airway, the architecture of the upper airway is more narrow, there's increased resistance to breathing. Breathing, if there's increased resistance to breathing, then you're more susceptible to snoring, you're more susceptible to hypopneas, which are a reduction in the flow of your breathing lasting for about 10 seconds, but enough to drop your blood oxygen saturation by about 3 to 4%. Now, what would that do? That will take you out of deep sleep. So apnea then is when the individual completely stops breathing during sleep. And generally, it'll affect more males than females. It affects older people more so than younger people. But it can affect plenty of younger people, especially the bigger guys. So if a guy has an inch, or sorry, if their neck circumference is 17 inches or greater, they're more susceptible to obstructive sleep apnea. If they're mouth breathing, they're more susceptible. If they're fast upper chest breathing, they're more susceptible. So what does it do? Well, it puts a big stress on the heart, number one. So you have an athlete who's exercising during the day, they're putting their heart under stress. But then they're also putting their heart under stress during sleep. Not good. The second thing is, it doesn't lead to a deep sleep. If you have the mouth open, and if you're waking up with a dry mouth, you're more likely to go to the bathroom, you know, during your sleep, during the night. And also you're more likely to wake up feeling quite tired. So for me, that was a huge thing. I started taping up, but I had such a stuffy nose that I had Breathe Right strips on my nose to keep them open. And I tape on my mouth. So yeah, so your wife thinks you're strange. I would have looked totally different. I woke up feeling alert and having a concentration. And very few sleep people are talking about this. But one was, and he sadly, he passed on about 6 months ago. He was a Stanford-based medical doctor called Dr. Christian Guilleminault. And he was originally a Frenchman living in LA for many, many years. He coined the phrase obstructive sleep apnea. He developed the main measurement called the apnea-hypopnea index. And he was a crusader for the importance of nasal breathing during sleep. I've seen him in conferences stand up. And I, he's, I've seen him talking to his peers. And he would say, you have talked about everything in relation to sleep, but you have missed the elephant in the room. The elephant in the room is the importance of nasal breathing during sleep. And if you Google his name, G-U-I-L-L-E-M-I-N-A-U-L-T, nasal breathing, and you'll see the papers that he wrote about for pediatrics, trying to get children to breathe through the nose. He said it's the only valid and complete correct— it's the only valid and complete correction of pediatric sleep disorder breathing. And I'm just going to make this because some of your listeners are going to have children. And those kids are going to be mouth breathing. It can cause a significant drop in academic ability, cognitive development, development of the face, development of the airway, and development of the child. No child will reach their full potential if they are persistent mouth breathers. But it does affect adults, but not quite the same as kids because they are developing. But all adults should wake up with a moist mouth in the morning.

And that is like, first of all, obviously if you have kids, do not, do not tape their mouth. And, and maybe it might actually be good because we're going to talk through a few of the exercises. Are there any kind of disclaimers that you have to, that you have to mention as well? I know you've, you've mentioned the part of like breath holds, only do it when you're in good physical shape.

When—

yes. So, so maybe you want to throw out a disclaimer just so we're clear.

Sure, sure, of course. Never do breath holding if you're pregnant, if the female is pregnant, if you have any serious medical conditions such as high blood pressure, cardiovascular issues, kidney disease, cancer, etc. Never do strong breath holding. For children, we do have a tape called Myotape, which is due out only in about 3 weeks. We've always had a problem, how do we ensure children breathe through the nose without risk? And after much kind of thinking about it, I brought out a tape called Myotape, but it surrounds the lips. So it's like myo, so it's in the shape of an O. It's based on kinesio tape. The kid just stretches, they take it off, they stretch the tape about 20%, and it completely surrounds the lips. And because of the elastic tension, it's bringing the lips together. But the child can still talk with their mouth open. Or, you know, if the child has a tummy upset, the child is still able to need to use their mouth if necessary. It's only very light elastic tension to bring the lips together. We're also using it for adults. So it's helping with an aspect to reduce risk. And with children, we're launching our free videos for kids, the complete program is going to be available in about 2 weeks, the videos are currently getting edited. And the complete Buteyko program that I've used with children for about 20 years. We're putting them free, absolutely free on the internet. And the reason that I'm doing it is because I know too well the effects that mouth breathing are having on children. But Floris, very few healthcare professionals are talking about it. Even though this is well documented in the literature. I wrote an article, I put it online there on our website, and it's about 3,000 words just looking through the literature of the effect of mouth breathing on the development of kids. It's not good news, but parents aren't aware of it. And we know from the literature that between 25 to 50% of studied kids are persistently mouth breathing. These kids need assistance in changing to nose breathing. Helping to decongest their nose, helping to improve their breathing patterns, learning how to breathe through their nose during physical exercise. So yeah, so I roped in my daughter, she's, she's 9 years of age, she had a bit of a head cold at the time, but I still roped her in. And we had all of the videos professionally done. So we're just, we're just adding text just in case people don't understand my accent, that at least if they don't, if they don't understand me, They can at least read the text.

Perfect. And where can people find it? That's going to be on your Oxygen Advantage website?

No, it's not Oxygen Advantage. It's, uh, buteikoclinic.com. So it's B-U-T-E-I-K-O clinic.com. And it'll be something like buteikoclinic.com/buteikochildren will be the URL, but I could send it on to you anyway. Like we currently have videos there at the moment, but they are about 10 years old. Now they are free. Um, but we've requested people's email addresses so that they get username and password, but now we're just going to leave them open access in the next 2 weeks.

Good, good, good. I do want to transition a bit back to the running component over here. For example, when I'm going out and I'm running at, let's say my max aerobic function, like my math pace of, for example, for me, that's 143 beats per minute. I'm still running about 30 seconds slower when breathing through my nose versus my mouth at the same heart rate. So how long, how long does that take until that difference becomes less? And will that become less over time, or will there always stay like a difference over there? Because on races, I'm still going to be racing with my mouth open, I assume.

Well, you can— what I would say to you during races is do a decent warm-up and warm-up in terms of a breathing perspective, but also alternate between nose and mouth breathing. So don't have all of your race with the mouth open and try and sustain nasal breathing for at least part of the race with the mouth closed. Now, in terms of if we just got a group of athletes, and if I had them do all-out effort with their mouth open versus mouth closed, typically, we would expect them with the mouth closed to reach about 85%, 90% of their peak. So there's a loss of 10% because of the resistance to breathing. But if that athlete was sustaining that over 8 to 10 weeks, we would expect it to come close to 100%. Now, in your instance, it hasn't, okay. It could be due to the anatomical size of the nose, because when you have a smaller nose, there's an even greater resistance. So it's difficult to precisely say it with exactly each individual. It's like I could have another athlete with, you know, a very broad facial structure, and they've got large nostrils, and they can handle a lot of air.

Oh, 100%. Last night, I was feeling air hunger and I make myself a pig nose and it became so much easier. Might be a bit odd to say it, but I didn't have the nasal strips. But as soon as I make myself a pig nose, I could get much more air into it.

And of course it's going to make a difference. And the size of the nose is going to vary from person to person. But George Dallum is an academic in the United States. I can't remember what university he's affiliated with, but He's a very well-known triathlete. And he's been, you know, an athlete for quite a long time. He changed to nose breathing, I think about 4 years ago. And he was very interested in doing a couple of studies on it. So he spent 2 years trying to recruit athletes to breathe through their nose for 6 months. And after 6 months of sustained nose breathing, he wanted to test their performance. Now he spent 2 years trying to recruit athletes. And do you know what the uptake was after 2 years? 10 people, only 10 people. Can you imagine? Only 10 people were prepared to change all of their physical exercise to nose breathing for 6 months. So he got 10 people. After 6 months, he measured their respiratory rate with a graded exercise test during nasal breathing versus mouth breathing. The respiratory rate with nose breathing was 39 breaths per minute. With mouth breathing, it was 49 breaths per minute. He measured their carbon dioxide, end-tidal CO2, which is CO2 in the lungs, which will give you a good approximation of the CO2, the carbon dioxide in the blood. With nose breathing, it was 44 millimeters of mercury pressure. With mouth breathing, it was 40. Now that's quite a big difference. He measured ventilation. With nose breathing, the athletes had 22% less ventilation for the same work rate intensity. Nose breathing, they could achieve 100% of their work rate intensity versus mouth breathing. So in terms of performance, there was no difference. However, these athletes were able to attain the same performance breathing through their nose, but with 22% less ventilation. Now, can you imagine an athlete going for a run, being able to do the same work rate intensity, but with 22% less breathlessness? Already, there's an economical saving there because there's an energy cost associated with breathing. If we, when we breathe, we are using VO2, you know, as we talk here, we're probably using about 2 to 3% of our oxygen consumption. Is just going to support the breathing muscles. If you go for a moderate physical exercise, it's going to be about 6%. Intense exercise, it's about 10%. Maximum physical exercise, 15% of your oxygen consumption is going to support your breathing muscles. So your breathing muscles require oxygen to be able to function. With 22% less ventilation, that's a significant drop in the, you know, in the amount of energy expended by the body to sustain that level of physical exercise. And when they looked at the fraction of expired oxygen, it was a lot less with nose breathing versus mouth breathing. And that will, again, it translates back into or confirms the theory which we put into the book. And the science is only starting to catch up now. We have very few papers looking at the effects of nose breathing during physical exercise. And the few papers that we have, generally a researcher will, he'll round up a few athletes. And he'll say, okay, I'm going to test you now running with your mouth open. And now I'm going to test you running with your mouth closed. And we're going to see if it can make, what's the comparison. It's a crazy thing to do. Because if you introduce nasal breathing to an athlete for the first time, number one is if they've likely never done it before, and number two is they're going to have a drop in their performance. So I think the only way to test this is to do what Dallam did, get athletes to sustain nasal breathing for 6 months. And his surname is D-A-L-L-A-M. And you'll pull up his papers pretty easy. He's got a couple of papers published on, on just on this topic and an interesting read, but I've given you the figures anyway.

So I just want to explore this a little bit further because if you, if I can assume, like even when I listened, for example, you had a conversation on the Runners Connect podcast, you've been on that twice. And I've, I've heard you talk a little bit more about the different approaches for different types of athletes. For example, for athletes just starting out and, and athletes who are quite advanced. And I'm sure that like even when I'm looking at, for example, low heart rate training, at the beginning for someone to run at the max aerobic function, it feels like they have to significantly slow down. Yet athletes who are further developed fat burning abilities and who have a better aerobic function, even running at their math pace is already going to be sometimes quite a bit of an effort. And I think even with the nasal breathing, like, would you apply this, this same approach of nasal breathing to all athletes across the board? Or would you say some advanced athletes might want to do this only on some of their runs, or, or when they're doing like higher intensity training, like it's going to be much harder to, to integrate this, I assume?

Sure. Uh, how you breathe during running is, is going to— is not influenced by how you normally breathe during running. It's your everyday breathing, which influences your breathing during running. If I have an athlete coming into me, I look at their breathing during rest. I look at their breathing, is it functional? I measured their breath hold time, I measured their maximum breathlessness test, I have them nose breathe during sleep. I don't care. It's not just about the athlete, how are they breathing when they're with me? It's more so with the athlete, how are they breathing when they leave me, when they're outside. So I want to improve their breathing efficiency by having a higher BOLT score. So by bringing this into their training, because this ultimately is part of the training, I've seen athletes come in, Floris, I've seen Olympic athletes with a BOLT score of 15 seconds. They are breathing fast and upper chest. And if I see any athlete breathing fast and upper chest, I'm gonna say to them, Listen, how you are breathing, you are going to have disproportionate breathlessness, you're going to have muscle fatigue, and you're going to gas out too soon. And you can train all of the hours under the sun. But physical training doesn't improve your respiratory fitness because the breathing muscles lag behind. And that's something why we have to address breathing. And we have to address it. Yeah, you could use something like We have, you know, the masks that we use. But that's, that's looking at your breathing during your training. It's also your breathing outside of your training. So say, if it's a recreational athlete, I would say to them, do your best to sustain all of your physical exercise with your mouth closed. It just makes a whole lot of sense. And yes, the recreational athlete, their performance could dip a little bit initially. But they will get so many benefits out of it. And in a few weeks, they'll have the same performance. Now, if it's an elite athlete, I would say to them, do about 50% of your training with your mouth closed. It's going to be tougher, it's going to add an extra load. And it's because of this toughness and the extra load that yes, your ability to maintain that intensity is going to drop a little bit. But spend 50% then with your mouth open, so that you're at least able to achieve your max rate intensity. And I would also say to them is, bring breathing into your warm-up. You know, we will have athletes start off, they take a normal breath in, normal breath out, pinch their nose, start walking, then jogging, and then run a bit faster. And, you know, not quite a sprint, but this will be just during the warm-up. So they're going at a low enough intensity. And then I will have them let go of their nose, minimize their breathing for about 6 breaths, normal breathing for 12 to 18 breaths. And then they do it again, normal breath in, normal breath out, pinch their nose, to continue walking, walk faster, jog, jog faster, keep holding, keep going, keep pushing, keep pushing. When the air hunger gets pretty strong, let go, breathe in through your nose, and back down to minimal breathing for 6 breaths, and normal breathing for 12 to 18 breaths. Why do we do it? Well, the oxyhemoglobin dissociation curve, it shifts to the right under two conditions. One is increased carbon dioxide, which causes a drop to blood pH. And the other is increased temperature of the muscles. And what that means is that you're able to get increased oxygen delivery to the muscles pre-physical exercise, before you go out there. But also by doing breath holding, it has a calming effect on the mind. And it also increases blood flow to the brain. So when you hold your breath, you've got increased blood flow and oxygen delivery to the brain, which will increase alertness. It also opens up the nose, and it opens up the lungs. So I do a sequence of slow breathing first of all with the athlete with lateral expansion and contraction of the lower ribs. Especially for athletes who are prone to say, pre-match anxiety. And then after the breath holding, I know this sounds complicated, it's actually not. After the breath holding, I have them take a normal breath in, normal breath out. And then I have them exhale as much of the air as possible out of their lungs, because I want to get rid of the acidity. And I do it a couple of times and then they go out. And the other thing about it is if you do a few strong breath holds just before you were about to go out, into competition. Your spleen is contracting. Your spleen is an organ just underneath the diaphragm on the left-hand side of the body. It contains 8% of your red blood cells, about 200-300 milliliters of blood. It's really high-quality blood, 80% is hematocrit, very rich in oxygen-carrying capacity. And if you do 5 maximum breath holds, you have maximum spleen contraction. You have increased oxygen carrying capacity for at least 10 minutes at the first 10 minutes of your competition.

Wow. Yeah. So, so that was, that is one other question kind of to follow up on this that I'm very curious to hear. So personally, I do quite a bit of sauna training, like heat training, or either in the summer I will go out and put on many layers of clothing and the effects of that, that like I've noticed quite a bit over time at the beginning, it's quite challenging and you can build it up over time. And I believe the effects last 7 to 21 days for that. So I time it correctly before I have like a race during the summer months or before I have like an ultramarathon that I know I'm going to be out in the heat for quite a while. How long do the benefits of the nasal breathing exercises last? Like, is this something that you do and you're going to stick with that and and you're going to see that benefit for quite a while if you've been doing that for several months? Or is it something that you have to continuously keep doing to make sure that those, those benefits maintain?

It will depend on your Bolt score. If your Bolt score remains at a pretty decent level, you're holding on to the benefits. And we don't just use Bolt score. We also use the maximum breathlessness test. So the Bolt score gives you feedback of the onset and endurance of breathlessness.. And it's a very simple test. You take a normal breath in through your nose, normal breath out, hold your nose, and you time it in seconds until you feel the first involuntary contraction of your breathing muscles. And then you let go and you breathe. So we want, we want athletes to be at least above 25 seconds of a BOLT score. If they're less than 25 seconds, they have dysfunctional breathing. Dysfunctional breathing equals dysfunctional movement. Dysfunctional movement equals increased risk of injury. But we also want them to have a decent maximum breathlessness time. And that's take a normal breath in, normal breath out, pinch nose, hold, start walking, and count how many paces, what's the maximum number of paces that you can walk while holding your breath? Now it's a push. That's measuring the upper limit of tolerance of breathlessness. So to answer your question, it's nasal breathing, during every day, and during physical exercise, but breath holding as well, and breath holding on the exhalation. So nose breathing, slow breathing is improving functional breathing, increasing oxygen uptake, increasing oxygen delivery, protecting the airways, you know, influencing the autonomic nervous system, etc. Cadence breathing, for example, increasing HRV, respiratory sinus arrhythmia, stimulating the vagus nerve, all that good stuff. But then we do breath holding to push the boundaries. So we have functional breathing on one hand, that's one pillar, and breath holding on the exhalation is the other pillar. And I want people to bring it into their way of life. You know, I'm not an athlete, but I'll have my mouth closed every night. I walk down the street with my mouth closed. If I'm on a treadmill, I have my mouth closed. I do breath holding. And, you know, if I'm doing presentations to large groups of people, I want to be fully in the present moment. I don't want to have my mind agitated by distracted thoughts. I want to enter the zone. And you can do that and you can replicate that by the breath. I was talking to Dr. John Dullard 2 weeks ago. And he wrote a book called, I think it's either Body, Mind and Sport or Mind, Body and Sport. And back in the late 1990s, he published a paper on the changes in the brain as a result of nose breathing during physical exercise. And these changes were conducive to entering the zone state with athletes. This isn't just about, you know, physical performance. This is also about mental performance and sleep. And our ancestors were nose breathers. Mouth breathing is a relatively recent phenomenon. If you go, you know, to a natural history museum, and if you look at Neanderthal skulls, or if you look at, you know, whatever skulls are available there that have been around a long time, you will see well-developed jaws. You don't see overcrowding of teeth. You see well-forward-developed jaws on the face, good airways, and you will see that there was plenty of space for the nose. And Neanderthals, 2 years ago, researchers said that Neanderthals had wide nostrils to nose breathe, not just during rest, but also during physical exercise. Why is man the only animal running about with his mouth open? The dog does it, but the dog has a reason. No other animal is doing it unless they're sick. So the only one that's sick or not sick that's doing it is, is the man. So we need to change that.

Yeah, very, very well said. I want to be respectful of your time over here. Um, I know, I know you have several different really good resources. Obviously, The Oxygen Advantage book— you've written 8 different books, but your latest one, The Oxygen Advantage, highly recommended. I'll make sure to link to that. You do have an online workshop as well, and you have in-person workshops. Where can people find out more about that?

So in terms of sports, we've kind of a lot of resources up on oxygenadvantage.com. And I give masterclasses online every few, every few months. And I traveled to Santa Monica now in about 2 to 3 weeks, London first, I think, then Santa Monica, then Sydney. So I do a lot of travel with it, with giving classes. And yeah, it's great. I've really seen it, you know, 20 years teaching people how to breathe. Not an occupation I would have advised people to go into 20 years ago, but it's pretty hot now. So it's gaining traction. And I think the science is going to catch up in time. But here was, you know, we've, we've seen this result. We have seen what can happen when you put this into practice. And I'd say to people, you have nothing to lose. The next time you go for a run, just go a bit slower and do your best to sustain regular Breathing in and out through your nose, but take fuller breaths, but take less of them.

Start with that. Awesome. Patrick, thank you so much for your time. I'll make sure to, uh, to link to all of the different tools and, um, people mentioned in the show notes, and hopefully we can continue our conversation again at a later point.

Great.

Thanks very much, Floris. Thank you for listening. I'm going to be giving away one copy of Patrick McKeown's book, The Oxygen Advantage., and I'm going to be giving that away on my YouTube channel. All you have to do is let me know what was one of your takeaways, one of the lessons or favorite quotes from this episode. I'm going to be picking one of the winners from the comments over there. How I'm going to be applying some of these different lessons that Patrick mentions— I want to continue to experiment in the coming weeks over here, and I will be posting more about this on my Strava as well, and majority of my runs is probably going to be nasal breathing. That being said, I want to be realistic as well. I'm also going to be running with some of my friends, and during these group runs, I'm automatically going to be breathing through my mouth. Also, when I'm going to be doing some higher intensity runs, especially like when I'm going to be pushing it, I know I'm going to be higher than the, the rate that I can comfortably breathe through my nose. So I'm going to be mouth breathing through those as well. I think sometimes the challenge that I see is when athletes are trying to combine too many things at once. So they're trying to do MAF, low heart rate training, combined with intermittent fasting for 18 or 16 hours a day, and then a ketogenic approach, and then nasal breathing, and all of these different things. It can be quite stressful on the body and on the mind as well. And this is for— to set yourself up for success, I would say experiment with one thing at a time. Maybe combine it with a second thing, but don't overdo it over there either. This is where I have to be realistic, even when I'm saying this right now. When I'm thinking back about myself yesterday as an example, I slept with my mouth taped, and then in the morning I jumped into my ice bath while I was still intermittent fasting for 18 hours, and then I went on a nasal breathing run for 90 minutes with breath holds. So I'm completely doing the opposite of what I'm just saying over here, but I truly enjoy learning a lot of these different things. Plus, I haven't signed up for any race either. I think if you're in the middle of a race training cycle and you have a race coming up in 2 or 3 months, starting to experiment with all of these different things at once might be too much as well. So be realistic of what you want to take there. Also, Patrick has a really good YouTube channel where he talks in much more detail about some of the different exercises and workouts that he mentioned on this episode, and I'll make sure to link to that from extramilers.com/30, all of the different show notes over there. This podcast is brought to you by PATH Projects, and if you would like to find out more, check out pathprojects.com. For running shorts, baseliners, shirts, and headwear. And we ship to customers all around the world. And it's actually been really fun to see several familiar names from the Extra Mileage community coming through over there in the orders as well. So to those who have already bought from us, thank you. And to those who would like to check it out, have a look at pathprojects.com. Many more episodes of The Extra Mileage Show are coming out soon, so make sure to subscribe. You'll be the first to know when a new episode drops. Thanks for listening and have fun out there on your runs.

Later.