Covid-19 Breathing Techniques & Tips from a Physical Therapist: From Lung Health Before to Recovery Post Virus
Stephen Williams is a UK Physiotherapist (known as a Physical Therapist in the USA) who is working for the British National Health Service (NHS) with acute respiratory patients.
**Disclaimer—I am not a medical professional. This is a question-and-answer session with Stephen Williams combined with my personal experience. As a family friend, his advice has been invaluable while I have gone through and now am recovering from Covid-19. If you have any medical concerns, consult your own physician, or emergency medical services.
Background: In mid-March, I began having Covid-19 symptoms which increased in severity around Day 9. I am on Day 40 and in a fragile recovery stage of lung inflammation and debris as well as laryngitis. Two of my family members had ‘mild’ symptoms for over 14 days including the typical shortness of breath, tight chest and coughing. My son and husband have since recovered, and though they are active and healthy, they have still felt the effects of post-viral fatigue. My teenage daughter remained asymptomatic. I would fall in the moderate/borderline severe category though I received all medical support from home.
**Update – I’m on day 76 and mostly recovered with lingering lung issues and fatigue. At week 8 I was concerned as it had not really improved significantly with at least the breathing. My x-ray result came back normal at 8 1/2 weeks – no scarring or infection. I fully believe consistent breathing exercises two to three times a day with some steam therapy (I take a steam shower) has kept me from infection. In the later weeks of 9 to my current eleven and a half weeks, I have to intentionally do this 2x a day and almost force out the excess lung debris. It is still there but with a dramatic decrease. I have coupled this with a low histamine diet, low inflammatory diet and pacing (not pushing exercise or activity). I am improving week by week.
This is a question-and-answer session with Stephen and we have also included links to videos and resources throughout this post.
Breathing techniques that can assist:
Before the virus for lung health and strength
Virus onset breathing challenges
Potential asthma or anxiety challenges
Fitness after illness recovery for any degree of the virus
Note – This does not cover if you go on a ventilator with Covid-19 as you will need medical guidance
Breathing techniques through different potential stages of Covid-19
BEFORE THE VIRUS AND THE ONSET OF COVID-19
What are your recommendations during ONSET of Covid-19, shortness of breath and tightness? Can this be for anxiety as well?
Jeannie: I’ve been practising mindfulness for a few years. It’s taking a ‘pause’ to subdue racing thoughts and focus on an anchor such as breathing for a few minutes. I’m grateful that I felt comfortable with these techniques prior to Covid-19 because I found I used it often to bring calm when I found breathing to be painful or challenging. I also believe that the daily practice of simple breathing techniques had strengthened my lungs as a voice artist but unintentionally prepared me for the weeks ahead with the virus struggle. I’m working on a upcoming post on the basics of mindfulness and especially how it helped during the scariest parts of my experience with the Coronavirus.
There are several things you can do for this but the easiest for me is the ‘box or square method’ I breathed in for five seconds (or four seconds to start), breathed out for five seconds with pursed lips doing this 4 times picturing a box in my head. As you get familiar with this, you can increase this by holding your breath after each inhale for 4-5 seconds and after each exhale to increase your lung capacity. This mindfulness technique helped me calm down and also know I could breathe deeply into my lungs despite the symptoms.
Here’s a link for a simple, kid’s version of the box or square breathing which is a great place to start.
Stephen: This is great, and I think mindfulness serves very well in these situations. In addition, given what’s likely to come next during the process of the disease (COVID-19 is the name of the disease, SARS-CoV-2 is the name of the virus causing it), I would strongly advocate preparing your lung capacity by practising 5 deep breaths with a 5-second hold each time. On the sixth deep breath, you would finish with a forceful cough.
Here is a link for before and with the onset of the virus:
How can you tell if it has triggered ASTHMA, and if so, any recommendations?
Jeannie: On day 9, the Coronavirus apparently triggered my mild childhood asthma and with the shortness of breath I started wheezing. This was combined with the chest constriction, shortness of breath and coughing. I had a severe asthma attack that led to my husband calling an ambulance. But I didn’t know this was asthma until the paramedics diagnosed it. This was new for me. A physician prescribed inhalers for medical support. I was apparently getting enough oxygen, so I did not need to go to the hospital. The wheezing calmed within a few days but I have stayed on inhalers until I am past the ‘lung debris aftermath’ under medical guidance.
Stephen: The initial symptoms of COVID-19 have some similarities with Asthma i.e. shortness of breath and cough. However, it could be a symptom of Asthma if you begin to wheeze. This is caused by narrowing of the airways (bronchoconstriction) and is usually treated with an inhaler administering a Broncho dilating medication. Here’s a helpful website featuring ‘Health advice for people with Asthma’ from Asthma UK, including a phone number to speak to an Asthma expert nurse (only in the UK but the advice online is helpful): https://www.asthma.org.uk/advice/triggers/coronavirus-covid-19/
What about a PANIC ATTACK – what is the difference and what can you do?
Jeannie: The asthma may have led to a panic attack when breathing felt very challenging. How can I know the difference?
Stephen: I wouldn’t say I’m any more knowledgeable here than the average person so here’s another helpful link below for advice on panic attacks including recognising and working through them.
How can you know if you aren’t getting enough OXYGEN?
Jeannie: I used a pulse oximeter on three occasions with a medical professional since the virus onset. Would you recommend? And are there other signs to look for if you aren’t getting the oxygen you need as this would need immediate medical attention? Personally, despite all my breathing challenges, I was tested three times and always came above 97%.
Stephen: Symptoms of Hypoxia or Hypoxemia differ from person to person but most commonly include: changes in the colour of your skin; ranging from blue to cherry red, confusion, cough, fast heart rate, rapid breathing, shortness of breath, slow heart rate, sweating, wheezing (Web MD). There are plenty of pulse oximeters out there if you’re willing to pay but I would be cautious about doing that unless you want to spend £300 on a good one, as you’re likely to get something that’s very unreliable and inaccurate which will put you in a worse position than not having one. I would pay more attention to the symptoms, to be honest, and keep NHS 111 (UK only nonemergent medical advice line) or your primary care physician informed if you feel that they are out of control or worsening.
Waking up with heavy tightness, choking, shortness of breath—recommendations and what to look for to seek emergency help?
Jeannie: This happened several times during days 9-14 in the middle of the night. I could sit up and everything calmed down within a few minutes, but it usually took a few hours to feel settled enough to go back to sleep. I got medical reassurance a few times in this process and found some movement and sitting up was key. But I have heard reports of people dying in their sleep. It is very concerning.
Stephen: These are serious symptoms, I would call 999 (US 911), or 111 (UK only) or your physician if it’s tolerable and you can wait for advice.
Any signs to show that a secondary infection could happen and where to seek medical advice immediately?
Jeannie: I know this can happen at any point when you have the virus. It is what can put you in the hospital immediately if it is in the crucial time period of the first fourteen days. For me, the high fever broke on Day 15, which was a relief. Around Day 20 I really thought I was improving. But I woke up on Day 23 with a fever, increased chest pain that felt like shards of glass in my lungs and muscle aches. I also had traces of blood after coughing. I immediately called a doctor who reassured me that the traces can happen after such a long period of illness. They prescribed antibiotics, and I was put on a close watch. Fortunately, within a day on the antibiotics, the symptoms dramatically decreased.
Stephen: Signs and symptoms of pneumonia i.e. secondary infection would be: a cough that produces green, dark yellow or even bloody mucus, fever/sweating/shaking, shortness of breath, rapid shallow breathing, sharp chest pain that worsens on deep breathing, confusion (especially in older people), nausea and vomiting (more so in small children). If you feel that the problem has progressed to any of these symptoms then it’s likely that you will need antibiotics so consult your physician or call 111 (UK only) again for further advice.
What are helpful breathing techniques during a SECOND INFECTION?
Stephen: Breathing advice only differs slightly throughout the process. Initially, at the onset of the illness, it’s likely that you will have a dry cough. The breathing exercises maintain good lung volumes and facilitate mucociliary clearance, which is the natural process for getting the mucous lining of your lungs to continue to move up and out.
The virus begins by reducing the production of this good mucous and that’s what dries out your lungs, gives you that constant cough as your lungs are now more sensitive to bits of dust in the air, fumes, smoke and so forth. This causes your lungs (especially the bases) to struggle to properly expand.
Try practicing 5 large deep breaths with a 5 second hold each time, then on the 6th big breath end it with a forceful cough. If you end up with further infection, and a productive cough, the deep breathing is still useful for the same reasons.
You should also practice 2 open mouth forceful huffs after the deep breathing (like you are steaming up a mirror) as this serves to move any excess mucous from the depths of your lungs to the upper airways where it can then be coughed up and cleared. Don’t worry if you instinctively swallow instead of spitting it out, whatever it was will end up in your stomach acid and no longer an issue. It’s out of the lungs.
A helpful cycle of breathing exercises is called Active Cycle of Breathing Techniques comprises relaxed breathing, then 5-6 deep breaths, back to relaxed breathing, then 5-6 deep breaths again, then 2 huffs. Repeat the cycle until nothing else is coming up or until you’re too tired to continue or have had enough.
Note – relaxed breathing should focus on movement of the diaphragm so that your abdomen moves outwards. Try not to deep breathe with your shoulder or other secondary breathing muscles.
More details and demonstration can be found at this link:
Initial RECOVERY post infection and virus—Debris
Can you talk about what debris and lung inflammation are from?
Jeannie: After the secondary infection cleared, I have still struggled with chest tightness, pain or discomfort and coughing up clear or cloudy ‘debris’ from my lungs. I also struggle with basic things around the house, such as picking up things off the floor, carrying anything heavier than my coffee or bringing a basket of laundry down the stairs. It can feel very constricted with my breathing and sometimes leave me short of breath for several minutes.
Stephen: Once a virus or bacteria foreign to the body are identified by the immune system and recognised as invaders, the immune system carries out nuclear warfare without concern for collateral damage. This leaves much of your own normal tissue damaged or destroyed (debris), then the normal healing process kicks in for repairs. The second stage of the healing process is inflammation, i.e. an increase in blood flow bringing resources to the area that is needed for repairs and reconstruction. All the while you feel very sore and swollen throughout and this can last for weeks in severe cases.
Any vocal cord advice as this is a virus that can impact your throat as well?
Jeannie: I’ve had laryngitis on and off from Day 3 until now. And after a spell of coughing up debris, my throat can really be painful. Though my voice has had longer moments of clarity, it comes back if I talk for an extended amount of time or if I have a bad coughing fit. As a voice artist, I have concerns, but a speech therapist friend recommends being completely over all the illness before embarking on vocal exercises to strengthen this area. She recommends massage in the shoulders, neck, and jaw area along with yawning often to stretch that area. Also, steam inhalation is helpful (I do two showers a day) for the vocal cords and the debris and to watch my acid reflux. AND a throat specialist for voice artists also says ‘silence is golden’ for longer periods of time to rest and emphasised not whispering as it is really hard on this area.
Stephen: My advice would be the same here really as any inflammation—rest from singing, shouting, lots of talking and especially whispering. The only thing I would add is regarding movement. Movement is helpful for blood flow, which is vital for the healing process. So don’t stop talking altogether.
Because I am still in quarantine, are there any exercises you recommend for someone else who could help me, such as my husband, as I won’t be able to get physical therapy at the moment?
Stephen: These videos below are helpful. It depends on the phase of the disease you are in and what your symptoms are during this time. Positioning is helpful for controlling your breathing and ventilating your lungs. Physical techniques are really helpful for clearing any retained secretions (phlegm/sputum).
Percussion – https://www.youtube.com/watch?v=1ZRk55sHJ1I
Positioning for breathlessness – https://www.youtube.com/watch?v=SxnX38Nk-FA
In patients you have seen – how long is recovery from a lung infection? What are the normal steps people go through?
Jeannie: I’m on Day 40, I feel improvement is about 1% a day which feels really, really slow. And even today, I feel the same as I did a few days ago. I don’t want to push it by doing any exertion, but this is challenging.
Stephen: As with any soft tissue damage, the healing process takes between 6-8 weeks, this is once the immune system has decided it has dealt with the invader and is no longer causing further damage. It decreases healing speed with age and other factors like hydration or history of smoking, so it will vary from person to person. Once all the healing has taken place it will take weeks potentially to recover lung function.
Recovering FITNESS POST VIRUS
Jeannie: I am not here yet. Just taking one basket of laundry downstairs left me breathless for five minutes and I felt ‘wiped out’ until I took a nap. My son and husband who had a mild form took about a month before they were running again. But even now, my husband, who is very active and healthy normally, can feel exhausted after a work-out.
Stephen: Once all the healing has taken place, it really depends on the extent of the damage done and the time you’ve been out of action. I would advise a graded return to whatever activity you want to get back to. The higher the level of physical exertion though, the longer you should allow to get back to it. The aim is to exert yourself and challenge your heart and lungs safely, so they can respond by getting stronger and you’ll get fitter. But have extreme caution. If you do a small amount of exercise and ‘pay for it later’, it may mean that you need to implement PACING. It is where you begin very, very slowly to avoid any relapses. A link is at the bottom.
If you’ve been severely affected, as much as walking up and down the stairs may be enough. Then progressing to outdoors up and down hills as you increase the speed or duration, move to jogging then running etc. It doesn’t matter what you do as long as you’re increasing your heart rate and depth/frequency of breathing. You’ll find that the more you improve, the harder it is to achieve the same level of exertion. That’s when you should make things harder but at an incredibly cautious pace. Recovery from Covid for even some people with mild to moderate symptoms is taking a long time so please be patient with yourselves. It may take many months before you are back to your previous level of fitness.
So if you’re experiencing any of the following here’s what you should do:
Reduced blood to your brain, heart or other important organs/tissues could cause abrupt dizziness, irregular heartbeat or unusual shortness of breath–stop exercising and seek medical help.
Muscle burn/pain because of lactic acid, you’re probably trying too hard or for too long, slow down significantly until this settles before considering increasing the intensity again
Chills, headache, severe muscle burning or blurred vision—stop exercising immediately, these are signs of overheating and you need to cool down immediately. If symptoms don’t ease, then seek medical help.
Sore, stiff muscles up to a day after exercises—this is normal and called delayed onset of muscle soreness (DOMS), likely because of the level of intensity that you exercised at. Consider resting for longer, and skipping exercise sessions until this has subsided. OR switch to pacing.
Swollen or painful joints—most of the time it’s fine to push through minor aches and pains, especially if they seem to disappear or stop altogether once you’ve finished exercising or warming up. If pain and swelling are persisting, it could be a sign of acute joint, ligament or tendon injury and you should consider changing the type of exercise to allow the area to settle down. Lower or non-impact exercises tend to be kinder to your joints, like swimming, cycling, cross-trainers, rowing, etc. You don’t need to be using formal exercise equipment or techniques though. Anything that requires your body to move can be made to challenge your heart and lungs if you add resistance to it or increase the speed. Think about timing yourself, vacuuming your stairs and try to do it quicker next time. Simple things like that may initially be enough. In fact, I would recommend to start at very small amounts and do small increases.
Always remember to warm-up and cool down, don’t start or stop exercises abruptly, especially at high intensities (after any lung pathology, it won’t take much to achieve high intensity so bear that in mind and please have extreme caution at first). A warm-up allows your arteries to open up before your heart tries to force more and more blood through them during exercise. A cool-down keeps your heart pumping blood through them while they take time to shrink back down to normal. You don’t want the blood to be forced through at too high pressures or too low pressures, so warm-up first and cool-down after by starting gently and finishing gently.
Do you have any ADDITIONAL ADVICE for those struggling with Covid-19?
If breathing deeply is painful, try holding a cushion tight to your abdomen. This allows you to maintain control of movement during your deep breath and still perform a good deep breath. This can be done at any stage of the virus or recovery.
When struggling with breathing consider your position—it’s easier to use your diaphragm (the most energy-efficient breathing muscle) when leaning forward onto a pillow on a table or lying on your stomach on your bed. You can also try laying on your front in bed as this allows the lungs to expand with more ease. Again, this can be done at any time of the virus.
Movement—it’s really important if you’ve got the virus, that you don’t become weak and deconditioned. You need to maintain as much ‘fitness’ as possible throughout so make sure you don’t retire to the bed for days if you can avoid it. Try to still move around regularly or even complete basic household tasks during the day if you can tolerate it.
Stay hydrated and energised—your body is mostly water, and its functions rely on it so if you’re dehydrated your body won’t be anywhere near as efficient as it could be. Make sure you drink 30-35ml per Kg of body weight every day. You also need energy for the healing process to be efficient, make sure you’re eating enough. If your appetite has gone, then focus on small, calorie-dense snacks as they’re likely easier to get down than a big dinner. This is not a time to worry about calorie intake but focus on getting what your body needs.
Consider pacing which means not pushing it on your activity levels or exertion. Many in the more long haul Covid symptom groups have relapsed and find pacing helpful.
Here is a link that has tips on pacing.
I hope you have found this helpful, if you have questions please contact me on my website on the contact page.