12 - Kelly Mitchell, the Breathing PT

Episode 12 of the Long Covid Podcast is a conversation with Kelly Mitchell, the Breathing PT.  Kelly is a specialist respiratory physiotherapist and has been treating lots of people with Long Covid, as well as other long term conditions.

Kelly has a passion for all things breathing and how it can affect our whole body; breathing poorly can bring on all manner of symptoms and not always the ones that we might expect.

This is a fascinating chat and has so much that can help so many people with Long Covid - I hope it's as useful for you as it was for me.


Useful links:
Kelly's website: www.thebreathingpt.co.uk   
Twitter/Instagram @TheBreathingPT
ANS study: https://link.springer.com/content/pdf/10.1007/s11239-021-02549-6.pdf
US study (on low end CO2): https://iopscience.iop.org/article/10.1088/1752-7163/ac3c18 

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(music - Brock Hewitt, Rule of Life)

Transcript

Jackie Baxter  0:00  
Hello, and welcome to the long COVID Podcast. I'm really excited today to have Kelly Mitchell, the Breathing PT. Kelly has been working with lots of people with long COVID. So I think this is going to be really useful. So welcome to the podcast. 

Kelly Mitchell  0:13  
Hi, thanks for having me.

Jackie Baxter  0:15  
So to start with, would you be able to introduce yourself, just sort of let us know who you are and what you do?

Kelly Mitchell  0:21  
Yep, sure. My name is Kelly Mitchell. I'm a specialist respiratory physiotherapist. I qualified as the physio in 2007 and began working in an acute NHS Trust in 2008. Worked in all sorts of areas across the hospital and eventually specialized in about 2014 in respiratory. And that was where my interest and passion for all things breathing began. And I work with long term conditions mainly. So cystic fibrosis, bronchitis, COPD, that kind of cohort. And as you can imagine, they tend to breathe quite poorly. So my interest in breathing pattern started within that time. And I worked in the trust until 2020. And then I left and I decided to start working for myself, and I now specialize in the treatment of breathing pattern disorder.

Jackie Baxter  1:13  
Great. Yeah, breathing pattern disorders is something that I had never heard about until very recently. And I suspect I'm probably not alone in that. Could you talk a little bit about what it is? And why do you think so many people with long COVID experience this?

Kelly Mitchell  1:30  
Yeah, absolutely. So breathing pattern disorder in a nutshell, is you are breathing in a way that is not optimal for your body. And as a result of that, you get a range of symptoms from it. The classic one that people probably have heard of is hyperventilation syndrome. So that would be when you breathe at an increased respiratory rate usually, and you over breathe, or you breathe in excess of your body's metabolic demands. And then you have a range of symptoms that follow from that. It's a whole body issue, really, although it's just your breathing that's at fault, you end up with a whole range of symptoms. And that's similar for long COVID, really. 

So something would happen to change the way that you breathe, and that trigger, or event could be anything. So it can range from an illness, or a one off illness. So COVID, for example, it could be long term stress, work stress, life stress, home stress, it could be exercise, it could literally be anything - anything that changes your breathing. So anything that would increase your breathing rate could potentially cause you to develop an issue longer term with your breathing pattern. 

So relating it back to COVID. Why do I think so many people with Long COVID have written pattern issues. Number one, it's the nature of the illness. COVID, by default, will increase your respiratory rate, just it's a respiratory illness, also, it increases your temperature as well, in some people, so an increase in body temperature will also cause an increase in respiratory rate. So there's that side of it. 

There's also the anxiety side of it that goes along with COVID, in that it was a new thing. We didn't know what it was, and people were getting very, very poorly with it. So understandably, the stress and the anxiety of having it would increase your respiratory rate, in some people, not all, but that certainly is a factor. And it's kind of that perfect storm of the nature of the illness, would then predispose certain people to develop a breathing pattern issue, during and afterwards.

Jackie Baxter  3:35  
Absolutely. Because yeah, if your breathing is affected, then you want to get that air in any way you can, don't you, I guess, even if it's really bad.

Kelly Mitchell  3:44  
Yeah, and if your lungs aren't working as effectively, because of what is happening inside of you, your body will respond appropriately. And that's the thing is - at the time, your body was responding fairly appropriately. But it then continues, and even after this event has passed, the issues then continue. And that really is what the breathing pattern problem is, it doesn't matter that it's gone, the breathing pattern issue has now become a thing of its own.

Jackie Baxter  4:12  
So it's like that kind of developing a habit thing, isn't it? For whatever reason it's happened, it can be quite hard to get out of, especially if you don't realize you're doing it.

Kelly Mitchell  4:21  
Absolutely. And you end up with physiological and biomechanical changes. So your body then maintains really fragile homeostasis as a result of it. So it's not so much of a habit necessarily, it's your body is keeping you, so you are actually being kept in that pattern.

Jackie Baxter  4:35  
It is, it's fascinating because I never really even considered this before - breathing was just something you did. The fact that you could do it in the wrong way or the right way or just different ways was definitely a bit of an eye opener for me. 

So how would somebody know that they might have a breathing pattern disorder?

Kelly Mitchell  4:54  
The most common way is symptoms really. So if we talk about long COVID. If you've been to your GP, or you've seen a whole range of specialists. And they've done all the tests on you. And they're quite happy that there's nothing medically underlying but you still have shortness of breath, chest pain, chest discomfort, pins and needles in your fingers, toes, around your mouth, dizziness, brain fog, fatigue, post exertional malaise, those symptoms are potentially being driven by a faulty breathing pattern and the resulting physiology that happens. 

So it's more to do with the symptoms that you have - the easier group to pick out are those guys that talk about things like - I have got air hunger, sothey talk about needing to take a big deep breath. And this inability to take a satisfying deep breath in or shortness of breath on minimal exertion despite being previously fit and well before, they can't catch their breath. They're the guys that are easier to pick up, because they're the more common symptom. But not everybody who has a breathing pattern issue has respiratory symptoms, you know, I've had loads of people say to me, if they reach out on social media, they'll say, my breathing is absolutely fine, I don't have any respiratory symptoms. I'm like, oooh you might do, you know, you may well actually have an underlying issue, don't just dismiss it. So it isn't just respiratory symptoms, it's all the other things that go along with it fatigue, you know, that can be as a result of how you're breathing. 

So I always say, if you really want to know that if you've got a breathing pattern issue,  you should be assessed by somebody who specializes in that area, to make sure that you're getting the right diagnosis. There are simple ways that you can do quick tests on yourself to have a look and just see how you're breathing, you can try and gauge how you're breathing. The issue with doing that is when you bring awareness to your breathing, you naturally change it. I always say to people, I'm gonna look at your breathing, but try not to change it. I know that's impossible. But it is really tough, isn't it like, because as soon as you start thinking about your breathing, either you completely slow it down, because that's what you think you should do, or it goes completely so you don't get a true representation. When I'm assessing somebody, I assess them in a way that they don't know that I'm looking at their breathing - it's the only way to do it. Because otherwise you don't get a true representation. 

But the basics are to look at your respiratory rate, and then the pattern of how you're breathing. So how quickly you're breathing? And how do you breathe? So are you breathing nicely into your tummy? Are you breathing into your chest using your accessory muscles? Is your breathing even? So does one breath look like the next breath? Or is it more erratic? Are there lots of sighs? Are you yawning a lot, doing catch up breaths, however you want to describe it, those sorts of things are what you would want to look out for. And if you notice any of those changes, I would certainly be going down the route of trying to get an assessment with somebody who can look at your breathing pattern.

Jackie Baxter  7:57  
Absolutely, yeah. And the idea that breathing problems can actually have such a wide range of symptoms. It's not just the breathing that it impacts.

Kelly Mitchell  8:07  
And one person with a breathing pattern disorder can look very different from somebody else who has the same issue. You might have somebody who has chest pain or shortness of breath, and then somebody else who's got gastro problems or anxiety and they don't have all the other symptoms. So they almost look like very discrete groups of how they're presenting. But actually, they've got the same underlying problem, it's just that they have a different symptom set from it. That's why it's hard to get picked up. 

So earlier on you said, you know, I've never heard of it - partly because it doesn't get picked up particularly well, you know, you rock up to your GP, if you read a textbook, you know, all medical textbooks say normal respiratory rate 12 to 20, in the breathing pattern world where like, that's hyperventilation, you know, our respiratory rate should be around eight to 12, in a normal, healthy adult, it's different for children. And if you have an underlying lung condition, you might fall out those parameters. But generally eight to 12 is where you should be aiming for - slow, deep breathing. Deep meaning low, not big volume. So when you go to the GP, even if they took your respiratory rate, and it was 17-18, they'll say, Oh, that's kind of normal, don't worry about it. But if someone came to my door with a respiratory rate of that, with the symptoms that correlated, I'd think this warrants further investigation, they are likely to be over breathing, or having an issue with their breathing pattern. So we should get that sorted. 

So it is under diagnosed in that perspective. And again, when people go to the GP with chest pain, that's a really serious symptom. So what happens is they'll get sent to cardiology, assessed, go through all of the tests and be told actually, there's nothing wrong with you. You're just anxious, you'll be fine, off you go. And that was pre COVID. So this just happened to people who have breathing pattern disorders, not people that have long COVID, even though that is what is happening now with that same group. But it's exactly the same - the underlying issue. There doesn't appear to be anything that's medically underlying therefore, they go, Well, there's nothing wrong with you. Relax, do some yoga do do do do but actually, what should then happen is, okay, we haven't found a medical cause. But maybe there is an underlying problem here with your breathing. And that is something that we should address and get sorted. It doesn't happen very often. You know, some GPs are brilliant, and they're like, really on it. And they know that this exists, and they know the impact that it can have. But others, they just don't have the knowledge or awareness of it, which is fine. You know, they can't know everything. But there's certainly many people out there who breathe poorly.

Jackie Baxter  10:34  
Yeah. And I guess they've maybe got away with it up until now? Maybe

Kelly Mitchell  10:38  
Yeah, I just think it just goes so under-diagnosed

Jackie Baxter  10:41  
Sure. Yeah, definitely. Are there people who might be more prone to developing breathing pattern disorders?

Kelly Mitchell  10:47  
Absolutely. So what you'll notice is actually the cohort who are more likely to get breathing pattern disorders are actually the guys that are more likely to develop Long COVID. I'm not going to talk about any cause or effect here, but it's just a really interesting thing. 

But people who are more likely to have breathing pattern disorders are female - women, we have a monthly cycle. And every month, our progesterone spikes, and progesterone is a respiratory stimulant. So every month we are exposed to breathing more each month. So we are kind of more prone to those problems. So women, asthmatics, so people who have underlying lung conditions are more likely, but the asthmatic group is 40 to 50%, more likely to have a breathing pattern disorder, which is quite interesting. People who speak for their jobs, so people who project their voices, teachers, call center workers, I had an ex-priest come to see me recently, and he was just classic for it. And then when you start to think about it he was like yeah, churches are really old. And actually, we don't have the mic system. So I would have to project my voice. And I have all the huskiness that went along with it. So those kinds of things. So people that use their voice a lot, they are much more likely to have breathing pattern issues. Athletes, you can really see it in that group cos they exercise at higher level. So what you'll notice there, it's not unwell groups, it's usually quite fit healthy people that develop those issues. And with the asthmatic group, it doesn't even have to be really awful asthma that's uncontrolled, or they have very, very severe symptoms, it can be in a really well controlled mild group.

Jackie Baxter  11:26  
It's really interesting, isn't it? Because there's a lot of crossover with the figures of more at risk for long COVID, like you say. I mean, I was wondering about this myself, since I've been thinking more about breathing. And I don't know if it's a question that you can actually answer. But do you think a lot of people with long COVID had dysfunctional breathing before they got ill and just didn't notice?

Kelly Mitchell  12:44  
So I can always talk about the people who I've assessed and treated. And when we start to do an assessment, like, I do a really in depth assessment, we go right back, you know, start talking about lots of different things. And it's when we start to go back into their life or their medical history, they're like, my goodness, I've been doing this for ages. I'm like, yay, possibly, you possibly have, you know, a breathing pattern disorder in the long COVID group could have started with COVID. That's enough to be a trigger. So it could have just been that, but then other people could have been breathing poorly for many, many years before. The classic is - Oh, yeah, my colleague always used to say to me, you're sighing a lot, are you okay? Because you do that classic "huuuuuh" And they'd be like you're doing it loads, are ou okay? Probably when they were more stressed. So they were in that, you know, environment at work bit more stressed, they're probably be sighing a lot more than they normally would. And it would present itself in that way. 

So yes, is what I would say - I can't just put a blanket rule out and say that it is definitely happening with that in everyone. But I do think a lot of people were possibly breathing poorly before. But then that's, you know, a lot of people generally in the population have some element of dysfunctional breathing. So you can be a mouth breather, which is technically dysfunctional, we should all breathe through our nose at rest. And that is a form of dysfunction, but not necessarily had a whole bunch of symptom set from it. So you wouldn't have necessarily done anything about it. That doesn't mean that later in life, you wouldn't have ended up with some symptoms as a result of being a chronic mouth breather. But having the COVID infection and going through all of that has exacerbated the whole thing and made it much more prominent, and given new symptoms.

Jackie Baxter  14:25  
Yeah. So is it really possible to alleviate symptoms by improving how we breathe? 

Kelly Mitchell  14:32  
Yes. And I think in order to understand how that can happen, we just need to understand what happens to our body from a physiological and biomechanical perspective, by changing our breathing and once you can understand that you can kind of see how the symptoms would improve as a result. 

So let's talk about hyperventilation, which is pretty much what most people are doing recently. There's a paper that's kind of just come out. It's kind of like pre release. But in their study, they found that 74% of long COVID people had a low end tidal CO2. That's indicative of poor breathing or over breathing. I mean, that's quite a high number. 

So I'm going to talk about hyperventilation, mostly. So over breathing. When we breathe, we breathe in oxygen and we breathe out carbon dioxide. Everyone thinks of carbon dioxide as a waste gas. But actually, it's really important in the function of us as human beings. So we actually need co2, okay. So when you breathe in, and then out, so you should be doing it at 10 breaths per minute. Keep it round numbers. But if you're breathing at around 20 breaths per minute, you are breathing twice as much as you should be. So it's not so much about needing to get oxygen in, you know, everyone's put their SATs probes on. And I can tell you now, everyone's pretty much like, yeah, my SATs are always fine. If anything, they're 90 900%. So we're well saturated. 

But the problem is, is that we're actually breathing out twice as much as we should do. So what happens is, we end up lowering our carbon dioxide levels. This is where part of the issue comes in. So this level, almost becomes reset in our body. So we have a lower carbon dioxide level, and our body resets it. Carbon dioxide is an acid, okay, so it's acidic in nature. Our bodies are a very careful balance of acid and alkaline, which maintains our body PH, and our PH should be between 7.35 and 7.45. So going back to school chemistry, Lesson - Seven is neutral. And so we sit a tiny little bit on the alkaline side of that as normal, for functioning healthily, okay. 

If you get rid of acid, so less co2, your body actually becomes a little bit more alkaline, and it doesn't like staying there, you'll get a range of symptoms and anxiety, being on edge, hyper vigilance from that alone. So your body thinks, oh, we need to get rid of something else that's alkaline within us to balance the scales. That alkaline substance is secreted by the kidneys, and it's called bicarbonate. And that bicarbonate is actually really quite important in terms of exercise. So when we exercise we produce lactic acid and bicarbonate would effectively mop it up. If we have depleted bicarbonate, we are not as effective as removing that lactic acid from our muscles. So when we start to think about symptoms, such as post exertional malaise, or heavy legs and those sorts of things, we need to kind of think about why is that happening physiologically? Is that happening in every single person with Long COVID? No, but you know, if you are hyperventilating, it's highly likely that that is playing a part in that symptom. So that's partly what happens. 

When also when you have a depleted bicarbonate like that your electrolytes can become disturbed - magnesium, calcium, potassium, muscle tremors for circulation. So those sorts of weird muscle cramping, those symptoms that can come from that - co2 acts upon your vascular tone, so it acts upon your vessels. When you're low in co2, we vaso constrict, which means our blood vessels get quite narrow. So then we have reduced blood flow, especially periphery. So people talk about cold hands and feet. And that tends to be - you're nodding knowingly. So those sorts of symptoms can come from that, but also, your vaso constricting in your brain. So actually, you have reduced blood flow to your brain when you hyperventilate. And that can explains why people may be feeling a little bit brain foggy because we don't have the blood flow to that area. 

And we use hyperventilation in medicine. So if somebody was coming to A&E with a head injury, who required ventilation as part of their treatment, they would commonly hyperventilate them on the ventilator to reduce their co2. Because we know that there will be an element of vasoconstriction in the brain, which would then help manage some of that swelling. So it's used as a treatment tool in some ways. But that's the effect that it has, like is quite significant and people are walking around in this state. 

The other thing that happens with co2 Is it is used to help transport oxygen out of the tissue. So when you have a low co2, what happens is your hemoglobin which is what carries your oxygen around your body in the red blood cells, so it spins around your body. And when you have a low co2, your hemoglobin actually has a higher affinity for oxygen. So what that means is it holds on to it, rather than dumping it readily at the tissue. So you then end up with less oxygen being delivered to your cells. You know, oxygen to your cells is where your energy is made and you know they are your powerhouses and if they're not being powered, you feel quite fatigued, you know, and that's where that those kinds of symptoms come from. And low co2 and all of the things that happen - pins and needles, numbness and all of the reasons that we've spoken about. And that's where those symptoms come from. 

So how we then treat those symptoms from changing your breathing is, you rehabilitate back to normal breathing, the physiology restores to normal, and then the things that are happening from a low co2 slowly go away. So therefore, you end up with the symptom improvement. And that's how it happens. But it's because breathing has an overall systemic effect. And that's the thing that people find really hard to get their head around, I think, because they just think, oh, breathing is breathing. 

I remember, I was talking to somebody on Twitter, and I'd commented on a thread like you do. And somebody said, I know that breathing can be used to try and calm the nervous system down, from sympathetic to parasympathetic nervous system, and I know that it's used there, but it can't possibly be a treatment for X Y&Z. And I thought Oh no, it can, you know, it really, really can. So then you end up trying to explain that really complicated thing over Twitter with like X amount of characters, you're like, Ah, it's really hard to get your point across. I think that's another reason it gets lost. It's hard to get your point across with that, because it's quite complicated. But if you understand what happens physiologically, you really can see - yes, you can have chest pain, you can have palpitations, you know, all of those things. It can be because of how you're breathing.

Jackie Baxter  21:27  
Yeah, it's amazing. When like, when you explain it like that, it makes it more clear how it is all completely inter-connected. Where I think yeah, again, like myself, and I'm sure lots of other people, that just have never really thought about it before. But it's, it's quite obvious when you put it like that.

Kelly Mitchell  21:43  
It is when you know, I think, but the general public, as you pointed out, most people just think you just breathe in and out. You don't even think about it, and you're alive. So it's working, like you're doing it okay. And that's all you need to worry about it. But people don't come to my door until they've got significant symptoms. I wish in an ideal world, everyone was taught how to breathe well from school, it should be like this thing that everybody knows, that actually, this is really good breathing. And most of my clients are just like, Oh, my goodness, if only I'd known that. If you see your child mouth breathing. You know, I'd be like, can you start closing your mouth? But you know, parents don't think about that. Because why would you, you just don't see it as an issue?

Jackie Baxter  22:25  
No, exactly. It's just not something we think about. I mean, I notice it in people all the time now. I keep telling my partner that he's mouth breathing, and he tells me to shut up.

Kelly Mitchell  22:33  
Is he? Oh, no, it's the worst - make him stop.

Jackie Baxter  22:37  
You mentioned nose breathing earlier. I mean, I'm sure, you know advice and treatment will obviously vary person to person. But is there any kind of basic advice that you can give to people just to kind of get them started?

Kelly Mitchell  22:49  
Absolutely. Number one is breathe through your nose, your nose is really cool. And it's designed for breathing - your mouth isn't - it's a great backup. We need it at times, especially during high level exercise. But your nose is actually what is designed to breathe. So your nose will heat the air, clean the air, wet the air. Really important. That's how your lungs like it, they don't like dry, cold, dirty air, which is kind of what happens when it goes through your mouth because it doesn't have the capabilities to do those functions. I won't go into the ins and outs of the anatomy of your nose, but it's designed and built for those purposes. 

The other thing that nose does is it releases nitric oxide, which is really cool gas which opens up blood vessels and airways and gets everything nice and open. And if you bypass that you don't have the benefit of the nitric oxide. So that's really, really important to make sure that you are nose breathing. The other thing nitric oxide does is it sterilizes the air. So really important - first line of defense against anything nasty in the air. So super important to breathe through your nose. So yeah, absolutely nose breathing. 

Most people, if they are habitual mouth breathers, they will just say, I'm suffocating if I breathe from my nose, it feels really tight. It's really uncomfortable. I can't do it. What I would say is, you need to make sure - your nose is patent. So most people actually when I assess them when they say that, to me, their nose is completely fine. It's just that the nose puts on resistance to the air much more than the mouth, so it will feel tighter and more uncomfortable. It's just something that you have to get used to. So in terms of how do you then reestablish nose breathing, if your nose is completely okay, it's you just practice. So you would do that in a relaxed, calm way - whether that'd be lying down on your sofa completely chilled. And you just take one nose, breath in and out. And if you could do one, do two and if you can do to do three, if after that you feel like - I need more air then just flip back to mouth breathing. You just slowly start to desensitize yourself to it and just keep trying to increase it slowly slowly. 

The other group of people are - they might be a bit bunged up in their nose if it's sinusy, you know over the counter stuff - sinus rinsing, steam inhalation that may well work quite well for those people. So they can just do some home remedy things themselves. They might need to go to the GP for certain medications, one thing I would say is, anything over the counter, just be mindful of it, they are only designed for very short term use, usually less than a week, you can get rebound effects, if you keep using over the counter medication for your nose like that. So you can actually make it worse. So make sure you're not using them too long, as directed by the pharmacist and your doctor, but try not to use them for more than necessary. 

And then there's guys who have got actual anatomical problems with the nose, they can't breathe through the nose. So if that's the case, you need to see an ENT doctor. Because you may well need a bit of surgery. The thing with the nose is, because people can breathe, they just think, Oh, well, I won't get it sorted. Especially now. Everyone's so busy. Nobody cares about the fact that I can't breathe from my nose. But actually, it's really important, you should get it looked at. I always say if you were to go blind, you would pretty much go to the doctor straightaway, wouldn't you? If you can't breathe through your nose, you are losing the ability to use that organ, which is really important. So you should get it looked at. And, you know, sorted if necessary. But that is a very small amount of people. Most people fall into that first camp of it's just uncomfortable. So yeah, nose breathing, really, really important thing to establish. If you can do nothing else, just breathe through your nose would be what I would suggest. But yeah, that is that is definitely the first line. 

The second thing is to think about your respiratory rate. So a normal respiratory rate, as we said, is around eight to 12 breaths per minute. If you've got a problem with your breathing pattern, you may struggle to pull back rate. So people use different breathing programs and apps. And what they find is that they become very air hungry when they tried to pull back their rate. But that's because their body wants them to breathe more. And they're saying no, we're going to breathe less, and they get into a bit of a battle with it. If you're in that boat, you need somebody to guide you through it, more than likely, so that somebody needs to be rehabilitated from your breathing perspective. But yeah, getting your rate down. So breathing nice and slowly. 

And then the third thing really is to breathe into your tummy, we might have heard it, abdominal breathing, tummy breathing, diaphragmatic breathing, so breathing low into your tummy. So at rest, we should not be using our chest at all. You don't need it that - our accessory muscles, so the muscles in our neck and our upper back and our chest, they'll elevate the ribcage rather than breathing low down into your tummy. So when you're at rest, you shouldn't have any movement from up here at all. 

So to assess yourself, get in front of a mirror, put one hand onto your chest and one hand onto your tummy and just have a look and see what's moving. And if you have upper chest elevation rather than low down tummy movement, chances are, you know you're an apical breather, and that is a form of dysfunction. So yeah, you need to get it sorted. What a lot of people do is they do breathing exercises in lying because they're usually doing it as part of a relaxation session. It's much easier to breathe into your tummy in the lying. So people think ah I'm an abdominal breather, but actually, when you get up, when you move, when you walk, when you speak, what are you doing? And that's where a lot of people aren't quite as aware of how they're breathing.

Jackie Baxter  28:23  
That's a really good point, actually, because, I think it was when we had a chat a few weeks ago, and I think you took like two seconds you looked at me and you said that I wasn't breathing enough into my my diaphragm, I guess. And since then I've been thinking about it all the time. So when I'm laying down, I'm pretty good at it now. And when I'm walking around, I'm pretty good at it. Because that's kind of what I'm thinking about it when I'm sitting on a chair, I've noticed that I find it really hard to do it. And because when I'm sitting on a chair, I'm doing something else. So I'm not thinking about it. So it's actually quite interesting. But, work in progress.

Kelly Mitchell  28:58  
And everyone is, and fixing your breathing is not an easy, it's not a quick fix. It takes constant awareness and perseverance and time and, you know, keep going and keep going. There's different timeframes, we say it takes around six to eight weeks to rehabilitate a breathing pattern, minimum. And then there's another saying in the breathing pattern world that for every year you've been breathing poorly, it takes a month to undo it. And some people are like I've been doing this 30 years. And I'm like it probably won't take 30 months. But it gives you an idea that actually it's not something that can be quick. That doesn't mean you're going to be living with the symptoms for a really long time. It just means that in order to keep going and perfect it can take a little while to get on top of, fully.

Jackie Baxter  29:38  
Yeah, absolutely. I think we always want a quick fix, don't we? Isn't it something that you have to work at? I quite like it when someone says you've got to work at it because it gives me something to get stuck into. 

Kelly Mitchell  29:49  
Absolutely. 

Jackie Baxter  29:49  
I think we all like to sort of press a button and everything be better

Kelly Mitchell  29:52  
or take a pill or just anything that's just easy. That is human beings. We always look for the easy way out sometimes and you know, when it comes to diet and exercise, we all know what to do - it's just actually getting down and doing it. It's the same thing.

Jackie Baxter  30:05  
Yeah, that's very true. So the fight or flight response, I think you mentioned that a little bit earlier. And obviously, quite a lot of things trigger this. I think you mentioned exercise and things, but the breathing - that has an impact on the fight and flight as well.

Kelly Mitchell  30:19  
Yeah, so if we're breathing poorly, it affects our cognitive state. So if we're hyperventilating, breathing poorly, our body is in a state of stress, we are more sympathetically dominated. So our autonomic nervous system, we look at it from the sympathetic branch and the parasympathetic branch. Sympathetic is the revenue our increased heart rate, you know, sweaty palms, increased breathing rate, you know, pre interview, that feeling, that will be your sympathetic fight or flight nervous system in control. Whereas your parasympathetic or rest and digest is that calming, you know, it's putting the brakes on to that. So it's, you know, you're nice and calm, relaxed, we're in a good place. 

As functioning healthy human beings, we should flip between the two, you know, it's not bad to be in a sympathetic dominant state, we need to be there, because otherwise we wouldn't really function, we'd have no need to get up and do anything, you know, it's okay to have stress and live the stress, we need it. But the important thing is, is that we can then access the parasympathetic nervous system and calm everything down. So we have the balance, that's the important part. 

When you're breathing poorly, you're basically telling your body in really simple terms, we're in danger, you know, things aren't right. We're breathing like, we're running, and we're not going anywhere, we've created all of this disturbance in our body, and our body's in a state of stress. And in terms of how that affects you, from a psychological perspective, is we tend to default back to those more emotional, responsive type of brain because when we're in that state, we don't access our nice calm, cognitive brain, you know, just think about being in an argument. How do you react - you're really you just fly off the handle, and you know, that that isn't really what you think or feel, or you might burst into tears or just be in rage, you know, your emotional side is coming out. And then an hour later, when you're, you know, you've calmed down a little bit, you're calmer, your rational brain comes back in and it was like, Well, that was a mistake, wasn't it? And it's, it's true, isn't it. But that's, that's a really basic example. But that's how it does affect us. 

And if we are in a state of sympathetic dominance, so we are over in that zone, way more than we should be, we have those psychological stuff going on as well. So it's kind of like this whole body experience. Again, going back to the symptoms, a lot of the symptoms from long COVID can be part of that sympathetic fight or flight dominance. And that is almost like the nervous system has, you know, short circuited in a way, it is just not functioning as well as it should do. I read a paper that came out, somebody written that every symptom of long COVID could potentially be put down to an autonomic nervous system issue. You know, I really do sit on board with that. I do think that a lot of it is a nervous system issue. Again, not in all people. 

And I just think it's really important to mention here that I don't think long COVID is one thing, and that's why it's I'm always a bit hesitant, say, oh, yeah, you know, this, I just don't think it is one thing, people do have underlying organ damage or issues with their vasculature or stuff going on. You know, there is definitely that then there are definitely people who just have breathing pattern disorder, you know, they are some of the group, then there are people who have completely short circuited their nervous system, and it is just not working particularly well. And people have to go back and rebuild that whole thing. You know, it is, there's so many different things going on with it. But I definitely think that that autonomic nervous system is playing a huge, huge part in a lot of people's presentation, and then ongoing symptoms.

Jackie Baxter  34:06  
Definitely. So, I mean, obviously the breathing will help with trying to calm that nervous system down. Is there anything else that you can suggest that might help as well and that people can look into? 

Kelly Mitchell  34:18  
They're all the classics, aren't they? So breathing to me is the foundation - if you don't breathe well, you don't feel well physically or emotionally. So I just think if you get your breathing, right, it's a really good foundation, like that has to be right. And then all the other stuff is exactly what all the long COVID cohort are doing, you know, trying to get adequate rest, good hydration, eating well, supplementation if required. 

There's other things that you can do to stimulate your vagal nerve. So some people are doing like cold water immersion and some people finding that really, really helpful, but those sorts of things are what I would recommend. So I don't think any of that is out of the ordinary or you know we've never heard of it before. But I just think it's about having really good routines. So if your sleep is disturbed, making sure that you've got good sleep hygiene routines, and all of those things that go along with that. And it's really basic stuff, isn't it, all of that - get outside, get some sunlight, you know, just basic, basic feel good stuff. But in terms of trying to get your nervous system back to normal, that's really, really important. 

And it's, you know, what, being just being a normal person again, many people have been so affected, that they aren't socializing in a way that they normally would, they're not having normal social human contact, that they would, just even all of that impacts you so much, you know, especially your emotional well being. Being outside in nature, I walk every day, because I've got a dog. And if I didn't get out every day like that, that would really affect me. And it's those sorts of things, isn't it. So trying to be able to get them in within the constraints of what is currently going on with you. So if you are able to get in a car, and someone can drive you to somewhere and you can sit and you know, chill, if you like being outside, brilliant, you know, don't go on a five mile walk, if that's what you're used to, you kind of just have to try and adapt what you used to do, but still get the benefit.

Jackie Baxter  36:14  
Yeah, definitely. Yeah, getting your sort of dose of the mountains by looking at them instead of going up there.

Kelly Mitchell  36:19  
Exactly. Yeah, that's a really good way of looking at it. It's those sorts of things, isn't it? But all of that will affect us? 

Jackie Baxter  36:24  
Yeah, definitely. And kind of jumping on to the relaxation and rest thing. How - I get bored when someone tells me to go and rest. And I think, right, I'm gonna go and lay on the sofa. And after about three minutes, I get bored and think, right, well I'm gonna read a book. But that's not necessarily very helpful, I think, is it?

Kelly Mitchell  36:43  
It depends. So I think there's two ways of looking at it, right. So I think in terms of trying to get you back into a more balanced nervous system and calm everything down, we need to have good quality relaxation, or rest, however you want to call it. But if we use the term relaxation. And people tend to confuse that word with downtime, so things such as watching television, or doing certain exercises, that would be more downtime. Whereas when we look at rest, what we're really trying to do is, all humans should rest every day, in some sort of way. 10 minutes, just unplug from this crazy world that we live in and just have a minute to rest. I obviously use breathing because it's just what I do, you know, it might just be in a bar. So I just in the bar for like 10 minutes, I just focus on my breathing for a little while. So just like nose, into my tummy, nice and slowly, nice and calm. Don't think about anything else. Because if I think about my breathing, I don't need to think about anything else. Or I just let my mind wander in a really cool way. That's fine, then you're talking about relaxation, and allowing your body time to just be calm. 

When you're - downtime. People are like, oh, yeah, I've watched the telly for hours. And you know, if you think about some of the programs that we watch, we were just talking about squid game. I mean, that is stressful, you know, your body is going to be revved up whilst you're watching. I mean, I was on the edge of my seat, I just couldn't watch it at times, you know, at not one point during that time, was I relaxed. So, you know, it depends on you know, the media that you're taking in and books and you know, all of that stuff is, it does have an effect on you. But taking relaxation - is about Yeah, really switching off. And if you're bored, a lot of people who I work with who are pacing, and then they do resting, then I do my breathing every time now during my rest. And I just it gives me something else to do. So they find that quite nice. So they feel like they're doing an activity, which is beneficial to them rather than just kind of just lying there and just getting frustrated that that's what they're doing. 

Jackie Baxter  38:39  
Yeah, definitely. Because yeah, I find that my brain is very difficult to switch off. It's always thinking something. So even when I try to relax, it's pinging all over the place, thinking what might happen for dinner. And, you know, all of these things that I don't need to be thinking about, but I still am and I can't turn it off. As soon as you sort of have something to focus on like breathing. It sort of focuses your mind, hopefully I guess enough, but without it being stressful. Yeah, I guess that's the point.

Kelly Mitchell  39:03  
Yeah. And I kind of always say to people, that people try to push out intrusive thoughts. And so when they do meditations or something, they're like, Oh, I'm not meant to be thinking so they try and push stuff out. The more you do that, the more stressed that you get. And the more you just think, Oh God, I wish this was over. But actually with breathing, if you're just thinking about in - out, or you're counting your breath or whatever, it's enough to have that thought in your mind that actually more thoughts can't jump on top as easily. So it's quite nice. It's a really easy way to do it. Just shut off for a little while. 

Jackie Baxter  39:32  
Yeah, yes. Just sort of simplifying life, isn't it almost. 

Kelly Mitchell  39:38  
Yeah. Basics. 

Jackie Baxter  39:39  
Yeah, pretty much. Yeah. So I mean, talking about the fight or flight, we talked about how sort of exercise triggers it as well as other things. And I was wondering, does that include gentle exercises, you know, things like yoga or a very short stroll because you've got your mental health benefits of it as well. And how does that kind of balance up?

Kelly Mitchell  39:57  
Yeah. So if you look at it, really simply, if anything that you do that increases your heart rate, your autonomic nervous system is increasing your heart rate appropriately. The thing with COVID and long COVID guys are, their systems are already stretched. So not going to talk about the guys who got fatigue. So people without, they'll be like, I really want to go for a run or something. And I'm a bit like, oh, I would probably just wait for a little while, especially if they are hyper ventilators, we need to get them right physiologically first, because otherwise that and that's what's causing the issue. 

But just doing things like, you know, calm, gentle stretches, yogas, yes, it's absolutely fine. And you're right, the mental health benefit is completely outweighs it, it's more the higher intensity stuff, which is where you're going to start to get that real, you know, huge increase in heart rate, and blood pressure and respiratory rate, and all of those sorts of things. But most people listening will be like, I can't even walk, let alone be even contemplating what you're talking about. So it's completely irrelevant. But when you work at those higher levels, you are actually using that sympathetic nervous system. But that's what - it's healthy to. It's just, we need to be able to flick between the two. And it's almost like the guys who have long COVID are very much stuck over on the wrong side a lot of the time, and it's about trying to just re access being able to go over to that quietening slowing down side. And that's kind of what the main, the main aim of the game has got to be really,

Jackie Baxter  41:23  
I'm thinking, you know, a lot of people are measuring their heart rate and trying to pace using that sort of thing. Is that helpful?

Kelly Mitchell  41:30  
It's really hard, again, blanket rules, isn't it? But yeah, for sure, it is important to do that. And if you are under the health care professionals that are telling you to do that, then absolutely, you should be following that advice. And that's what you should be doing. It's about being able to know when you can start to increase your activity, though, that's kind of the issue, isn't it? And some people, especially that I see, they kind of get a bit stuck with that. 

So it's about knowing when they can start to push things, but the guys that have got the real dysautonomic heart rate issues, you know, we do not want to be throwing people up into exceptionally high heart rates on minimal exertion and holding them there absolutely, that's the group that I would be very, very careful about. But it is normal to have a heart rate increase in people. So if you're not this autonomic, you know, and you're getting a normal heart rate increase, that's okay, you know what's interesting, I'm seeing less people with all of those dysautonomic issues than I was at the start, I've just thinking that I was like, Oh, I used to see that all the time. And actually, I'm not getting that group of people through so often anymore.

Jackie Baxter  42:36  
It's interesting, yeah 

Kelly Mitchell  42:37  
I don't know why 

Jackie Baxter  42:38  
You sort of touched on it just then, when people should be starting to increase? And how do you know? How do you know when you can start increasing? And how would you do it? That's probably a really impossible question. 

Kelly Mitchell  42:52  
Really impossible question to answer. But what I will say is, with my guys who are definitely having an issue, and you know, they've probably got a problem with their bicarbonate. And once we start to normalize things, and they can then have a normal response to exercise, what tends to happen is, they'll come to me, week on, you know, as we go through, and they'll be like, Oh, my step count is going up, or I can do X now, and I couldn't do that before. And it's this organic kind of growth in the beginning. So this sort of insidious creep of getting better. Once I've kind of got to that point where we start talking about breathing and moving, and we know how to link things, I just say to them, right, this is the real basic stuff, breathing and moving as in walking. And then once we've nailed that, then I'll be like, Okay, if you want to start to try and increase pace for a little bit - short interval, 20 seconds, pull it back, and then we slowly start to test the water without going mental with it. That's absolutely fine. And that's kind of how we do it. So we'll just gradually increase. 

And then you've got other people. And you've heard Rachel on this podcast, and actually the reason that she was having issues number one, her breathing was poor. But number two, her thoughts and beliefs and all of that kind of side of it, which is very, very prevalent in long COVID, about, you know, how you think about things and respond to things. Once she addressed that she was actually able just to lift up the gates and go, and there wasn't any need to pace anymore. That was her scenario. 

So basically, there are two extremes that I'm presenting you. And then there's everyone in between, because like you say, everyone's very, very different. And some people do need to pace but - if you are hyperventilating and post exertional malaise and fatigue is coming from a perspective of the underlying physiology, you can rest all you like, you need to address that underlying issue, don't you? And then once you've done that, then then we can start to move on. If that's not your underlying mechanism, something else is, then the parameters are going to be very, very different.

Jackie Baxter  44:53  
Definitely. Yeah, you know, that sort of fear of relapse it almost makes you too scared to try anything sometimes. I certainly find I sort of think, well, I've had so many relapses that, I don't want to do that because it's going to make it happen again. But you can't live the rest of your life like that.

Kelly Mitchell  45:09  
No, you can't. But I completely understand it. But most people, what they tend to say is, Oh, I did this, and I was tired. But I rested for a couple of hours, and then I was better. And once people sort of reached that point, then they're like, whoa, I can deal with that. Like, that's an okay trade off for me to be dealing with. But what people are not okay with is I walked 100 meters, and I ended up bed bound for a month, like that's not an okay trade off. So, you know, people aren't going to push it there, and they shouldn't be. But those guys, once you really start to think actually, my relapses are nowhere near as bad or as frequent now, then the confidence starts to build. 

And we've spoken about this before. But one of the biggest things that I ended up trying to help people with is the fact that we need to rebuild confidence in their body again. So we start moving them forward in a really safe way. And everybody's safe is really different. So some people find that, oh, you're breathing really well. Everything's normalized that we're doing, we're really move in the right direction. You know, do you want to go and do this? They're like, Yeah, I'm just gonna go and do it. And they're like, Yes, I did it. I feel really good. Nothing happened. I'm like, Yeah, awesome. Then other people are like, Oh, I'm really anxious about doing that. And maybe I just kind of want to do this. I'm like, Yeah, cool. Do it - it's your time, like we don't then want to add a psychological issue to anything. So again, everyone's really different. We're human beings. What's the right thing to do for one person is definitely not the right thing to do for another.

Jackie Baxter  46:37  
Well, thank you so much for your time today. It has been absolutely fascinating. And there's loads of stuff that certainly will be helpful for me, and I'm sure for lots of other people's so thank you so much.

Kelly Mitchell  46:49  
Thanks for having me. Again. It was really good to talk about breathing as always

Transcribed by https://otter.ai