Controlling Your States Through Breathing – Patrick McKeown, CEO of the Oxygen Advantage

Shiv Gaglani: Hi, I'm Shiv Gaglani. Recently on Raise the Line, we've been giving extra attention to the issue of burnout, and helping listeners become aware of various approaches to managing the stress, fatigue, and negative mental health impacts experienced by many who have been providing health care during the pandemic. 

Today, we continue that focus by welcoming Patrick McKeown, a leading expert on breathing, bestselling author, and CEO of the Oxygen Advantage. Over the past two decades, he has provided breathwork training and mindfulness coaching to thousands of people to help them improve sleep, overall health, mental focus, and performance. He's trained hundreds of breathing instructors as well. Patrick, thanks for taking the time to be with us today.

Patrick McKeown: Pleasure. Great to be here, Shiv.

Shiv Gaglani: I'd like to start first with learning more about you and what got you interested in the subject of breathwork and breathing.

Patrick McKeown: It's like many things. It's very much left of field. It's not a career choice that your parents are going to encourage you to go into, and mine didn't. I fell into it by accident. I had asthma growing up as a young kid into my teenage years, and I found school very difficult. It wasn't because I wasn't necessarily bright, but my problem was my sleep. 

I never equated my asthma, and my stuffy nose to my sleep disordered breathing. I never equated my sleep-disordered breathing to falling asleep in class. It was undiagnosed. Nobody told me if I was stopping breathing or snoring heavily. I was waking up with a dry mouth in the morning. I got through the education system, but it took a lot of work. I was very driven to do well. When concentration is impacted, it takes a lot of work, because even though you're putting in the hours, you're not necessarily putting in the quality of work.

It was 1997-98. I was in the corporate world then. I wasn't doing so well in that either. I felt highly stressed in the corporate world. I used to dread going in every Monday morning. I was in middle management because I did get into a university, I got my business degree, and it was one of the better universities in Europe. I wasn't shown how to deal with stress. That was my personal journey. 

I read a newspaper article. The article spoke about two things: Breathe through your nose and breathe lightly. I was doing neither. I was a chronic mouth breather. I was a fast breather, chest breathing, harder breathing. My system was in total sympathetic drive, and it impacted sleep and dysfunctional breathing patterns. My physiology was off.

It was no wonder that I couldn't cope with the corporate world, because it wasn't necessarily the stress of working in the company that was the issue. It was my reaction to it. I started putting all this stuff into practice. It made a huge difference in my life. My asthma symptoms reduced by about 50% in one week. I know that might sound a little bit… People are saying, "Is he telling lies?" Genuinely, I'm not. By making simple changes to my breathing... My sleep, I taped my mouth closed at night. Now I use nasal dilators as well, just in case anybody's thinking it's totally off the wall. I had nasal dilators to open up my nose. And I tape my mouth closed using micropore tape, which I picked up down at the drugstore. The first morning waking, up I didn't notice much of a difference. But the second morning, I woke up, and it was the best night's sleep I had in about 15 years.

A couple of years later, I decided I'd love to work in this field. I retrained and went to Russia. I met Dr. Konstantin Buteyko there. I learned his technique and started teaching it then, primarily for people with asthma. And then people with sleep issues, people with anxiety and panic disorder, then working with a lot of kids. Then in 2014, bringing it to athletes. One day, for example, I was working with an elite group of snipers, and teaching them how to change states, but even going as far as changing breathing patterns and when to pull the trigger of a gun. 

You see that the application of breathing is really amazing. I think every human being, Shiv, we should know how to change your states. Sending these kids to school and going into the workforce, not being able to deal with situations—going into that fight or flight response. The one thing about breathing is we can have some degree of control over our physiology.

Shiv Gaglani: Absolutely. It's a fascinating subject. There's been a sleep revolution over the past decade where people -- like former Raise the Line guest Arianna Huffington, who has written a book and popularized this issue of sleep -- they've said things like we spend a third to a quarter of our life sleeping, but we don't spend enough time thinking about sleep hygiene and now more people are thinking about it. It's our smartwatches and tracking etc. I think breathing is still not where even sleep is, even though we spend all of our life breathing. Even that difference of nose breathing versus mouth breathing was new to me six months ago.

Patrick McKeown: Arianna Huffington has missed the elephant in the room as has Matthew Walker. In the vast majority of books, when you look at sleep, how are they missing out on nasal breathing? It's not just me because... I'll give you this story. I was in Bordeaux, I was giving a talk. Again, I give a talk. I go to the World Sleep Congress in Rome, I'll give a talk there on the 16th of March next week. I remember I was giving a talk in Bordeaux, and Dr. Christian Guilleminault stood up in the room. The individuals in attendance there were primarily healthcare professionals. Dr. Christian Guilleminault coined the phrase "obstructive sleep apnea." He developed the apnea-hypopnea index. He's a French doctor who was based at Stanford. He's considered one of the founding fathers of sleep medicine. He said to the doctors, he said, "Doctors, you have missed the elephant in the room here. And it's the importance of nasal breathing during sleep."

He has written papers on this, which you'll find in PubMed, especially in the pediatric population, but not just limited to the pediatric population. He says the only valid and complete correction of pediatric sleep disorder breathing is restoration of continuous nasal breathing, both during wakefulness and sleep. He said it, but it hasn't trickled down. The problem with this is it'll take 20 years. He started in 2015 so by 2035, we'll have a growing awareness of the importance of nose breathing during sleep, even though this has been written about for hundreds of years. There is nothing new in this, Shiv.

Shiv Gaglani: That's a theme. People like you are popularizing things that we've known about for hundreds of years that just have kind of fallen out of the public consciousness. For our audience, many of whom, like me are training or trained in medical school or other health professional schools, what are some of the core tenets of the Oxygen Advantage? I practice the BOLT score method. Our audience may not know what that is. Breathe light to breathe right is another one. One thing I love about your book is not only how simple the scientific explanations are, but all the exercises you include which are very easy to put into practice. Can you give our audience a rundown of some of the core tenets of your method?

Patrick McKeown: Sure, yeah, it comes with a measurement known as the BOLT, and the BOLT stands for body oxygen level test. Basically, this is a simple measurement you do while sitting. If you're sitting down for about five minutes or so, just with normal breathing, and then take a normal breath in through your nose and out through your nose, you pinch your nose with your fingers, and your time within seconds, how long does it take until you feel the first definite desire to breathe, or the first involuntary contraction of the diaphragm. 

Of course, the diaphragm breathing muscle is also linked with muscles in the throat. it might be like a sensation of a swallow. When you resume breathing, your breathing should be fairly normal. It's the length of your comfortable breath-hold time, after an exhalation.

Now, what's the significance of it? It gives you a good indication of whether you're breathing is functional or dysfunctional. There was a paper that was published by a professor of physical therapy—Kyle Kiesel—that was published in 2018. He looked at a sample of 51 individuals. He looked at their breathing from a biochemical point of view, a biomechanical point of view, and also a physiological point of view, because breathing is multi-dimensional. It's more complex than just saying to a person, breathe low, using greater recruitment of the diaphragm. That's only one aspect of it.

See, the problem with screening for breathing patterns is, because it's multi-dimensional, by the time that you've done the biochemistry tests and biomechanics test and psychophysiological, there's a lot of time spent. He wanted to develop a simple screening tool. He used the breath-hold time. And his conclusion was that if your breath-hold time is greater than 25 seconds, there is an 89% chance that dysfunctional breathing is not present. In other words, the objective is to have a minimum goal of 25 seconds. Now, again, this has been written about since 1975. Nishino wrote about it again in 2009. There has been a number of studies looking at using breath-holding as a means of assessing breathlessness during physical exercise. For example, people with cystic fibrosis, people with asthma. 

Normally, the lower your breath hold time during rest, the faster the respiratory rate, and also you're more likely to be upper chest breathing. You could also, for example, then have chronic hyperventilation syndrome, and I understand that it's a gray enough area—chronic hyperventilation syndrome—you'd think that it's black and white, but it's not, per se. It's when minute volume is obviously in excess of normal metabolic requirements to cause the lowering of carbon dioxide. But researchers back in '96 discovered that you could have individual hyperventilation. And if you kept your carbon dioxide constant by re-breathing carbon dioxide, you were still able to produce the symptoms from hyperventilation. It's not just the gas per se, but it's also the behavior of the breathing pattern. I think it really comes back into what we talked about earlier on. I remember getting into difficult situations, as we all do, and my physiology was already stuck in that stress response. It didn't take too much to push me over the edge. I was already there.

I was listening to a podcast by Dr. Rangan Chatterjee. He's a UK-based doctor. He was interviewing a brain surgeon called Dr. Rahul.  I couldn't imagine a trickier occupation. Dr. Rahul says "when I get into a tricky situation, the first thing I do is prevent myself from hyperventilating. People think that I'm born with nerves of steel." Of course, the doctor knows it, because he knows physiology. But not so many people know that. How many people, when they get into a difficult situation, their normal response is that they're reacting with this faster breathing pattern, harder breathing, upper chest breathing, irregular breathing pattern. And all of this information is conveyed from the body up to the brain. The brain is interpreting that the body is under stress. All the brain wants to do is to protect the body and get you out of the situation. The very time that you need to be able to plan and come up with a good decision and have a clear level head, you can't because your brain wants you to get out of there.

So what do we do? Whenever we get into a difficult situation, bring your attention onto the breathing. Always think of the exhalation. Because if we have a fast exhalation, it's a stressor. If we have a really relaxed and slow and gentle exhalation through the nose, the body is telling the brain that everything is okay. The brain will in turn send signals of calm back to the body. This could be based on the vagus nerve, but there could be other stuff going on as well because in 2017, scientists at Stanford identified a new structure in the brain, in the locus coeruleus, and they said that this structure is spying on your breathing. The speed of how you breathe is going to influence your state. I, as a chronic mouth breather, was breathing faster and harder all the time.

Anybody who's listening to this, if you have a BOLT score of less than 25 seconds, it's a sign that your resilience may not be where it should be. You know that you can improve on that. I would say definitely for people, work to improve your BOLT score. 

But I'd come back to this Shiv. You know, mindfulness is wonderful. People talk about mindfulness, and it gets all of the attention. I worked teaching mindfulness and functional breathing in 2010 to 2013 because Ireland was falling apart economically here. 3,000 people came to short courses that I was doing over the three years. These were people with panic disorder and anxiety. 75% of this group has dysfunctional breathing patterns. That's the literature, and cognitive-behavioral training will not change breathing patterns.

I asked this group, I said, "How many of you have done mindfulness or meditation? And how many of you still continue to do it?" Maybe 5-10% of them had at one point done meditation. How many of them continue to do it? Hardly any. I was just wondering, here's a group that really needs mindfulness. They really need meditation. But if I was in their position, with dysfunctional breathing and poor sleep, the last thing that I'd want to be doing is paying attention to what's going on in my mind. One aspect here is if we have high stress or a racing mind, the first thing to get right is our sleep. 

We will not get anything else right unless sleep is right, because even if we wake up feeling groggy in the morning, we're going to be more irritable. We're less likely to be able to deal with difficult situations. Tied-in with that is functional breathing. When I'm talking about functional breathing, I'm talking about breathing from a biochemical point of view, and a biomechanical point of view, but also to look at the autonomic nervous system to bring that balance in terms of the stress response and the body's real relaxation response to improve heart rate variability. But then to bring in breath aware, bring in body aware, bring in mind aware.

Mindfulness is great when you get the basic tenets right. We have to also bear in mind that there's a connection between breathing, emotions, and sleep. We can't isolate either one of them. If your sleep is off, it's going to impact your stress levels the following day. If your stress levels are high, your breathing is off. If your breathing is off, your breathing is faster and harder, that feeds into your stress response.

But also, if your breathing is faster and harder during wakefulness, you're going to be breathing faster and harder during sleep. There's increased turbulence in the upper airways. This can contribute to snoring. It can also contribute to obstructive sleep apnea. Because how many of us have sleep disorder breathing, but it's undiagnosed? We’re not great at going to our medical doctor. This is the reality of it. I've been once to my medical doctor in 20 years. On my heart on that one. 

I'm nearly 50 years of age…we are the very group of people who are most susceptible to sleep disorder breathing, but we're not going to our medical doctors. We're not getting the diagnosis that we should be getting. But we are going to the dentist. I think there has to be a better relationship between the dentist and the medical doctor. The reason being is because the dentist is able to look into the mouth, which they are doing anyway. Look for scalping of the tongues, look for a high narrow palate, look for any sorts of recess jaws or narrow airways, and at least a dentist could be in a position to start identifying the risk factors associated with sleep-disordered breathing, and at least get that person seen. Because this comes back to resilience. The sleep part of it is very, very important.

I'm going to come back to: What would I do when I get into a difficult situation? Think back to what Dr. Rahul said. He says when he gets into a tricky situation, the first thing he does is he prevents himself from hyperventilating. What is hyperventilation? It's when our breathing speeds up, and/or the tidal volume increases to cause an increase in minute ventilation. Whenever we get into a tricky situation, bring your attention inwards. Focus on the airflow coming into your nose and take a soft inhalation, just a soft, normal inhalation through your nose, and have a really relaxed and slow and gentle exhalation. Even if you do that for just 90 seconds, you could time it and you don't have to take full big breaths either. If you wanted to time that you could slow down your breathing rate to about six breaths per minute to breathe in for about four seconds, and to breathe out for about six seconds. It's probably better if the length of the exhalation is about one and a half times the length of the inhalation.

The slow and relaxed exhalation is stimulating the vagus nerve, which in turn will secrete the neurotransmitter acetylcholine, which in turn will cause a slowing of the heart. When the heart rate slows down, the brain interprets that the body is safe, that there's not a trap there. But it's not just about breathing slow. I know sometimes people can be critical of heart rate variability, and it might not be a perfect measurement, but it's lasted the test of time. It's out there and after three decades, there seem to be tons of research on it. What's accepted seems to be that people who were either physically or mentally unwell have reduced HRV because of increased stress response -- whether people with diabetes or epilepsy or any chronic health problems, depression, anxiety, panic disorder, etc. There are a few ways to help improve heart rate variability. It's not just about slowing down the breathing rate to between 4.5 and 6.5 breaths per minute. 

Breathing light, for me, was the game-changer. This is what I practiced back 25 years ago, or whatever it was. I put one hand on my chest, one hand just above my navel. I deliberately under breathed. Don’t be worried about whether you're breathing upper chest or diaphragmatic. Don't worry about that. With your hand on your chest and your hand just above your navel, take a really soft and slow gentle breath coming into your nose, almost as if you're hardly breathing any air into your nose. Then have a relaxed and slow gentle exhalation. Then you're taking a really soft and slow and gentle breath coming into your nose, and a relaxed and a slow and a gentle exhalation.

The whole purpose with this exercise is to soften the speed of your breathing, to the point that you have air hunger, not by holding your breath, not by freezing your breathing, just by simply softening your breathing. Taking a really soft, gentle breath in, when you take that breath into the nose, and you breathe in almost such that your breath is imperceptible, that you're hardly taking on the air into your nose. On the exhalation, you're having that relaxed and slow and gentle exhalation.

So with that exercise, we're targeting the biochemistry, and dimensional breathing. We're doing it correctly when we feel the air hunger. Now three to four minutes into that exercise, it's very common that people noticed increased watery saliva in their mouth. They also notice that their hands are getting warmer because cold hands and cold feet are often a sign that our breathing is that little bit harder and faster. That is causing vasoconstriction due to the loss of carbon dioxide. I understand that chronic hyperventilation syndrome is not always associated with low CO2. But we can't show carbon dioxide out altogether either. That's an interesting exercise. That was a phenomenal exercise for me and I'll tell you why. Because there's an idea out there in the big, big world, that the more air you breathe, the better. You know, the harder you breathe, the better.

We have to say, listen, think about the stress response of the body. If you breathe out fast, it's a stressor. If you breathe out really slow and relaxed. It's a relaxer. And when we look at breathing, we look at breathing from a biochemical point of view. What's the technique doing to the biochemistry? Is it causing an increase of carbon dioxide, which by the way can stimulate the vagus nerve? Is it causing a decrease in carbon dioxide to drive blood pH up? What's it doing to the biomechanics? Are you targeting the diaphragm breathing muscle? Are you helping to improve function or strength of the diaphragm? What's it doing to the autonomic nervous system? It is a stressor or is it a relaxer? And when we break down any breathing exercise, we always have to ask the question, what is this breathing exercise doing? What is it doing to the biochemistry? What is it doing to the biomechanics? And what is it doing to the autonomic nervous system?=

The biochemistry is very important, but it has been overlooked in most instances. Individuals with a strong chemosensitivity to carbon dioxide, or a strong ventilatory response to carbon dioxide…they feel their hunger during their normal everyday breathing pattern. And because of the air hunger associated during their normal everyday breathing, they typically breathe fast and shallow. With this group of people, it's really important not just to focus on the biomechanics, you have to eliminate what's causing them to breathe fast and shallow. They're breathing fast and shallow because of a feeling of suffocation. You may say, "Well, it's the airways that are narrowing." But yes, of course. Their airways are narrowing. They're feeling air hunger. So they're responding to the feeling of air hunger by breathing out fast and shallow, which is going to increase dead space, which is going to reduce alveolar ventilation, which is not going to do anything to alleviate the feeling of air hunger, but also associated with that, they can have an increased chemosensitivity to carbon dioxide buildup. This is where breathing just becomes a little bit trickier. This is where it's wonderful. It really is in terms of that application.

Shiv Gaglani: Totally. I mean, even understanding the physiology, as you described eloquently in the book and just on this podcast, has been really helpful to people like me and obviously, our audience cares a lot about the actual understanding of the physiology. You mentioned chemosensitivity. One thing that I realized after reading your book was the fact that you're a better athlete if you're able to maintain more carbon dioxide in your bloodstream for longer because of the Bohr effect, which I learned multiple times in my preparation through med school. I never really knew how it affected me personally until I started realizing I can increase my BOLT score from 20, to now it's about 30. I still have a long way to go to get to the 40 that you recommend.

Patrick McKeown: It's still good. Thirty is good, though.

Shiv Gaglani: Yeah, but it changes day to day depending on my stress and if I'm actually practicing, but generally I’m trying to get to 30. And even though I could do like a long breath-hold, like a two and a half minute breath hold through the Wim Hof techniques and stuff like that, I was shocked with my BOLT score when I first started measuring it after reading your book. It was like 15 to 20. 

I think one of the reasons I really like what you've written about and how you talk is that you've worked both with people who have issues—a lot of children with asthma—as well as elite performers. You mentioned the elite sniper unit or soccer/football players. I'm curious, have you worked with physicians or nurses? Do they have similar flight responses that you mentioned? Are there things they could be doing in the moment when they feel themselves having that? Is it just paying attention to the out-breath, for three to four minutes, as you were saying? Four seconds in, six seconds out? We want to give them some actionable things, and that sounds a good one.

Patrick McKeown: I think, Shiv, we need to look at the overall picture here. Of course, if you get into a difficult situation, it's really important to take a little bit of time out. You don't have to move anywhere. All you have to do is bring your attention out of your mind and onto your breathing, soften the inhalation, and have really, really slow and relaxing exhalation. However, we have to think that some people are more susceptible to difficult situations and a stress response than others. Those individuals could be impacted with sleep disorder breathing. It starts off with sleep, and it starts off with waking up with a moist mouth in the morning.

Also, if you're overstimulated during the day, it can be quite difficult to fall asleep so readily. You're lying there and you're thinking and thinking, you're twisting and turning, and then you're waking up feeling tired. It's very important to be able to down-regulate before sleep. I'm not just talking about, don't be looking at your mobile phones and having an airy bedroom, a cool bedroom, and all of that stuff. 

That stuff is great, but down-regulate your physiology. The last 10 to 15 minutes before you go to sleep, sit in a nice, comfortable chair, put one hand on your chest, one hand just above your navel, and really start slowing down your breathing. Taking that soft breath in and the relaxed, gentle breath out. Do it to the point that you have air hunger. You know that you're downregulating if you experience increased watery saliva in the mouth, because of course, we all know that when the body is ready for the digestion of food, we've increased watery saliva, so we've activated the body's rest and digest response. You will feel groggy, you'll feel tired. Have your mouth closed, have your bedroom airy. Have a silent bedroom, cool bedroom, dark bedroom. You’ll wake up feeling alert, a great way to start the day.

With that, work to improve your BOLT score. When you do physical exercises, people are doing it because the most important first thing here is to develop habits. This is not a breathing practice that you're doing while sitting on a mat. This is something that I need people to be bringing into their everyday life. You go for your walk, why not do it with your mouth closed, you know? Now initially, you feel that the air hunger is a little bit stronger. That's normal because there's an increase in carbon dioxide in the blood when you do your physical exercise with the mouth closed because carbon dioxide is not going to leave the body so quickly through the lungs. 

If you continue doing your physical exercise with the mouth closed, the air hunger diminishes. The body does have a higher tolerance of carbon dioxide during physical exercise. The fraction of expired oxygen is less as a result of doing your physical exercise with the mouth closed. Then pay attention to your breathing throughout the day. The problem of breathing is that it has got so many left-of-field connotations, and robes and tree huggers and open sandal brigades and all of that stuff. It's got nothing to do with that. 

Like, genuinely I was working with an elite European military squad on Monday. Now I've worked with them before. Also, some of our instructors are in the Navy SEALs. One is in the Delta forces, and special weapons and tactics as well. Why are they practicing breathing techniques? It's because they use it to change states. Going into an operation where it can be a highly stressed environment—and when you're highly stressed, you're more likely to make mistakes—you have to bring balance in the autonomic nervous system. 

With that, for example, just a couple of approaches that I could use. One would be box breathing, which is a tactical breathing exercise. You're breathing in for four seconds, you're holding for four seconds, you're breathing out for four, you're holding for four. Another one that I use typically myself for giving public presentations: I take five or 10 minutes out, and I take really soft gentle breaths coming into the nose, and a relaxed and a slow and a gentle exhalation just as I've done to downregulation. But then I do a few breath-holds to upregulation. I want to go out into an audience but I want to go out into an audience with flow stage…to achieve that state of mind whereby you're in a state of relaxation and alertness at the same time. It's when the speaker and the talk becomes one, that the right action happens by itself, and the right words appear. Also, when you're in that state, your audience is more engaged.

But how many of us are spending half of our lives going around stuck in our heads? I'll give you the analogy of you can go to a beautiful restaurant, go to a Michelin star restaurant, and the chef cooks up this absolutely wonderful meal, and it's put in front of you. How can we appreciate that meal? If we're stuck in our heads, do we really see the meal in front of us? Do we smell the meal? Do we taste the meal? Do we feel the texture of the food as we are eating it? Because if we are stuck in our head, we are not savoring or prestaging. We're not experiencing that meal because our attention is stuck in our heads. 

When we bring our attention out of the mind, and into the breath onto the breath, and into the body, into the present moment, we see and we truly see, we taste and we truly taste, we feel the meal, we smell the food. It's a wonderful way, but it's not just something that we do in specific situations. It's something that we want to bring into our everyday life. Because I could imagine the stress on medical doctors…the time-demands on them, the long shifts. Number one is you don't want to be living in your head because it's draining of energy. You're more likely to be in that increased stress response. Having some of your attention on your breathing, and also having a higher BOLT score, will result in being more resilient, you've got increased heart rate variability, you've got increased and improved sleep quality. 

You also have the attention to do what you're doing. Because any of us go into a job, if our attention is stuck in our head, we don't have all of our attention doing what we're doing. When I talk about attention, I'm talking about 100% of undivided attention on the task at hand. But education doesn't teach us this. Who was teaching us how to concentrate? You know, education teaches us how to think. It doesn't teach us how to stop thinking. It doesn't teach us how to be able to switch off. 

What is concentration? Concentration is the ability to hold our attention on that one thing. Our attention span is the length of time that we can hold our attention on one thing. Nowadays there are so many distractions that the mind has literally become almost that we are drowning in thoughts, that our attention is consumed by every multimedia platform and social media platform, all-devouring our attention, but seldom do we give ourselves some attention. 

On Monday, why would a group of snipers want to know about breathing? When they go into an operation, they want to be absolutely there in the present moment. But their ability to be focused on what they're doing in that situation is dependent on their attentiveness outside of the situation in their everyday life. They need good sleep, they need functional breathing, they need resilience. There's no point in going through the motions of spending our everyday life going around drowning in thoughts and then expecting to be attentive when we need it. No, it happens outside of the workplace. It happens in our everyday life. 

But the benefits are even more. Back to working with snipers: Every time the heart beats it puts the finger off in terms of…it will knock off the target. When I was initially asked to work with this group, I says well, how could I think of the physiology here and what's happening with the breath because I was brought in for only one thing -- how to breathe when pulling the trigger of a gun? That's all I was brought in for. I said okay, should you pull the trigger of the gun during the breath in? Or would you breathe in and then hold your breath at the top of the breath and pull the trigger? Or would you breathe out and halfway throughout the exhalation do you pull the trigger, or do you pull the trigger at the end of the expiration?

During the inhalation, the vagus nerve is stepping back. The foot was taken off the brake. It's more sympathetically driven and the heart rate is increasing. That's not when to pull the trigger because there's a little bit more stress response. During the exhalation, especially if you have that prolonged and relaxed and slow exhalation, it's very much under the control of the body's relaxation response. The vagus nerve is stimulated, secreting acetylcholine, the heart rate is slowing down and the time to pull the trigger is in between heartbeats, because every pulse of the heart is knocking the finger off target.

A good sniper has to have absolute focus. They cannot have their attention stuck in their head. They have to have their total attention on the target in front of them. And also to be aware of the physiology, and to be following the breaths, taking that very soft breath in, and that relaxed and slow and gentle exhalation. Just towards the bottom of the exhalation, you pull the trigger. That's changing states. I could have done with those same ideas when I was doing exams at university. I'll give you this example Shiv. I know I'm probably talking too much and you'll say, "I'll never bring this guy on again because I never get a word in edgewise."

Shiv Gaglani: No, it's fascinating. I feel I'm learning so much and you're answering all my questions before I can even ask them.

Patrick McKeown: That's good. It's simple stuff. I remember going to do my final exams. You know what? I don't consider myself ever having anxiety, but I did have poor concentration. I was feeling stressed going into the exam. Before I went into the exam hall, I went for a walk to clear my head. For about three or four minutes, I took these full big breaths, because this is the idea that we often hear out there. We hear it across so many modalities: If you're stressed, take a deep breath. I remember walking into the exam hall and I was not there at all. I was lightheaded, I was spaced, I can remember sitting down, I couldn't gather my thoughts. It was the worst thing possible that I could have done. In fact, I should have done the opposite.

How would I do it now going into the exam hall? Well, number one is I'm an introvert and I want to always conserve energy, especially in a situation like that. I would arrive to the exam, but I would hide somewhere in my own time out of the environment. I would sit down and for even 10, 15, 20, or even a half an hour before a major presentation—I could even take an hour out—just to work on my states. For that half-hour, I do really slow and gentle breathing -- light, slow and low. I haven't forgotten about breathing low but you don't have to take that full big breath to get good recruitment of the diaphragm. 

For half an hour, I'm downregulating. Then when I'm walking back to the exam hall, I'll do two easy breath holds just to prepare my body for the longer breath holds. Then I'll do three or four strong breath holds. Initially, I'm activating the body's parasympathetic response, but then I'm coming out of it. I'm putting myself into the stress response. Then to walk into the exam hall, or into a public presentation with every cell of my body, because I want to be fully immersed in that present moment. This is where I use the breath as the tool to help me there.

Shiv Gaglani: I really love that. There's so much application here for any of our audience members who do get test anxiety, which is something we often like to cover. Then maybe if they wind up becoming a surgeon or an ICU nurse, or whatever it may be where they will be in constant, high-stress environments. The other key takeaway I think is you can't just show up in the high-stakes environment expecting that everything's going to work out. If you can make your day-to-day habits incrementally better than when you are in the stress environments, you can go even further because your baseline is much better. Again, I meant what I said where I'm looking at my questions, and you've answered so many of them already.

I recommend our audience to learn more, go to the Oxygen Advantage, read the book, start practicing. I know when I started practicing, I saw pretty much immediate improvements. I do mile runs with my mouth closed now. I basically incorporated that and am running as fast or faster than I used to. My BOLT scores increased because of it. 

I did have one other main question for you. What advice would you give to our audience about their journey becoming a healthcare professional? You have already given them a lot of advice about how to control their breathing and “get in the zone,” as you'd say. What other advice would you give to them about their own career journey similar to your career  in which you started somewhere very different and then fast forward, training thousands and thousands of people, writing a book that reaches hundreds of thousands of people? And then, is there anything else you'd like to leave our audience with before we let you go for the rest of the afternoon?

Patrick McKeown: It's amazing how life works out, it really, really is. When you're starting off in any career, you will never forecast where it's going to end up. I think the most important thing is to have our attention on the process. Don't worry about the outcome. It comes back to attention. Here was the mistake that I made as well in university. I was so driven to get my degree that I literally reduced every waking moment as a means of getting to the future. It stressed me out. I didn't have quality of learning because my attention wasn't “now” and sometimes people don't understand when I'm talking about that. I'm talking about when the critical thinking mind is out of the way, that your attention is not in the front part of the brain, but even to bring your attention into the middle or towards the back of the brain and hold your attention there.

Forget about the outcome. It's like writing books. I've written a few more books, but one that I think could be useful for your audience is called The Breathing Cure. Now, by the way, I didn't choose the name. That was my publisher. But Shiv, it's a 190,000-word book. I referenced it with hundreds of papers because I want to try and bring the science to the breath as best I can. We don't have all the science. 

I'll come back to that question. I really feel that breathing has been so left afield and letdown for decades. It has been let down and the surface has been barely scratched. It's coming back to the young doctor. It's an amazing vocation. And if you're suited to that, it's absolutely tremendous. I could imagine no better. But I would focus on the process and allow it to happen. If you're giving it your best shot, it's going to happen. Also, think of your physiology and think of your sleep. Think of your states.

For me it has been wonderful 25 years of working with the breath for myself. 20 years teaching. But there's not a day that I don't connect with my breathing. It has given me a softer life. The highs are not so high. Yeah, we get a book contract or whatever, great. But the lows are not so low. Of course, you have bad days, but you recover. Life is just softer. 

There were Harvard doctors, Gilbert and Killingsworth who did a study with this app called trackyourhappiness.org. I think they tracked 250,000 data points. They asked the question: "Are you doing something, but are you thinking about something else?" So the very basic thing is you could be brushing your teeth. You're brushing your teeth, but you're off on this train of thought. Human beings very much have a wandering mind, but they found that people whose minds wandered the most were least happy. The doctor who is able to hold their attention, the doctor with functional breathing, and with deep sleep will find it a lot softer, and I would say they will thrive.

Shiv Gaglani: Equanimity. Awesome. Great advice, especially in a career where it's always the next step. You’ve got to get the grades in high school to get the grades in college to get the grades in med school or nursing school to then get that residency, match, and career to get the salary to pay back your loans. It's a lot of living in the future and then maybe living in the past. I love this, I think it's one of my favorite episodes because it has actionable things that our audience can do today with the breathing techniques you were mentioning, and hopefully reading the Oxygen Advantage. I'll check out the Breathing Cure. I saw that you had written that, but I haven't read it yet. It's on my list.

Then you said other really interesting things. We have a lot of dental schools that we work with, dental students. My sister is a dentist with several practices in Chicago. We've had her and her husband on our podcast a couple of years ago. This whole idea of the dentist could be the first line of diagnosing or helping with disordered sleep because of the ability to look at signs of that in the oral cavity—very fascinating, Patrick. 

I really appreciate your time and obviously, the work that you've done to bring breathing to the forefront. My hope is that this elephant in the room you mentioned will no longer be an elephant in the room. It'll just be an elephant and we'll understand it and our audience will practice it and then be able to share that with their patients as well.

Patrick McKeown: It's a pleasure, Shiv. Thanks so much.

Shiv Gaglani: Thank you. With that, thanks to our audience for checking out today's show. Remember to do your part to flatten the curve and raise the line. We're all in this together. Take care.