Breathe 2022: Virtual Conference in Hawaii 

By Janet Winter

A review of select presentations from the conference (postponed from 2020 due to COVID)

OVERALL:  There was a wide range of interesting talks at this conference but for now I will focus on COVID, especially Long COVID as that is what many Buteyko educators are likely to encounter. 

One of the organisers, Dr Rosalba Courtney, had acute COVID during the meeting and shared with us that she was getting some relief with humming on the outbreath, pausing for a count of 4 before breathing in the resultant higher (presumably as humming is known to increase NO levels in the sinuses) levels of Nitric oxide that may be anti viral.

WHO definition of long COVID:
Post COVID-19 condition is defined as the’ illness that occurs in people who have a history of probable or confirmed SARS-CoV-2 infection; usually within three months from the onset of COVID-19, with symptoms and effects that last for at least two months.’ The symptoms and effects of post COVID-19 condition cannot be explained by an alternative diagnosis.

(Several of the speakers prefer the 4 week point for the definition of Long COVID).

Speaker:  Umakanth Katwa (Pediatric pulmonologist and sleep medicine Boston Children’s hospital).

This presenter gave a great presentation on COVID and said that even though children are unlikely to get it severely, you can get occasional atypical presentations. Acute COVID can give bronchitis, interstitial pneumonia, ARDS (acute respiratory distress syndrome) and sepsis with multi organ failure (MIS-C or multisystem inflammatory syndrome in children) which can be fatal. Heart failure is common as is a characteristic rash.

Dr. Katwa said that long COVID should be suspected If symptoms persist for over four weeks, with the patient testing negative for COVID for at least a week.

Symptoms:Fatigue (53%), Shortness of breath (43%), Joint pain (27%), Poor exercise tolerance dizziness, headaches, brain fog, chest pain, trouble speaking, muscle aches, loss of sense of smell, anxiety or depression POTS (postural orthostatic tachycardia syndrome) and insomnia.

From his earlier studies Dr. Katwa said the incidence is 30- 90% of children having Long COVID at six months after the acute infection and the pathophysiology is an enigma.

Risk factors for long COVID include: Obesity, cardiac conditions, inflammatory disorders, age. It's unclear if there's a genetic susceptibility and it can affect anyone, they may not necessarily have had severe COVID acutely.

The most common Long COVID/ long term respiratory symptoms are: shortness of breath (most common), persistent cough, sleep hypoxemia (especially in those with severe lung involvement), tachypnea, exercise intolerance and hyperventilation. 

Dr. KIatwa quoted from a paper by Motiejunaite et al (from January 2021, Frontiers in Physiology) that suggested hyperventilation could be a possible explanation for long lasting exercise intolerance in mild COVID survivors.

He speculated on the origin of the hyperventilation:  Hyperactivity of activator systems, or failure of inhibitory systems 

Consequences of alveolar hyperventilation are well known, most importantly a decrease in depolarization threshold of cell membranes that is to become “sensitised). 

Neuronal hyperexcitability, imbalance in the autonomic nervous system.

The hyperventilation in long COVID can be at baseline or intermittent or just occur with exercise. Hyperventilation induced hypocapnia can cause a multitude of extremely disabling symptoms dyspnea chest tightness, tachycardia, chest pain fatigue dizziness and syncope (fainting) at exertion, Hypocapnia due to the Bohr effect, less oxygen released to tissues. 

Hyperventilation syndrome in Long COVID and anxiety, breathing dysregulation may contribute to anxiety attacks in teenagers following COVID. It's commonly seen in children and teenagers with anxiety and panic. Evaluating breathing retraining is critically important in management of these young patients with minimal or no medications. 

POTS/ orthostatic intolerance/orthostatic hypotension prevalence: 10-40% post COVID mechanisms of POTS in COVID hypovolemia could include, fever, loss of appetite and decreased food fluid intake, cardiac deconditioning, blood pooling, autoimmunity, cytokine storm, inflammation chronic neural dysregulation, auto antibodies interact with autonomic ganglion. 75% of patients with POTS positive for anti-acetylcholine receptor antibodies that could respond to immunotherapy.

Breathing rehabilitation in long COVID, 3 publications:
In patients with long COVID, exercise capacity, functional status, dyspnea, fatigue and quality of life improved after six weeks of personalised interdisciplinary pulmonary rehab (Respiration February 2022).

Pulmonary rehabilitation is a feasible safe and effective therapeutic option in COVID-19 patients independent of disease severity (ERJ Open res 2021).

 Hyperventilation and symptoms of long COVID can be treated with breathing retraining and rehabilitation.


  • Long COVID symptoms are predominantly associated with breathing  dysregulation. 
  • Hyperventilation is most common breathing problem but this is usually not suspected or tested in patients
  • Breathing retraining is an important part of management of long COVID syndrome


Speaker:  Dr. Todd Davenport (Professor of P.T, an expert in chronic fatigue or myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) presented a case study of a woman with “deconditioning.” The client had been sick with the respiratory virus but not hospitalised: this occurred during 2020 so it couldn't be confirmed as COVID. She recovered to 75% fitness for three months and then she decided to do a hard workout to kickstart her recovery and she got brain fog fever and shortness of breath for three days -this is PEM (post exertional malaise.) It's very typical of ME/CSF and very common in long COVID. And it's not just fatigue, it's more than just tired.Mr Davenport described that with long COVID, PEM and fatigue can increase with time even when some of the respiratory symptoms are getting less. Although shortness of breath tends to persist, pulmonary rehab can cause “crashes” “and PEM by exceeding the patient’s aerobic threshold. In both Long COVID and chronic fatigue syndrome, you can find PEM and impaired systemic oxygen extraction (possibly related to hyperventilation?)


Speaker:  Samantha Holtzhausen, M and Jessica DeMars, physiotherapists who specialise in pulmonary rehabilitation reported on success stories in Long COVID. Main point: physical therapists working with people with Long COVID should measure and validate the patient's experience. Post exertional symptom exacerbation (PESE) or PEM (post exertional malaise) must be considered, and rehabilitation needs to be carefully designed based on individual presentation. Beneficial interventions might first ensure symptom stabilisation via pacing, a self-management strategy for the activity that helps minimise PEM.

No inspiratory muscle training is recommended if the patient is unstable: normalise breathing first and watch out for PEM or you could “crash them” with breathing exercises. 

 Breathing retraining helps with some symptoms but is not the “cure-all”.


Speaker:  Dr James Hull PhD, FRCP, FACSM spoke on COVID in athletes

Catching acute COVID- Professional athletes and regular serious exercisers are less likely to be hospitalised with acute COVID.  Risk factor for “couch potatoes” as big as those with poorly controlled diabetes! (data from ZOE study) ~9%

Long COVID is a big deal for athletes to have symptoms that stop them competing or training for >4 weeks. 1 in 4 not ready after common viruses,  only 1-20.

Actually similar chances as the general population of athletes getting Long COVID, symptom burden and pattern similar.

Dr. Hull divided the breathing problems into 1) EILO, exercise-induced laryngeal spasm, 2) EIB, exercise-induced bronchospasm-after peak exercise (asthma, beta agonists effective), 3) BPD, breathing pattern disorder

Lower respiratory symptoms are a big problem in returning to sport (above neck symptom, loss of sense of smell, stuffy nose not too bad).

Common symptom affecting athletic performance: SOB (shortness of breath) 58%

Long COVID clinic

  1. Unexplained fatigue
  2. Inappropriately high heart rate in response to exercise
  3. Can’t catch a breath (disproportionate breathlessness).

Tidal volume is erratic and high, inefficient breathing.

Coaches must not push athletes too hard when returning them to post long COVID fitness.


BBEA Member, Hadas Golan, MS CCC-SLP, Level 4 trainer, presented on  Current airway and breathing issues in speech, voice therapy and cough 

Take home, mounting evidence that breathing retraining can help with many symptoms of Long COVID, but care must be taken not to push too hard but to pace. Even reducing breathing can cause crashes, and best to avoid cueing “air hunger” initially. 

For more information, Breathe 2022  

AN ASIDE:  This is a presentation (not from Breathe 2022) from a Buteyko trained specialist, Viklki Jones, who had long COVID herself may be useful.  Vikki also shared a case study working with a client with Long COIVD.

In for the Long Haul - Zoom    

Janet Winter: 

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