On the count of four... box breathe your way to de-stress

Breathing is a fundamental physiological process often taken for granted, yet it plays a crucial role in maintaining overall health and well-being. Dyspnoea is a subjective experience of breathing discomfort that arises from interactions among multiple physiological, psychological, social, and environmental factors and may induce secondary physiological and behavioural responses. The prevalence of dyspnoea is reported to be as high as 50%–87% in lung cancer patients, 56%–98% in Chronic Obstructive Pulmonary Disease (COPD) patients, and 91%–95% in acute asthma patients. Dyspnoea, a common and distressing symptom that is associated with anxiety, insomnia, and fatigue, causes prolonged hospital stays and severely impairs quality of life, which further gives rise to the fear of getting into a dyspnoea cycle.

Fear of dyspnoea cycle

To manage dyspnoea effectively, recognition of its high prevalence, optimising treatment of the underlying disease, and a holistic and comprehensive approach to symptom control are necessary.

Mindfulness: In the era of modern medicine, often supportive and rehabilitative care is neglected. Controlled breathing practices have been a part of various cultural traditions for centuries, often associated with meditative and health-promoting effects. Incorporating these simple techniques can significantly improve patients’ quality of life, reduce hospital visits, and manage small exacerbations at home. Breathing is of utmost importance not only in patients with chronic lung disease but also in reducing anxiety among patients with the above-mentioned diseases. There are various kinds of exercises advocated like deep breathing, pursed lip breathing, diaphragmatic breathing, and box breathing. While most of these require some assistance from physiotherapists and have a short learning curve, box breathing is a technique which can be easily performed by all individuals and has been linked to improved stress management and pulmonary function. 

Box breathing, also referred to as four-square breathing, involves a four-step process of inhaling, holding, exhaling, and pausing, each for an equal count of four. This creates a “box” or “square” pattern in the breathing cycle, hence the name. This rhythmic pattern of breathing works thanks to its influence on the autonomic nervous system as it activates the parasympathetic nervous system, promoting a shift from sympathetic to parasympathetic dominance, promoting relaxation and reducing stress and anxiety levels.

The practice of box breathing has been found to positively impact lung function, as evidenced by improvements in Forced Vital Capacity (FVC) and Forced Expiratory Volume in one second (FEV1).

Several studies have reported positive effects of box breathing on respiratory parameters, such as improved pulmonary function, reduced shortness of breath, and enhanced exercise tolerance. These improvements are particularly notable in individuals with chronic obstructive pulmonary disease (COPD), suggesting that box breathing may serve as a complementary therapy in the management of such conditions.

Evidence suggests that box breathing can be effective in managing pain, likely due to its calming effect on the nervous system.

Box breathing can be a helpful pre-sleep ritual for those struggling with insomnia to encourage a restful night.

The box breathing technique

First, find a quiet space and sit with your back straight and feet flat on the floor. Follow these steps:

Exhale: Begin by slowly exhaling through your mouth to empty your lungs.

Inhale: Inhale slowly through your nose to the count of four, filling your lungs completely.

Hold: Hold your breath for another count of four.

Exhale: Release the air from your lungs by closing your mouth and counting to four.

Hold: Hold your breath again for four counts before repeating the process.

For beginners, it may take some practice to get comfortable with the technique. Start with shorter counts if necessary and gradually work up to longer periods.

While further research is needed to fully understand the underlying mechanisms and optimal implementation strategies, box breathing represents a valuable complementary therapy for individuals seeking non-pharmacological approaches to support their respiratory health, particularly those with lung diseases or COPD.

(The author is a consultant pulmonologist.)