You’re breathing, I’m breathing. But neither of us is probably thinking about our breathing right now. Do you ever think about your breathing during your workouts or races? Do you ever wonder if you should be “training” the act of breathing as a skill? Or whether you should do something differently during rest and recovery, or between intervals, or even on long endurance rides?
In some ways, breathing is a much-discussed topic—often, however, that’s in the context of meditation or in the practice of yoga or other such disciplines. Breathing for performance, in the context of training and racing, however, is not something that gets a whole lot of attention. And that’s the focus of today’s episode.
While Trevor was sitting in Toronto and I was in Boulder, we caught up with a leading expert on the science of breathing, Dr. James Hull, who joined us from London.
Dr. Hull ‘s experience is vast and varied, and all of it focuses on breathing. He is a respiratory physician at Royal Brompton Hospital in London and the clinical lead looking at unexplained breathlessness during exertion. He also works at the Institute of Sports, Exercise, and Health at University College London. He also works with elite athletes, both as part of the English Institute of Sport working with British Olympic athletes, and as a contributor to the International Olympic Committee’s respiratory guidance committee.
Dr. Hull takes us through the science of respiration, from the state of the system—is it overbuilt or underbuilt?—to pathological concerns for athletes. Think you have asthma? There’s a good chance that’s a misdiagnosis. Finally, we discuss the things you can do to improve performance through breathing.
Not to be forgotten, also on today’s episode, we talk with several guests about the meditative side of breathing, as well as the practice of breathing. We hear from coach Colby Pearce—catch him on his own podcast, “Cycling in Alignment” if you haven’t already. We catch up with Erica Clevenger, a member of the Tibco-Silcon Valley Bank women’s pro team, and someone who suffers from asthma. And we also hear from two elite coaches: Julie Young and Neal Henderson.
Inhale, exhale. Let’s make you fast!
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- Dempsey, J. A., Gerche, A. L., & Hull, J. H. (2020). Is the Healthy Respiratory System Built Just Right, Overbuilt or Underbuilt to Meet the Demands Imposed by Exercise? Journal of Applied Physiology. Retrieved from https://doi.org/10.1152/japplphysiol.00444.2020
- Fairbarn, M. S., Coutts, K. C., Pardy, R. L., & McKenzie, D. C. (1991). Improved respiratory muscle endurance of highly trained cyclists and the effects on maximal exercise performance. International Journal of Sports Medicine, 12(1), 66–70. Retrieved from https://doi.org/10.1055/s-2007-1024658
- Foust, G. D. and C. (2020). Can Yoga Breathing / Pranayama Concepts Be Reasonably Extended to Conventional Endurance Training? World Journal of Yoga, Physical Therapy and Rehabilitation.
- Hull, J. H., Godbout, K., & Boulet, L.-P. (2020). Exercise-associated dyspnea and stridor: thinking beyond asthma. The Journal of Allergy and Clinical Immunology: In Practice, 8(7), 2202–2208. Retrieved from https://doi.org/10.1016/j.jaip.2020.01.057
- Klusiewicz, A., Zubik, Ł., Długołęcka, B., Charmas, M., Broniec, J., Opaszowski, B. H., … Ładyga, M. (2017). Effects of Endurance Training on Functional Status of the Respiratory Muscles in Healthy Men. Polish Journal of Sport and Tourism, 24(4), 235–241. Retrieved from https://doi.org/10.1515/pjst-2017-0023
- Lucía, A., Carvajal, A., Calderón, F. J., Alfonso, A., & Chicharro, J. L. (1999). Breathing pattern in highly competitive cyclists during incremental exercise. European Journal of Applied Physiology and Occupational Physiology, 79(6), 512–521. Retrieved from https://doi.org/10.1007/s004210050546
- Lucía, A., Hoyos, J., Pardo, J., & Chicharro, J. L. (2001). Effects of Endurance Training on the Breathing Pattern of Professional Cyclists. The Japanese Journal of Physiology, 51(2), 133–141. Retrieved from https://doi.org/10.2170/jjphysiol.51.133
- Mota, S., Casan, P., Drobnic, F., Giner, J., Ruiz, O., Sanchis, J., & Milic-Emili, J. (1999). Expiratory flow limitation during exercise in competition cyclists. Journal of Applied Physiology, 86(2), 611–616. Retrieved from https://doi.org/10.1152/jappl.19126.96.36.1991
- Nicolò, A., Massaroni, C., & Passfield, L. (2017). Respiratory Frequency during Exercise: The Neglected Physiological Measure. Frontiers in Physiology, 8, 922. Retrieved from https://doi.org/10.3389/fphys.2017.00922
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Chris Case 00:12
Hello, and welcome to Fast Talk your source for the science of cycling performance. I’m your host, Chris Case.
Chris Case 00:19
You’re breathing, I’m breathing. But neither of us is probably thinking about our breathing right now. Do you ever think about your breathing during your workouts or races? Do you ever wonder if you should be training the act of breathing as skill, or whether you should be doing something differently during rest and recovery between intervals or even on those long endurance rides? In some ways, breathing is a much discussed topic – often, however, that’s in the context of meditation, or the practice of yoga or other such disciplines. Breathing for performance in the context of training and racing, however, is not something that gets a whole lot of attention. And that’s why we focus today’s episode solely on that topic.
Chris Case 01:07
While Trevor was sitting in Toronto and I was in Boulder, we caught up with a leading expert on the science of breathing. Dr. James Hall who joined us from London. Dr. Hull’s experience is vast, its varied, and all of it focuses on breathing. He is a respiratory physician at Royal Brompton Hospital in London, and the clinical lead looking at unexplained breathlessness during exertion. He also works at the Institute of Sports, Exercise and Health at University College London. He also works with elite athletes, both as part of the English Institute of Sport working with British Olympic athletes, and as a contributor to the International Olympic Committee’s respiratory guidance committee. Mouthful leaves you breathless.
Chris Case 01:55
Dr. Hull takes us through the science of respiration today from the state of the system. Is it overbuilt? Is it underbuilt? – to pathological concerns for athletes? Do you think you have asthma, there’s a good chance that’s a miss diagnosis. Finally, we discussed the things you can do to improve performance through breathing.
Chris Case 02:18
Not to be forgotten today. We talked with several guests about the meditative side of breathing as well as the practice of breathing. We hear from Coach Colby Pierce, catch him on his own podcast Cycling in Alignment if you haven’t already. We catch up with Erica Clevenger, a member of the TIBCO Silicon Valley Bank, women’s pro team, and someone who suffers from asthma. And we also hear from two elite coaches that have been on the program anytime before Julie Young and Neal Henderson.
Chris Case 02:49
Inhale. Exhale. Let’s make you fast.
Chris Case 02:57
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Chris Case 03:17
Well, we want to welcome Dr. James Hull to the program today to Fast Talk. It’s a, I know your background is extensive. It hits at the heart of our listeners: athletes. And so we’re really excited to talk to you today, Dr. Hull. Welcome to the program.
Dr. James Hull 03:34
Thanks for inviting me.
Chris Case 03:35
Now today, we have a physician on the show we do not have a yogi on the show. And that’s because we’re not going to talk too much about how to breathe, to relax and how to breathe when it comes to meditation, how to use some of those yogic practices in breathing. This is more about the science of breathing, the performance enhancements that can come from proper breathing, the pathologies that some athletes might suffer from out there. We’re going to try to cover a lot of ground when it comes to to breathing today, all in the context of the science of breathing. Trevor, I know you have a little way to kick off the show. So hit it.
Trevor Connor 04:21
I think the good starting point is the fact that many athletes they focus on power, they focus on what they can do about their form, what they can do about the strength of their legs, all these other factors and maybe don’t think that much about respiration. And something that kind of caught my attention as I was researching for this episode is I found this 2018 study in the Journal of Sports Medicine and Physical Fitness, that was trying to look at what physiological factors differentiate flat riders from hill riders from sprinters. And so they looked at 17 different variables. And I’m just going to read to you their conclusion, which are the the one line and the initial line, their conclusion, which is, “respiratory indicators mostly contribute to the discriminant power of the model.” Basically saying of all these things that they looked at the best way they could differentiate these different types of riders was with respiration indicators. So that really caught my attention that this is probably a very important factor that maybe some of us aren’t thinking too much about. With that we have somebody who is an expert on this subject, I definitely am not. So I guess the the place that I would love to start is maybe Dr. Hull, you could just tell us, what are the things some of the things that we need to know about breathing or respiration from the scientific standpoint that we haven’t really thought about?
Dr. James Hull 05:54
Well, that’s a great introduction. And, you know, it’s it’s a fascinating area, as you allude to, the respiratory system is highly evolved over thousands of years, such that it’s a beautiful system, when you really break it down, it’s got a huge air space capacity with fantastically intricately designed blood flow, which allows delivery of oxygen, and then the transmission of that oxygen through to the exercising muscle. And when we look at the way that it’s evolved in the airways allow ventilation to perform, then you start to say that actually, the ways in which the system has evolved so highly, allows people to really do incredible things, and to actually put that system under massive amount of pressure. So we increase our ventilation from resting values of 10 to 15 liters, up to almost 200 or 200 more liters, when you’re exercising very intensely, I think we’re probably going to touch on some of the factors that we think may limit the ability of the exercising research system to function. But I think one of the things that’s overlooked is the fact that this interlinks with other systems. So for instance, if you start to get fatigue in the respiratory muscles, that feeds back and plays into blood flow and contractility within the peripheral musculature, so the systems are all interlinked, as you might expect in a highly adapted physiological system.
Breathing and the practice of yoga
Chris Case 07:24
Before we dive into the science, and so that we don’t sound like we’re beating up on yoga, let’s hear from top coach, Julie Young. She’s a physiologist at the Kaiser sports endurance lab. And when we asked her about breathing, she talked about encouraging her athletes to practice yoga.
Julie Young 07:39
No, it’s interesting, because I’ve just recently been thinking more about the nose breathing, which I always thought was a little impractical. But it is interesting, the effect that I’ve found just personally, the effect that has when I’m out, like riding more just at an endurance pace, in terms of like the calming and the, it’s just, it’s, it feels, it’s not very scientific, but it feels very effective. But just started just to play with that a bit more in terms of athletes, it’s trying to remind them like in our off bike work, we’ll do some breathing, deep breathing exercises in terms of that deep belly breathing. And I kind of picked this up from from a yen yoga class in terms of a belt around the lower belly and just feeling like you’re breathing 360. And I also really have found for myself, like, I feel like there’s so many benefits to yen yoga and one being it really makes me mindful of my breathing. And in terms of that deep belly breathing, and then also when you’re kind of in a sticking point to really breathe through it. And I think about it, like starting a sprint or starting effort. And we start to start to hold your body tightly and start holding your breathing tightly. And that really, that practice helped me tremendously. So I really encourage my athletes to try to incorporate yen yoga into their their week. And that’s not just for the opening and the stretching, but it is also for the breathing. And hopefully they can bring that deep belly breathing into the onto the bike and it becomes more of a you know, a default, as opposed to something they have to think about.
Trevor Connor 09:28
And that was something in your review that I found really fascinating that I admit I haven’t given a ton of thought to which is we have a lot of respiratory muscles. Some of them are quite strong. And when they are working hard, they actually have a high demand for blood flow. They have a high demand for oxygen, but if you’re on a bike, they’re competing with your leg muscles for that oxygen for that blood flow. And you even cited a study where they had I think it was cyclists while they were doing a test They had mechanical ventilation. So they didn’t have to rely on their internal muscles and they were able to perform better.
Dr. James Hull 10:07
As you allude to, we recently published an article, I was very lucky to co author with Jerome Dempsey, who’s a very famous name in respiratory physiology. And Jerome for almost two decades really done a lot of work looking at that with his research group, and looking how the, there is an interplay between researching muscle work and loading, and an interplay with the so called metabolor reflex, and how that links into peripheral motor function. And you’re quite right, if you can offload those respiratory muscles, at least at moderate intensity exercise or above that affects the function, blood flow, and potentially the neural traffic to the peripheral musculature. So there is something about the amount of work that you’re doing with your breathing, which is impacting affecting the performance of your peripheral muscles.
Is your respiratory system overbuilt?
Trevor Connor 10:56
So I need to ask you the big question that might be a huge disappointment to me. And so I’m going to point out even the the review that you just published is called “Is the Healthy Respiratory System Built Just Right or Overbuilt or Underbuilt to Meet the Demands Imposed by Exercise,” and I’m just going to qualify here, very early in my career when I started studying physiology, I studied how the system is over built. And so we never are stressing the respiratory system. And that was fascinating to me. That was one of the things that said, Okay, this is my career. So I’m kind of worried after reading a review that I picked the wrong career, because apparently I’ve had this wrong. Is this the is this the case? Is that not overbuilt?
Dr. James Hull 11:50
Well, I mean, so this has been an error has been debated for some considerable time. And I think if you if you go to most exercise physiology, testing laboratories, some of the techniques or ways in which people assess and ventilate your respiratual performance, are based on relatively crude measures. So for instance, you might do a rig test on an exercise bike, and determine from a preset point what you expect someone to have as a ventilator capacity, or as a maximum. And, for instance, people would calculate that based on a multiplication of a resting lung function indecy, and then you you’d exercise on the bike, you put in as much as you could as the subject and then determine the ventilation that was achieved at the peak of exercise and compare that to the predicted maximum, to try and work out whether people had encroached on this ventilator three limitation, or we’re both becoming ventilatorly constrained in some way. And I think what we’ve learned is that actually, when you start and you think about whether the system is over built or under built on that very crude basis, you really miss a trick, and certainly within the review, and I encourage anyone who’s got a spare couple of hours to read it to- when you start to look at that, and you think about the other factors, which might be relevant, for instance, and how different segments of the airway tree perform. Whether you develop a phenomenon called expiratory flow limitation, which isn’t characterized by those very crude measures, you actually start to see that rather than seeing what you might think, is a capacity that is always there at the end of exercise. Some of those issues aren’t quite so clear cut. And in fact, what looks to be overbuilt from crude measures or a crude perspective, actually, isn’t particularly overbuilt when you push it quite hard, particularly trained individuals.
Trevor Connor 13:41
Yeah, I wrote a very lengthy paper for one of my master’s classes all about the pronghorns. And what I’d read, but this is older research is that pronghorns and humans are the two species on the planet that have overbuilt lungs.
Dr. James Hull 13:55
I mean, yeah, and I think, you know, certainly some of the evidence has really evolved relatively recently. So, within this review, we highlight two relatively, I think, new areas of understanding, and we’ll probably come on to them in a little while, but, and certainly an increased insight with respect to the upper airway, or the extra thoracic airway and how that performs, particularly in very young and athletic individuals. And how when you increase ventilation to a certain certain level, that seems to cause pressure drops across the extra thoracic airway, which in many ways causes it to fail, and then to drag in which to further restrict performance. And then likewise, our increased understanding of how the right ventricle performs. Now, I’m no expert in this area. But you know, there’s certainly an evolving understanding with some of the more modern physiological techniques we have that the right ventricle is a particular pinch point and comes under considerable stress during the extremes of exercise, particularly in the highly trained individual.
Trevor Connor 14:55
I found that fascinating your review so and this is remarkably complex, we probably shouldn’t even be touching on this. But the kind of simplified version is the the left side of your hearts, your left ventricle, which pumps the blood out to your body is really designed to handle high stress high activity. But what you’re saying in your review is the right ventricle, which handles blood flow to the pulmonary system is really designed more for passive flow and has a harder time with high intensity high activity.
Dr. James Hull 15:30
Yeah, exactly. And I mean, I think that people, you know, only really started to grips with how high the pressures can rise to in the pulmonary circulation. And that puts immense strain on the right ventricle, which, as you say, isn’t used to pumping against those very high pressures. And over time, you know, that has effects on remodeling the right ventricle, as you would see in the left ventricle, where you see changes that, you know, certainly differentiate, highly trained or highly trained endurance athletes, at least from the from the relatively normal, untrained individual. And we’re starting to learn more about how that occurs in the right side of the circulation, the right ventricle.
A simplified rundown of the complex respiratory system
Trevor Connor 16:13
So why don’t we take a step back here and try to do the the 5000 foot overview, your area of expertise is the respiratory system, forgive me, that’s one of those words I struggle to pronounce. But you know, another thing I really got from your review is just how complex that system is. And I say that because I read your entire review got to the end of it went, Wow, I absorbed absolutely none of that I have to go and read it again. It was it was quite complex. And it was fascinating. Like I thoroughly enjoyed it. But I had to really take my time going through the review to understand the complexity. So can you give us a simplified version of how the system how the system works?
To try and unpick this overbuilt versus under built, this is a perfect system concept, I think it was necessary to go through the various different components of that system. And so when you think about it on a simplistic, simplistic viewpoint, you know, you’re talking about, do the spiritual muscles do what they need to do, and do they fail at times, Are there times when actually, the load overcomes the capacity to deliver. And of course, in a commercial sense, there is a there is a lot of interest in that. And there is a there are many advocates who would say that actually yeah your respiratory muscles are a weak point with you as an athlete and the way you might perform. And that is an area that you could actually enhance your performance. And again, I suppose we’ll come on to that. And then if you look at the other components, what happens when you ventilate, in order to deliver the an effective ventilation, you need an effective airway, which isn’t obstructed, and then you need an alveolus and gas exchange system, which allows you to transmit things, transmit oxygen and to clear the waste gas carbon dioxide in an effective way. And if there is a problem in that system, you have what is so called increased dead space. And so with increased dead space, that means space that isn’t actually really doing anything effective in terms of gas exchange, you have to ventilate that much greater. So for a unit of ventilation, if you’re if your breathing is efficient, then you can clear more of the waste gas, if he’s less efficient, then you’ve got to breathe, breathe, you got to breathe harder, really, and increase your ventilation for that given, you know, waste gas.
Dr. James Hull 18:36
And then you’ve got to, you’ve got to appreciate the actually, in terms of the performance of the exercising muscle key to all of that is delivery of oxygen. And so the fact is, you can’t discount the ability for the circulation to function deliver that, and also what happens to the oxygenation, oxygenation status of the blood. And so, you know, in that review, we touch on all of those issue issues. So we talked about, for instance, exercise induced arterial hypoxemia is a phenomenon which is recognized in athletes, that, of course, will impair oxygen delivery to the muscles, we talked about how the right ventricle functions and how that might impair circulatory performance. We talk about exercise induced asthma and the extra thoracic airway, and how that might impair flow or ventilation.
Dr. James Hull 19:22
And then you try and pull it together. And, and if you like, make some sensible comments about how that leaves us and in fact, you know, as you’ll know, from reading the summary, in the conclusion, there’s a lot of unanswered questions in this area. Um, and he, as I said before, you know, the ability to perform more detailed scientific experiments and some of the new techniques that are available, has allowed us to really progress our understanding, and hopefully get closer and closer to an answer.
Trevor Connor 19:51
Yeah, so that was something that you just brought this up and something that kind of surprised me at the end of your review because I read through all this and you just took the whole system apart piece by piece and said, “Well, here’s where you’re gonna have potential issues with this part, here’s where you can have potential issues with that part.” And as he went through it, a lot of the theme was most of these things are untrainable. And worse, most of them get worse with age. And there’s nothing you can do about that. And before I got to your conclusion, I was sitting there as a 15 year old going, “Oh, my God, I’m going to stop being able to breathe within the next five years. This is horrible.” And then one of the first lines in your conclusion was the cardiovascular system in general and maximum stroke volume specifically, together with circulating blood volume and hemoglobin mass, are the major gatekeepers regulating O2 transport. And then you say, the respiratory system inadequacies or constraints did not occur in all healthy subjects. And when they do they account for relatively minor limitations to performance, which I admit I was surprised to hear, you’re saying, well, all this adds up to not a big impact.
Dr. James Hull 21:06
Yeah, and I mean, I think that, you know, as a sports researcher and physician, especially sports physician, I always, like customers, my sports cardiology colleagues, and you know, they always get ahead in terms of major publications and grant funding. And in, you know, we’re seen as a sort of population, I have to say, to sports cardiology, and of course, in many ways, that’s because some of the pathological conditions they look after are utterly devastating instantly. So, you know, the cardiac dysrhythmias, or cardiomyopathy conditions, which have a huge impact straightaway. You know, when you look at the impact of significantly, or at least moderately impaired cardiac output, or an anemic individual, those limitations far outstrip subtle defects in ventilation, for instance, from exercise induced asthma. And in fact, within this review, were quite candid in saying that if we look at all the papers that have looked at how pathological conditions such as exercise induced asthma, or indeed this more recent condition, which is becoming more well known, quote, “exercise induced laryngeal obstruction”, the levels of impairment are relatively subtle in comparison. So even in experiments where you have exercising an individual with asthma, and you bronchoconstrict them before performing exercise, by means of abraca provocation test, and then you look at the impediment to performance, whilst there’s quite an impediment in terms of the subjective sensation of breathlessness. Actually, in terms of the overall impairment to the excellent performance, it’s very marginal. So I think those statements are true, we’ll probably come on to say that one has to bear in mind of course, there any impediment when you’re at an elite level or a competitive level is an impediment you don’t want at all so you need to discount the respiratory system and just assume that that statement is something which means that you just need to focus on cardiovascular and hemoglobin conditioning is all you need to do I think is somewhat missing, actually, you need every benefit you can get if you want to perform at the top level.
Asthma and how athletes manage it and other pathological concerns
Chris Case 23:15
Despite being a top Pro with Team TIBCO SVB, Erica Clevenger, has struggled with asthma, she shared her experience with us and also described what she does to manage it.
Erica Clevenger, 23:26
Um, breathing is definitely something I think about a lot, I do have asthma. It’s something I think probably more about off the bike than I do on the bike. Why not? When I’m on the bike, though, I really think about, especially in those times when I’m kind of doing that like midway between I’m you know, that low zone 2 versus like going anaerobic. So anything that’s kind of that tempo or like threshold, I am often thinking to myself, like about my breathing and how I can kind of slow down my breathing, if I can take deeper breaths. And really, really, belly breathe is kind of the term that I was taught. But I think it’s like breathing through your diaphragm kind of a thing helps me perform a little bit more efficiently. Usually, when you’re anaerobic, of course, you’re you don’t really have a choice, you’re gonna be breathing pretty hard, you know, asthma, there’s a lot of different things that can can cause an asthma attack, but certainly, you know, hyperventilating or things like that can bring on an asthma attack. And so really, being able to force yourself to take a deep breath and like, like, sort of chill out, is kind of important for just having asthma. So I think that’s partly also where I sort of learned to kind of keep my breath under control and think about it more.
Chris Case 24:45
I think many people out there have heard this term before of belly breathing, but I’m wondering if I can put you on the spot and tell us what that actually means. How does somebody quote unquote “belly breathe,”
Erica Clevenger, 24:58
and I’ll say what it means To me, obviously, I’m not an expert on this kind of stuff. But really, one thing that I found that helps me practice this stuff actually is yoga, because they talk about this kind of stuff a lot. Um, and, you know, sometimes I can get frustrated doing yoga, because because I’m like, ‘Oh, it’s too slow. You know, why don’t I just lift some weights or something.” But I really love how the focus, there is a lot of focus on breathing. And so to me, belly breathing, means taking that deep breath and feeling it go like, down into your belly, like, through your diaphragm and into your diaphragm. And just like if you were to lay on the ground, and put one, like your left hand on your chest and your right hand on your belly, you should feel both sort of expand as you’re taking a deep breath.
Chris Case 25:48
Now, going back to the topic of asthma, are there things, you know, I do not have asthma, so correct me if I’m wrong but, if in a race situation, there are times or situations, triggers, I suppose that could elicit an asthma attack? Are there certain things you can do with your breathing to prevent that from happening?
Erica Clevenger, 26:13
Yes, so I think that asthma, and even for those who have, it isn’t always the same. For me, I, it tends to be more of something that is like a constant, low level affliction for me. So it’s not that I get a lot of asthma attacks per se, but it’s that I just, you know, have this, I just need to take slightly deeper breaths, because it’s a little bit harder for me to force that air down when my lungs are kind of inflamed. And so I find that that happens for me, depending on the time of year. So like, for some people, it’s worse in the winter. And for some, it’s in the summer. For me, I have a really tough time in the summer because of pollution actually, and especially right now with some of the fires that have been going on. So I just find that I have to force a little bit more air down there. So it’s almost like I’m living at you know, I live at 5000 feet now. So it’s almost like I’m living at like 9000 feet or something, or at least that’s how it feels to me.
Erica Clevenger, 27:10
So but when it comes to preventing that, I’m like just having less, I guess symptoms of asthma in general, like, I definitely take like a, you know, an inhaler like a long term control kind of a thing. But there’s actually a lot of other things that I do. So for example, another aspect of breathing, when you’re off the bike is breathing through trying to breathe through your nose a lot, when you’re not exercising, there’s a lot of benefits to breathing through your nose, or so I’ve read, but you’re filtering air by breathing through your nose, and your air into your lungs a little bit longer by breathing out through your nose. And it actually when you’re in a place like Colorado where I am or if you’re in Arizona, or you know, one of those really arid states, you lose a lot of you, you lose a lot of moisture through your mouth, so you actually end up getting dehydrated a lot more quickly. And all of those things are kind of aggravating to at least my lungs, I feel Um, and so if I’m constantly breathing through my mouth, and I’m not really filtering anything through my nose, and then I’m also getting more and more dehydrated. So that’s one of the things I kind of think about a lot when I’m, you know, off the bike to prevent some of those more severe, like asthma symptoms sort of constantly.
Erica Clevenger, 28:31
I also have, like, you know, I, I have a humidifier and I have an air filter and all of those things and make sure that those even if I’m don’t have them on or around me all the time, like especially when at night, when you have like, you know, eight hours of being in the same room sleeping all the time, like that’s a really good time to try and make sure that you’re getting like good air and a good good moisture.
Erica Clevenger, 28:56
And then yeah, I mean, I suppose I’d say like, during a race, if I were to have an asthma attack, I usually it’s pretty rare that I’ll have one during a race, actually, my asthma tends to be really bad after training. So like after, you know, I think of my lungs as like a muscle. And so, you know, when you are working out and or you’re doing a hard ride, or you’re like lifting or something and yeah, I mean it kind of, you know, you feel like you’re pushing your muscles, but they really don’t hurt until like a little bit later, like, you know, afterwards and I feel that that kind of that’s how I feel about my lungs a little bit. So I tend to feel like I really struggle with my asthma after training. So it doesn’t come up that much when I’m actually racing, except for maybe when I’m doing like a really hard effort and then recovering. And at that point, I think it circles back to what I mentioned before, about really bringing that breath down and try not to like, you know, panic or hyperventilate, because those things certainly make asthma attacks far worse.
Chris Case 30:01
It’s probably a good time now to talk a little bit more in depth about some of the pathological concerns that athletes might have asthma, some of these other conditions. Could you, Dr. Hull walk us through some of those conditions you see most often and define them for us.
Dr. James Hull 30:18
Yeah, sure. And I think the thing to say, first of all, is that if an athlete feels an impediment to their performance, they often feel breathlessness or they feel a sensation they can’t get an adequate breath. And so you know, there are lots of different conditions, including, for instance, cardiac conditions, which can make you feel breathless. And just because you’re breathless, it doesn’t necessarily mean it’s coming from a respiratory problem. If we think about the main conditions that I see clinically, a lot of individuals report problems when they’re working very hard, where they can feel a sensation, they can’t get a satisfying breath. They sometimes feel or hear wheezing sound. And that might be a wheezing, sound breathing out, or it might be a wheezing, sound breathing in. And they might have other allied features such as cough, chest tightness, a constriction in the throat. Historically, when most particularly young athletes present with breathing difficulties and exercise, it’s just assumed straightaway that that’s got to be exercise associated asthma or exercise induced bronchoconstriction – a phenomenon where the airways tightened down, particularly the smaller airways and it’s usually classified by looking at lung function before and for instance, after an exercise test and looking for a fall in the lung function.
Dr. James Hull 31:34
Usually what happens when people present they go to their primary care physician, and then usually, generally speaking, people are just given a blue inhaler, so an albuterol inhaler, and told to just go away, try that and see if it does anything. And what we’ve known from years and years of research now is that it’s really poor way to try and make a definitive diagnosis. So we know that in athletes, the presence of respiratory symptoms isn’t very predictive, actually, of it being an asthma based process. And so if you want to get a really robust diagnosis, and you need to do objective testing, and really look at what happens to the lung function, in exercise.
Dr. James Hull 32:11
And of course, there are other conditions which can mimic asthma. And so certainly over the last five to 10 years, we’ve become very aware of key differential diagnosis, many of your listeners on this podcast will have this condition. In fact, I would say it’s almost as common as asthma as a cause of breathing difficulties. And that’s a condition called EILO or exercise induced laryngeal obstruction. Sometimes in the States, it’s known as exercise induced vocal cord dysfunction. And what happens is the upper airways close up. And essentially, they limit air getting in when you’re working really hard, and that makes you feel very breathless. And it can sometimes be associated with a wheeze, that when you’re breathing in, like a, what’s called a stride or sound, but really, you hear a wheeze you’re breathing in, and as you back off the intensity, so things start to settle down. And it’s often misdiagnosed as asthma.
Trevor Connor 33:04
So in the review, you said about 15 to 20% of athletes have this? What’s the unexplained exertional breathlessness is I think the terminology used. So it’s quite common.
Dr. James Hull 33:17
Yeah, it is common. And in fact, we did a study in Scandinavia, where we looked at almost 100 athletes with if you like unexplained breathlessness, and this diagnosis of exercise induced laryngeal obstruction was as common as exercise induced asthma when we performed objective testing. And so, you know, if I go to the, you know, the park run in on a Sunday morning, and I listen out for runners coming in, you know, in a standard Park run, there’s at least two to 3% of the runners coming into the funnel at the end of the run, who got classical features for EILO, they’re coming in, they can’t get their breath, they’ve got a wheeze breathing in and they’re grabbing for a blue inhaler. And that’s never going to help them.
Chris Case 33:57
I think that’s probably the important point here is that a lot of people might think that they have asthma. They’ve been mis diagnosed, they have this EILO. And so the treatment for EILO is substantially different than asthma. Is that correct?
Dr. James Hull 34:11
You got it. Exactly. And, you know, just to speak to cycling, you know, I work with British cycling and as a significant number of elite riders. And in fact, within the world, the world tour pro ranks, again, I, you know, look after a significant number of athletes in those ranks who do have this condition. So, if you’re out riding or you’re out racing, and you’re in a break, or you’re on a climb, and the person next to you is wheezing, it’s more likely they’ve got EILO than they have exercise induced asthma.
Trevor Connor 34:37
I have to admit, I had never heard of this and I read it and kind of went bingo myself, because I have wheezing problems. I have periodic breathlessness to the point that frequently I get emails from our listeners saying “Are you not feeling well?”
Dr. James Hull 34:53
That’s the case and when I give talks about this, so I mean, I was even once on a plane and I was looking at my slides for a talk I was going to give and both people on either side of me on the flight, they lent over, and they were listening to the things and I think I’ve got that condition. And you know that’s how common This is. I mean, you know, many of your listeners will be listening and thinking, I wonder if that’s what I’ve really got. Because when I push it hard, I get breathless. And I get, I can hear a Wheezy noise and I can feel my upper chest and throat feeling a bit tight on me,
Chris Case 35:21
briefly, what is the treatment for this?
Dr. James Hull 35:24
and the first thing is to raise it as a diagnosis. So most people haven’t heard of it. So even by just knowing or thinking about it, you can then start to alert people around you, and particularly a doctor to say, look, actually, I might have this condition and it stops you going down the line of being treated with more and more asthma treatments. So that’s the first thing.
Dr. James Hull 35:42
The second thing is to take a selfie recording on a video because on your phone, or whatever to show to people say, look, you know, this wheeze isn’t really like asthma is it’s a breathing in wheeze. And it occurs at peak intensity. Whereas in contrast, asthma tends to occur and, you know, often very classically, when you stopped exercising, or when you, you know, exposed to very cold air, and it’s a very sort of insidious tightness in your chest, it’s not as dramatic as EILO.
Dr. James Hull 36:09
And then those so those first two steps, establish the diagnosis, and then thereafter, largely that the treatment is centered on some special breathing techniques. So this goes right full circle back to the physiology where what we think happens in EILO is that when you increase your ventilation up to very high levels, for instance, when you’re attacking, you’re gonna break or you’re you’re climbing, essentially, as you dragging large volumes of air into the upper airway, that causes a pressure drop across the small laryngeal inlet. And in those people who’ve got a slightly vulnerable structures in that area, that acts by similar sort of forces of physics, the Bernoulli principle to drag in these structures even even closer together, and the harder you breathe, the worse it gets. And that’s why sometimes you see people at the end of a rowing race who just can’t get a breath in. And they almost blackout because they’re effectively hyperventilating. Because they can’t get any air in and out. And so we work with breathing exercises to try and give athletes way to modulate air flow into the upper airway.
Trevor Connor 37:07
And one of the things I really appreciated is, so this is one of your papers from 2013, where you really emphasize the difference between asthma and EILO. And you also said, you know, people talk about exercise induced asthma, better terminology is exercise induced bronchoconstriction. Because it’s not the same thing. But the other thing that I enjoyed that you commented in there is you said, clinical testing is about as accurate as flipping a coin.
Dr. James Hull 37:34
From that, I mean, really, clinical assessment. So for instance, if you go and see a primary care physician, and you sit in a console, and you’re an athlete, and you say to them, when I exercise, I get breathless, and I wheeze You know, there, there is likely to get the diagnosis right at that point was flipping a coin in the air. And so they got, you got to push on to do proper testing for asthma. And if you like proper testing for EILO really, and certainly the selfie video type of approach can help people think about it. And in fact, can start off with some breathing exercises to try and help you want to make a robust diagnosis of exercise induced bronchoconstriction got to do some physiological testing, and you’ve got to look at air flow, you can’t just assume it from the history, I really, really do not like people just being given, you know, an albuterol inhaler and saying, you know, if you go and try that, because for so many difficulties, and let’s not forget that the diagnosis you’re given, often sticks with you for a long time, it affects your insurance premiums. And it also, you know, if you’re a young athlete, say you’re on a pathway to an elite performance system, no one will ever challenge that diagnosis again. They will just assume that they don’t want to change it, because you already you have to have the treatment. So, you know, we have to, you have to, you have to challenge those make sure it’s robust from the very onset.
Trevor Connor 38:51
So that’s what I was going to ask you: are there are a lot of people who have this condition who are being misdiagnosed with asthma?
Dr. James Hull 38:59
Yes, a lot. I mean, I see five or six a week. And and the evidence is the same across different countries. So particularly the Scandinavian countries who really pioneered a lot of this work, they find huge numbers of misdiagnosis. And it’s the same within the states, certainly taught all in one of my colleagues who works in Denver, finds huge numbers of misdiagnosed athletes. And the tragedy is, the tragedy is that this is a condition which has its peak prevalence around the ages of sort of 14 to 16. So if you come and see me when you’re 19, or 20, and you say, “Look, my my elite performance was held back a certain critical point in my career development,” around 17-18. Maybe you’ve already missed the chance to get on to the next step. And I’ve seen that so many times, especially with elite cyclists who come to me 21-22 and haven’t remade the cup. And actually it was all ILO all along and they were just given more and more athma treatment. So it’s not it’s not a minor issue there. So we talked about minor impediments to performance. This will be career defining if you don’t get the diagnosis right.
Chris Case 40:01
Is there something about taking up athletics at a young age that is causing these high rates of ILO in athletes? Or is the function or the the act of exercise at high intensities? Just exposing, you know, sort of a naturally occurring in the general population, weakness of our, our system?
Dr. James Hull 40:26
That’s a fantastic question. I thought, if you asked that question about exercising too fast, then you’ve got a really, if you like, difficult issue, because we have seen over time and over longitudinal studies that certainly exposure to pool environments appear to be associated with the development of airway hyperresponsiveness. And by that I mean, the lower airways becoming more twitchy to the kind of chemical stimuli that we would use to see whether people have asthma. And we know if we take athletes outside of the pool, and that airway hyperresponsiveness starts to regress. So there’s definitely that if you like, dare I say causal, but there is some sort of relationship between doing high volumes, you know, in particularly chlorinated pool environments, and not trying to deter people from swimming, of course, is incredibly important sport, and it’s fantastic. But if you’re in poorly ventilated environments, and you’re doing huge amounts of time in that environment, so this sort of elite level, there is an association with the development today, we hyperresponsiveness, which is reversible. And trying to make that message for ILO, we don’t have the data.
Dr. James Hull 41:31
I think one things interesting in ILO is that you probably have, if you like some form of a genetic predisposition to the condition then and then you reveal that by the amount of sport and ventilation you do. And so I sometimes see athletes or athletic individuals who have taken up vigorous endurance sport, later in life. So the and when you ask them, you say, Well, did you have symptoms when you did cross country running at school? And they say, Yeah, I did. That’s why I didn’t do any cross country running of school. Because I was always last, I’ve always struggling and everyone used to mock the Wheezy noise I made. And then as they’ve got back into it, it’s occurred again, and it’s probably some imbalance in the elastic and the integrity of the structures in the larynx, which make them more predisposed to fold in at a hyperventilation, that was which caused the pressure drop.
Differences in breathing between men and women and across age groups
Trevor Connor 42:19
Now, the question I want to ask is, you pointed out in the review that there’s also a an age and sex effect, that it appears that females have a slightly narrower airway. And also, as we age, we lose some of that elasticity in our airways and in our lungs. And so this this breathlessness, this dyspnea gets, gets more is more common in women and and older athletes. To have that, right.
Dr. James Hull 42:53
I think there’s evolving data and certainly evolving research work, which supports those statements. And there are a number of expert labs across the world looking at these areas in detail. If I speak to the question about aging, as we lose elasticity, and our lungs become more stiff, the operating volumes in the lungs change and the way in which we move air in and out considerably changes. So that actually, when you exercise very hard, you start to encroach upon some issues with the flow of air and through the system. And that’s called expiratory flow limitation. And we see that, for instance, in a more dramatic form in people who’ve got Chronic obstructive lung disease, so if you smoked a lot, and your airways narrowed down, it starts to look more like that. And of course, because you might be performing exercise, you’ve got a you’ve got a mixture of an increased load with a slightly reduced capacity, and you can start to hit upon that flow limitation.
Dr. James Hull 43:55
And the same is true, potentially within the, from some data within the female anatomy and airway system where slight narrowings appear to predispose you to some of the pressure changes and some of the flow limitations, which you might see for instance, in in a more elderly otherwise lung. If I go back to ILO, certainly we do see that actually, this is a condition which has a female preponderance. And so very classically, I would say in female, athletic individuals in the age range is sort of, again 15, 16, 17. So they’ve got sort of development of the airways, which is still still occurring until you’re about the age of 23-24. And at the same time, you’ve got some slightly different dimensional issues, which change the pressures and the predisposition to close the airway.
How much does expiratory flow limitation affect performance
Trevor Connor 44:45
So you mentioned expiratory flow limitation, and we’d love for you to quickly define that. But that kind of segues to our next conversation of how much does this affect performance and I’m right now looking at to review one that says expiratory flow limitation during exercise and competitive in competition cyclists, it basically says that it’s it can be an issue in high level cyclists and another one that’s titled “The prevalence of expiratory flow limitation in youth elite male cyclists.” So it seems like this is a potential performance session.
Dr. James Hull 45:20
So expiratory flow limitation by that, generally speaking, what we mean is that if you increase your ventilation as you have to when you’re exercising hard, within each breath, you develop something called a tidal volume, which is essentially the amount you breathe in, and then you breathe out. And generally speaking, you increase the tidal volume. And as you work harder, your diaphragm adopts a position when you’re healthy, at least, to try and improve its contractility and to reduce the work of breathing. And so that changes the position of your lung volume slightly. And it tries to optimize the position of the lung volumes in order to try and, you know, if you like maximize bang for your buck. So your muscles are in the best position possible. And you can think about it in a way that if you know, if you’re lifting weights, if you try and lift a weight with your arm outstretched, it’s going to be very difficult if you start with it in a sort of half bent position, you’ve optimized the load and the way in which the muscles position to start with. So the respiratory system is naturally doing that in healthy individuals. As you start to increase your tidal volume, it changes the lung volume, it changes the position on this so called pressure volume curve. And that acts to optimize performance. As you work harder and harder, your tidal volume has to increase further and further. And before you start doing exercise, you take a maximum breath we do as much as you can on the way in and then you blow out as hard as you can on the way out, you can then start to work out when you’re increasing your tidal volume during exercise, you start to encroach on what is that maximum envelope or threshold. And when people talk about expiratory flow limitation, what they’re really saying is that actually, in some ways, conceptually, you’re starting to encroach on that flow limitation envelope, whereby, because there’s a certain amount of flow that you can drive through the airways, and that’s to do with pressure changes in the structures, which keep the airways open, and the pressures which are acting to try and close them down, you start to get a point where you can’t increase the flow, no matter how hard you breathe. So doesn’t matter if you’re if you’ve got the strongest muscles in the world, or if you over train them with lots of more respiratory muscle training you cannot increase that flow, because it’s a physical property.
Dr. James Hull 47:36
And so there’s been a lot of interest in that. And if I take it to an extreme where you’ve got, for instance, a chronic airways disease, where you have smaller Airways, for instance, if you’ve got poorly controlled asthma, and you’ve got thickening of the airways, that flow is already reduced. And then when you try and increase the tidal volume, you start to hit against that flow limitation. And that causes you to feel breathless.
Dr. James Hull 47:59
And it goes back to the previous point, we talked about that, you know, is there evidence of some flow limitation or this process occurring earlier when you’re older because the elasticity in the way the lung volumes moves different? and also your airway elasticity slightly different? Is it different in female athletes? Is it different in master athletes, people have studied it in, for instance, Kenyan endurance athletes, because they can increase their ventilation so much. And I think the thing to say is that what you really want to start with is you want really optimized flow from the very beginning. So if you had a hint of a tendency towards airway narrowing, for instance, in exercising just bronchoconstriction already, that’s going to give you an increased drive towards expiratory flow limitation, which is then going to impair your performance
Are lungs trainable? And if so, what are some breathing techniques
Trevor Connor 48:42
That then leads us to the big question of what can athletes do? What is trainable? And what what can they do to train it?
Dr. James Hull 48:52
The million dollar question, really, I mean, I suppose what is what’s really interesting chatting to athletes and coaches is that there’s this natural assumption that the larger your lungs are, the better you are. And so people come into the physiology lab, and they do the breathing test to look at the measure of your forced vital capacity, which is the amount of air you can breathe out in total. And the amount you can breathe out in the first second called the FPV one on a peak flow, some people might know. And they go, you know, what’s my peak flow? Was my FPV One, Can I do anything to get my lungs to be bigger? Because if they’re bigger, they must be better.
Dr. James Hull 49:25
And again, over over many decades of research, what we found is that actually your lungs develop up to about the age of 25. And then from there on, sadly, it’s a sort of inexorable slow decline in your lung volumes. And in fact, you cannot train or adapt your lungs after the age of about 25. And in fact, there’s some debate as to whether you can change your lung volumes or at least the development of your lung under that age. So you there is this focus from an athletic and coaching point of view that people need to try and get their lung volumes to be the biggest and the best they can. The reality is that those aren’t trainable phenomenon, that to do with a development, and certainly in your younger life exposure to cigarette smoke, poor environments, being born prematurely are the real key factors which dictate the level at which you get your lung volumes to. People say that swimmers have fantastic lung volumes. And in fact, if you look in a cross sectional studies of adolescent and adult swimmers and compare them to, you know, other endurance athletes, they do have larger lung volumes. But there doesn’t appear to be the substantial evidence that actually that lung volume is trained during swimming, maybe more that actually, those individuals are selected into swimming, because I don’t know lots of different reasons are being proposed, but potentially they have buoyancy advantages, because you’ve got larger lung volumes.
Dr. James Hull 50:50
So then the first thing to say is you got to know what you’re looking at, to start with. And there’s a lot of, if you like mystery about what you can train, and what could be better for you to try and increase your performance.
Dr. James Hull 51:00
I mean, the second thing to say is that, you know, breathing, generally speaking, happens naturally. So, most of the time for most people, they don’t think about their breathing, they don’t think about the breathing rest, they don’t think about it when they’re at work, and they don’t think about when they’re exercising. So if he’s not causing you any problem at all, you’re not having any sensations or discomfort for or other issues. And what I say to people is, look, try your very hardest not to disturb it, because if it’s disturbed, and you become focused on it, and you know, it can really cause problems. And I look after a great number of athletes who are breathless, or have unusual sensations from their chest or from their upper airway. And it really detracts them from being able to train or perform in their most natural way. And we spend a lot of time doing tests to determine if there’s a problem, but also then trying to work with specialist breathing techniques to allow them to return back to a state where they just feel like their breathing flows for them. So if your breathing is flowing for you, I don’t think you should Tinker or mess around with it too much if you just let it be because, as we talked about earlier in the podcast, it’s unlikely to be a major limiting factor in your overall performance, if it’s not if it’s flowing, okay.
Dr. James Hull 52:10
The other thing that people don’t think about is that actually, and one of the things I’ve been really closely involved with the English Institute of Sport and Team GB recently is to try and say, Look, one of the major factors or one of the limiting factors that our respiratory system tends to throw in is the fact that people get respiratory tract infections. So if you think over the course of an athletic year, there are a number of events that you really want to do well in, and then your performance targets. Now, over that course of that year, you will prepare you’ll have a very detailed training program. There will be peaks and troughs, of course, with potential some injuries and niggles, but a key factor that people often overlook, is the impact of illness on ability to sustain a steady training load. And again, people might scoff at that and say, Well, you know, a couple of respiratory tract infections, we can live with that. But it’s amazing the number of athletes who are getting at least three or more respiratory tract infections, which at each time, impact them for five to seven days. And then after that, they got to get back to recovery, they got to step it back up again.
Dr. James Hull 53:13
And so you know, you probably expected me to talk about, you know, expiratory muscle training or, you know, little nasal strips you can put on to increase nasal flow. The reality from my point of view, when I look at the athletes that I look after is that I want them to be as close as I can to infection free. Now, of course, you’re going to get one infection a year everyone does, but as close as I can to knocking that down. So they can have sustained periods where they’re not being knocked out by their respiratory system, causing mischief for them.
Dr. James Hull 53:41
And then the second thing I wanted to do is to obtain a respiratory flow where they feel like there’s no problems at all is not an issue. So they don’t even know why I’m there. Because, effectively, you know, there is no issue. And they can do the other things that are so much more important in terms of nutrition, loading, and the other key issues and sleep and other things which are important. So, I mean, those would be my major points. And of course, we can talk about other trainings around the edges, in terms of other things that people could think about, particularly if they’re running into problems and have symptoms.
Chris Case 54:12
We asked Wahoos, head of sports science, his thoughts on breathing, working with World Champion time trials, we knew he’d have a lot to say. He talked both about the autonomic response of the system and the importance of diaphragmatic breathing. Here’s Neal Henderson.
Chris Case 54:27
Do you work with athletes on breathing technique? If so, what are you hoping to elicit there? What are the performance gains you’ve seen there?
Neal Henderson 54:38
Yeah, there’s there’s a few things. When we think about breathing, it’s you know, there’s kind of an autonomic, you know, autonomic and automatic way that we breathe. And when we get stressed, we often get more of that kind of chest breathing and through training, we want to develop more of that diaphragmatic breathing where we get that belly breathing deep breath, we have better exchange and so in a time trial It’s really important to think about controlling that breath and getting that full diaphragm breathing rather than just relying on that, that kind of upper chest breathing. So breathing rate is often one of those things that we we have people think about when they’re doing different efforts in their training and trying to control that effort and manage it with the breath control, as well as then the power in cadence.
Trevor Connor 55:28
I find this fascinating because you’re basically saying you want to get to the point where you can just kind of ignore your breathing, if that’s what I’m hearing from you. Yeah. So what about all these people who say no, you need to do so we’re gonna go back to where Chris started this with with all the yogi practice where there are people feel you you need to be doing all this deep breathing type work to improve your your breathing on the bike, what is your feeling about that? Do you think it helps,
Dr. James Hull 55:56
there’s a lot of people talk about this. And so your readers or listeners will certainly be aware of podcasts and seminars on modulating your techniques. Some people have advised breathing slowly, in order to allow you to if you like drop your oxygen levels. So you can be exposed to a hypoxic environment when you’re training by holding your breath. And others have it others advise modulating breathing techniques, often ins for instance, in soldiers, I get told that they’ve been they’ve been coached and trained to breathe every third step or second step. So they’re very old breathing patterns, as they’ve been told us how they should March and breathe at the same time. Others are told that you should breathe and tie through your nose, which you know, as physiologist, you know that actually, you know, it’s impossible once you start to breathe it at least a moderate exercise intensity, because, you know, our nose is such a resistive source to the airflow. So once you get above 35 liters a minute, which is basically going up a flight of stairs fast, you have to open your mouth to allow enough air in to allow enough oxygen to get to the exercising muscles.
Dr. James Hull 56:59
So, you know, I’m not here to dismiss people’s concepts or thoughts or beliefs about these different systems. But my feeling is that generally speaking, the system is so well attuned to exercise to adapting to the loads that are placed on it, and the regulation of carbon dioxide and excretion of waste gases that have been working well, and it isn’t causing you any problems, I wouldn’t go near trying to mess around with it. And as I said, You know, I look after a lot of people who haven’t caused this themselves, but they’re struggling with symptoms, and they feel a lot of discomfort or they feel distress, they can’t get a satisfying breath. And I’m on the other side and having to try and work out a way to try and help them breathe effectively.
Dr. James Hull 57:41
Now, if I talk about cyclists, one of the problems of cycling a bit like rowing is that you know, you’d think it was basically a lower limb predominant exercise. And of course, you know, the power delivery is pretty much lower kinetic chain and downwards. But cyclists carry a lot of tension in their upper body, the carry through their neck, they carry in their chest, we did a study where we placed EMG, which is a way of looking at muscle activity EMG sensors on the upper kinetic chain, and particularly around the traps and around the back of the neck, essentially, when we see huge amounts of activity going through that chain, people gripping on tightly onto bars. And that translates into bad patterns. So it causes stress and tension through the throat. And it causes a pattern of breathing where people tend to start to disengage the diaphragm, and they’re starting to breathe more quickly. So through the higher part of their chest, it’s not a very efficient way to breathe, and effectively is associated with the presence of dismay. And if we adjust that pattern, we see people’s breathlessness scores going down. So, you know, I would say just to summarize that burn, I would say Look, don’t mess with it is not broken. Think about things which allow you to have sustained load without getting for instance, infections is broken, and you need to think about how to repair it. But finally, on a bike, for instance, you need to think about your upper kinetic chain being relaxed and you breathing through the diaphragm because that’s the most efficient way to breathe. It’s the the area that is the muscle which allows you to transmit the best ventilation. And that’s what you need to deliver oxygen.
Chris Case 59:15
Colby Pearce needs no introduction on our show. When we decided to do an episode on breathing Trevor and I knew we had to talk with him. His answer is loaded with practical advice, both from a scientific point of view and a holistic perspective.
Colby Pearce 59:28
Well, yeah, I mean, obviously Cycling is a sport that is for many athletes, the rate limiting factor for their performance is O2 transport, right. And it can be an oxygen to co2 ratio kind of situation going on. In some cases, like firms case. He says in interviews, he’s got small airway, and that’s why he’s always riding with his head looking down. Everyone thinks he’s looking at his power meter, but he insists that he breathes better. So breathing obviously has a pretty big impact on our sport. Both the technique and the volume of breath and There are all kinds of gizmos out there and spirometers you can use to measure your lung capacity and so forth and, and devices that proclaim to make you to train the inspirational and aspirational muscles and make you more efficient at that. And the science from what I’ve seen on that is pretty up and down depending on the device and the technique used, etc. But I will say there’s a pretty clear connection in my experience between breathing technique and core stability, which a lot of people don’t put together. But those two are related. And it’s far more common than I then someone might initially expect or that I would hope to find athletes come through my door when I do a fit with them, who are afflicted by dysfunctional breathing, or an inverted breathing pattern or are chronic chest breathers – chest, chest breathing is, is pretty common. And a lot of these terms are being thrown around now by people who study the world of breathing. And some of them may be terms that are overused and, and whatever, I don’t really care about that, to say that so. But if you look at an infant breathing pattern, right, when they inhale, the diaphragm drops, and the belly expands. And as the exhale, the diaphragm rises, and the belly draws, the belly button draws closer to spine, you might say, right, and that is a air quote, correct breathing pattern, and it’s bringing power that we should have during exercise, but it’s quite common for athletes to do the opposite, they inhale, and their chest and collarbones rise up towards the ears and get taller and, and in some cases, the belly actually comes in. And there are a lot of reasons for this. That can be stress responses that have brought about this breathing pattern. There can also be childhood experiences, and also for women in particular, but even for men as well, anytime an athlete has been involved at a younger age and a sport that values aesthetics in any form that can be ballet or gymnastics, they don’t want to be seen as having a belly or a puch. And so they learn to kind of brace themselves in the ABS while they’re breathing. And that usually leads to an inverted breathing pattern that’s very problematic.
Colby Pearce 1:02:02
So, in you know, it all depends on what the rate limiting factor or the athlete is. Some athletes have very high vo twos, but really poor leg strength, for example. So we can give them breath exercises all we want, but they may not go any faster until their legs are strong enough to handle the load of their race. But there are many athletes who are limited by their ability to process oxygen in the in the appropriate way. And some of that can be technique related. And some of it can be that they aren’t trained in certain aspects of breathing. For example, Patrick McGowan, in his book, “The oxygen Advantage” talks about simple techniques you can use to extend your capacity to tolerate high levels of co2 in the bloodstream. And he gives you some really simple exercises to do. If you decided to read his book, I recommend it it’s a great read. If you decide to try these only do them on the trainer because if you push it too far and pass out while you’re riding your bike, obviously bad things can happen. And even on the trainer, you can hurt yourself if you fall off. So you have been warned.
Colby Pearce 1:02:58
But you know, one of his simple techniques is you inhale fully and then exhale, let all the air pass out of the lungs, draw the belly button towards the spine. And then do a simple breath hold until you become moderately discomfort/uncomfortable, discomfortable. And that simple exercise you can spread those out, you know over a trainer session or 30 minutes you might do you know 1012 reps of that perhaps that’d be probably enough for most people. You can train your body to tolerate higher levels of co2, which is a whole world that you know freedivers get into. And that’s that’s their universe is learning how to tolerate that there are all kinds of interesting physiological effects that jump out when you start to train that aspect of the system.
Trevor Connor 1:03:45
So an urban legend is that Pantani used to like to train in the pool where he would swim laps underwater, right to train that taller yes to building up
Chris Case 1:03:54
to in a practical sense, you’re such a great time trialist and don’t don’t refute that fact. I know you use sometimes like to do that. But we’re going to let you we’re going to give you all the credit in the world for being great at it. You’ve done a lot of our records, how does breathing? What have you learned from from those disciplines that those particular experiences about the importance of breathing?
Colby Pearce 1:04:21
Yeah, interesting. So there are definitely books out there. Written by athletes and coaches that talk about having a specific breathing technique and coordination with your pedal stroke during time trials, overuse one of them. There are lots of books out there that talk about this. And I tried all those and man none of them worked for me. It just for whatever reason, trying to coordinate my breath with a certain number of pedal strokes. You know, for example, the sale pedal three times on the left during your exhale and then three times of the right during inhale or whatever depending your chemo thing on there for me it was too mechanical, and it just didn’t, I couldn’t it disrupted my rhythm. But there may be athletes who find a technique that works well for them and breathing is let’s be clear. Breathing is directly related to the status of the central nervous system. And breath is really interesting because breath is really the only clear window we have, I’ll say we meaning sort of common folk into accessing and influencing our central nervous system, right? That’s why when you’re learning how to meditate, it almost always begins with breath work. Why? Because, okay, we have the parasympathetic and sympathetic nervous system, and the central nervous system on the whole, or the autonomic nervous system, and you look at activities that basically we have direct conscious control over, like, I can pick my nose or wave to Chris, or, you know, whatever, drink some water and I’m controlling my hand in my arm. When I do that breath, then we have other activities that we don’t really consciously control on what unless we’re a yogi or a monk. So our heartbeat, for example, our core temperature, unless you’re Wim Hof, then you can start to control that stuff. How your immune system responds to external attackers or invaders, such as a virus also. Wim Hof, right. So most people don’t have control over those aspects of their body, those are automatic breath is the one that switches back and forth at all times. Because of course, we breathe all day every day, otherwise, we would die. One of the fastest ways to kill yourself is to stop breathing. So it’s a very essential function. But we can also consciously take control of our breathing at any time if we decide to focus on it. And the simplest way to activate more parasympathetic nervous system response, and downregulate, sympathetic nervous nervous system response is to time the exhales and inhale and make your exhales longer than your inhales. That’s a really simple technique you can use when you’re stressed out on the start line of a race, when you’re trying to make your flight on the way to the bike race or on the way to your business meeting, whatever.
Colby Pearce 1:06:41
So, um, breath work is a critical window into that aspect. And how people breathe does influence the way they relate to stressors in the world, both during competition and in daily life. One another simple drill I’ve given my athletes is I’ll have them do recovery rides, and have them exclusively naseley breathe or breathe only through the nose with a mouth closed. And some athletes find this incredibly challenging. If they do, that’s probably a pretty good sign that they have some infrared or dysfunctional breathing patterns. It’s also a good sign that there’s some low hanging fruit to be made there in terms of gains. Even just being conscientious of that motion of breathing during your riding and not taking the mouth breath for granted can make some changes in an athletes perspective. So there’s a lot to breath.
Colby Pearce 1:07:28
I’m a big fan of people exploring it and looking into it, I think athletes, some athletes might find that there really no gains there. Because it’s a game of it’s it’s a paradigm of looking for rate limiting factors in the athletes performance. And again, if you happen to have a really huge co2 in a giant airway, and you process it very efficiently, metabolically, then that may not be where your gains are made. You might be most of the time when you’re getting dropped, it might because your legs are on fire, or you don’t have the raw force. That’s possible, right? Or you know, the force default accelerations, but you’ve got a massive co2, so you tend to diesel, your way back up to those accelerations, right? So think about the skinny climbers who ride that way. Then on the flip side, we have the variedades, the punt, the sovereigns, who are very explosive, and high have high aerobic capacity. And they’ve got both going on. So just to illustrate that contrast.
Chris Case 1:08:18
I think people will often refer to that as belly breathing, is there a tip or trick you can help people for for those that aren’t familiar with that, or the the Act, the action of belly breathing that will help them understand how to do that?
Dr. James Hull 1:08:35
Yeah, lots of lots of people talk about it exactly like that. And those terms. And you see, you see some very famous cyclists or an elite cyclists who look as though they’re actually overweight. And that’s because they’re so effective at dropping the diaphragm, and they’ve got such big lung volumes. And Miguel injuring is a classical example of that. And where you see and people are overweight, but exactly the diaphragm is lowered. And if you breathe with the diaphragm, effectively, your shoulders shouldn’t move, but your stomach comes out because the diaphragm is going down as you breathe in. And that’s displacing abdominal contents. And so you see a distinction of the abdomen, if you don’t see that, and you see a lot of shoulder and upper body movement, with breaths in and out. And so I, you know, one of the things I do ask an athlete, when I see them is to take a deep breath in and if I see the shoulders going up in the air, you know, that’s atypical breathing. And atypical breathing isn’t a very efficient way to breathe. And if you think about the way that blood flows distributed through the lung, you know, it’s largely it’s largely governed by the presence of gravity. And so if you are at the top of the lung, you’ve got relatively poor blood flow and at the bottom of the lung, you’ve got better blood flow. So you want to try and optimize the matching of ventilation to perfusion by engaging the diaphragm and increasing ventilation through the basis.
Dr. James Hull 1:09:53
So I say to athletes, you know, look, think about your stomach and if it’s coming out, particularly red If you’re at rest, and you’re not on the bike, you should be breathing through your nose, you shouldn’t be breathing through an open mouth and sitting there with a sort of Gopi open mouth expression, because you just drag air in through the mouth, and it’s not filtered, so the nose filters or the muck out the way. And it also, as you breathe in through your nose, it sends a parallel neural traffic to the diaphragm gets the diaphragm to contract. And then when you’re on the bike, think and continue to think about whether your your your shoulders and your neck are relaxed. And think about when you’re breathing out if you have a nice flow on the exhale, a tree breath, which allows you to have control of the breath. And again, just thinking about those processes is important to relax your shoulders and just keep going around that cycle washer racing.
Is inhaling or exhaling more important?
Chris Case 1:10:44
I guess that brings up a second question here, you just touched on it a little bit is inhalation or exhalation are is one of them. More important, would you say
Dr. James Hull 1:10:57
depends on the individual and depends on what you’re trying to achieve. So and if I talk about ILO, which, as I said, is a very common, often overlooked cause of breathlessness in cyclists. And what happens is that the the main limiting factor in that condition is as you take a breath in the structures in the throat, and it feels like it’s the upper chest really, they close in, and they they stop you from being able to obtain a satisfying in breath. So in those individuals who are reporting that problem, you’ve got to modulate that in breath. And so we use specialist techniques where we put a slight break on the very start of the breath. And that, in my mind, at least has not been proven in studies. But in my mind, just modulates the pressure drop across the larynx and allows that breath to be modulated sufficiently to allow the larynx to stay open, and allow the high quality breath to be taken in.
Dr. James Hull 1:11:48
In contrast, for individuals who may over breathe, or have problems slightly lower down in the airway, where the trickier is slightly more floppy. And you need to modulate the axillary flow. And we do that with something called pursed lip breathing, which is essentially a technique which is narrows the outlet lips, and then just modulaes airflow on the way out. And that, you know, is different ways of adapting these different breathing techniques, depending on an individual’s problems. I mean, I, I’ve tried these myself, and when I ride and you know, in many ways, they’re satisfying way to breathe anyway, because they modulate the airflow slightly in it, and it gives you a more satisfying breath out. And it’s the same thing that’s used in sprinter. So if you look at 100 meter final, and you look at people sprinting, effectively, as they’re moving their arms, they’re making that very aggressive and with pursed lip breathing out maneuver, which acts as to provide a bit of back pressure into the airways. And it’s a comfortable, a powerful way to breathe.
Trevor Connor 1:12:46
So can you describe in a little more detail, this this method of breathing?
Dr. James Hull 1:12:51
Yeah, it’s difficult to do without a video, which is a shame. But um, you know, if people on the way out if people envisage, you know, or they think what a sprint is, like, actually, you know, you can’t see me but you know, you’re sort of basically which is that sort of blowing, so you’re trying to, it’s almost like I say to people, you know, when you’re breathing out, imagine bringing your lips together, and you’re trying to blow up a balloon, but forcibly or some people say you’re trying to blow out against a rotating like a sort of like a hamster wheel or something like that. You’re trying to, as you blow, you’re trying to get that hamster wheel to turn in front of you. And you can use that analogy to say, look, you know, is it turning? Is it turning things forward? Is it turning the wheels to make you go faster?
Chris Case 1:13:31
Yeah, so it’s an active form of breathing in that you’re not just letting air come out, you’re directing it in in a way.
Dr. James Hull 1:13:41
exactly that. But again, I mean, you know, if you breathe, you’re causing any problems, you know, people are always looking for ways to say, look, you know, can I get an extra naught point, whatever 1% of performance out of this, I, you know, I can’t speak to any evidence, which will give you that and that if you’re, if you feel distressed by your breathing, some of these techniques can certainly help.
Dr. James Hull 1:14:03
And, you know, at the same time, if you’re feeling distressed by your breathing, it’s really important that you go to see someone take the selfie video, like I said, think about what the diagnosis could be. Take the take the this podcast and take it to your primary care physician or your coach and say, Look, you know, listen to this, this, I think I’ve got this, is there anything else that could be done for me is, you know, and work around it that way, rather than saying, you know, look, it’s gonna be asthma. There you go. There’s your inhaler. Off you go. You know, hopefully it will challenge people to think more outside the box in this area.
Trevor Connor 1:14:35
So I’ve mentioned that on the show before, so I’m glad you talked about that way of breathing, where when you watch a very experienced Time Trialist versus somebody trying to do a time trial is very new to cycling. You see that that difference? very experienced Time Trialist you hear a very forceful exhalation they’re really focusing on getting rid of the carbon dioxide, exhaling out Where often you’ll see inexperienced cyclists really focusing on their the inhalation. And that’s where you hear the sound.
Dr. James Hull 1:15:06
I think that’s right I am. It’s difficult, from my point of view, and certainly from all my method of practice is really to give people very simple techniques. So, for instance, in the ILO world, I use a technical the Hoover technique, which is essentially getting people to think rhythmically rhythmically about the sound of the word Hoover. So, you know, the outbreath is ooo and on the way in, you’re making like a verse sound system, but it goes. And it’s, you know, modulates airflow in a bi phasic. way. And to try and improve things. You know, I’ve written a bit about this that people can access online, have a look at, but it goes back to the fact that if you’re really struggling, you need to see someone because they need to get things right for you to start with, there’s no point trying to just go for this and say, Oh, I wonder if this will work for me, when in fact, then you find out actually is asthma on this occasion, and you needed to meds to try and optimize it. And so it has to be in some way personalized. If you get to a point that you think that diagnosis is, you know, people happy with it, then, you know, there’s lots of written on the different techniques. And, you know, I’ve tried to write and be on Twitter and things like that, to try and inform people on the different ways to help with their breathing
Myth-busting breathing techniques
Trevor Connor 1:16:21
So I would say, the last thing I want to do, unless there’s there’s anything that both of you would like to bring up is just hit you with a couple potential Mythbusters here. Whether so there, there are things that go around as Hey, this is really effective. I would love to get your opinion, as you’ve already addressed one, which is that nasal breathing. So there’s been some recent studies on that, and actually, they’re coming out of Colorado, Colorado State University, Dr. Dalam, saying that we need to practice nasal breathing. And if you practice it, you can get quite good at it. And he’s claiming it’s better for performance. What’s, what’s your feeling about this?
Dr. James Hull 1:17:01
Well, I’m gonna get myself in trouble with Johnny. So I’m going to be
Trevor Connor 1:17:05
You can give us a diplomatic answer. Yeah,
Dr. James Hull 1:17:07
I’m gonna be diplomatic and careful. Because I you know, as I said, Before, I you know, I’m not I’m not here really to sort of rubbish people’s approaches. And I, you know, if you look in Amazon, there’s like, you know, 35 books written on how to breathe. And people’s careers are defined by some of the techniques that they’ve talked about. So I mean, what I would say is that, if you think about it in simple physiological terms, you know, when you start to work harder, you need to be able to satisfy the exercising muscles requirement for oxygen, with a certain amount of ventilation, which is entirely dictated by how efficient your lung is. So providing you with lung disease, you know, as you exercise harder, you’ve got to breathe harder to be able to deliver oxygen. And the the nose is a particularly resistive segment of the airway. You can’t get away from that. And, and certainly putting plastic strips on it, I’m afraid isn’t going to suddenly make you be able to breathe through your nose, you know, when the break goes down the road. So the other thing about the nose is it does some really important things. And so it filters in environmental toxins, it filters pollen, it humidifies the air and humidification. And warms the air is such an important feature, because, for instance, if we look at exercise induced asthma, we know that dry cold air getting into the airways is a really prime stimulus for the airways to narrow down, they don’t like that irritation. So the nose is really important. But it’s it’s as far as you can take it when you’re exercising hard. So yeah, you could train yourself to get some more leverage out of your nose. But there is going to come a point where you have to open your mouth. And so I would say look, you know, yes, you have to breathe through your nose when you’re at rest. It’s really important. If you see an athlete who sat there, brilliant out through an open mouth and missing all those advantages. Do I see a technique that allows you to breathe more and more through your nose in peak size and satisfies the ventilator requirement? No, I don’t I think that’s difficult to obtain. The other thing I’d say about the nose, which I think is really important is that people often overlook hay fever, for instance. So they say you can tell I’m a physician, so just go back to sort of medicalization of things. But if you if some if an athlete comes to see me and says, You know, I keep getting sore throats. My voice is a bit funny, you know, around sort of June, May, June and my performance starts to dip away. You know, one of the first things I says Tell me about your allergy Oh, yeah, have hay fever. But is it treated with this? I said it does it does it really treat it properly? Well, no. Now mostly stuff in my nose, but I breathe through my mouth is not a problem. Well, the problem isn’t simply an exercise. The problem is all around exercise. So at nighttime, when you’re lying in bed and you’re trying to sleep, your nose is blocked. So if we have to breathe through an open mouth, you’re in an air conditioned room because you onto a fixture and you’re in a hotel and it’s kind of a one time of year. So effectively, you’re dragging dry cold air into the airways, I’ve already said that humidification do is really important to stop them from being irritable, or from closing down. And so you’ve got all these things into playing with each other. And of course, the dry air is causing irritation of the mucosa the back of the throat, and then the sore throat arrives. And then the restricted tract infection loss. And so, you know, far more important training, breathing nasal flow techniques for me is saying, look, make sure the nasal flow is good, make sure nothing uses the nose at rest, when you exercise, go back to trying to get the natural flow and not trying to overthink it.
Trevor Connor 1:20:36
One other potential mythbuster. I remember something that used to go around among cyclists that if you’re going really hard, like in a sprint or up a 15% climb, or everybody’s trying to race to the top, and you have your mouth wide open trying to breathe, that moving your lower jaw route will cause a more turbulent flow, which will help your ability to breathe. Is there anything to that?
Dr. James Hull 1:21:04
I’ve not heard that before. And yeah, I don’t know. That’s interesting. I mean, what is interesting is that if you think about the nerve supply to the jaw, and the mouth and particular facial area, and inside the buccal, mucosa, we’re seeing more and more that certain degrees of even what might be deemed to be subtle distractions appear to reduce the sensation of work. So a prime example, as you’ll be aware of his carbohydrate washing in the mouth, and more recently, a menthol within the mouth. People have shown that using a cooling fan on the side of the face. Some people have said that chewing gum, all those things appear to reduce the perceived effort that someone’s doing at that time. And that’s really intriguing and interesting to me, because, you know, it, it speaks to what you’re saying, really is that, you know, is there a way that you can distract something around the face or the musculature or even within the mouth, which allows the perception of work to be reduced or modified. And, you know, I can’t, you know, cite any evidence to support moving, the jaw around is changing, but there’s other factors appear to be relevant. And, you know, it’s, it’s, I suppose, conceivable that moving the jaw rounds in the same way, forming some form of a sensory distraction, and reducing the work. I mean, you know, from my point of view, again, you know, if you’re working hard, you’ve got high levels of ventilation. And bearing in mind, the high prevalence of laryngeal flow problems, you know, what I really want is a relatively simple flow, which isn’t distracted or turbulent by the time it hits the back of the throat. So, you know, I would encourage people to think about the other sensory distractions, as opposed to moving the jaw around a lot. But it probably it probably actually scares the opposition, which is probably, you know, away from drowning and grimacing when you’re climbing.
Trevor Connor 1:22:56
But well, the trick there, this is one that I was taught very early in my career is if you’re going up a hill beside somebody, if you want to intimidate them, you pass them but just before you come into their line of sight, you close your mouth and nose, breathe, and try to get make sure you get by them quickly, so that they can no longer see your face and then start gasping for air. But
Dr. James Hull 1:23:20
We’ve seen that in the Tour de France this last few weeks, where people effectively breathing with not much mouth open, you know the latter stages of the stages, which speaks to the high level of conditioning of some of these athletes.
Chris Case 1:23:33
Being that you’re new to the program, Dr. Hall explain. But very simple. We love to close out a program, each episode with our take homes, we like to put people on the clock a little bit, give him a little pressure to perform 60 seconds. What would you say in your words are the most important messages from this episode today,
Dr. James Hull 1:23:56
it’s been great to talk to you about how highly evolved you respiratorial system is and what a fantastic system is when it works well. So I would suggest to athletes, if it’s working well for you, and you have no problems. Don’t tinker with it, it’s not going to cause you problems. Having said that, there are a number of conditions which can cause you to breathe, have difficulties with your breathing. And you know, you need to think about that and make sure you get the diagnosis, right. So if you think you’re getting wheezing, you’re getting breathlessness, think about the conditions that we’ve talked about particularly exercise induced laryngeal obstruction, take a selfie video on your phone or get someone to do that so they can see what the weeds is like when you take it to your coach or practitioner. And also think about times outside exercise. So make sure you avoid getting infection, make sure you treat a fever properly, so your nose works. Make sure you got good levels of hydration on board. So you’re always nice and moist and well conditioned. And otherwise, I would try and avoid anything else to tinker with it if it’s working well for you.
Chris Case 1:24:54
Great, Trevor, are you still sad about the fact that problem hornsund humans are not the it’s not so simple when it comes to the overbilled underbuild discussion? Yeah,
Trevor Connor 1:25:05
well, I do I’m a little sad.
Chris Case 1:25:09
What? What do you have for your take home today,
Trevor Connor 1:25:11
I’ve lost one of my favorite points that I’d love to discuss. Another one, which you you’ve kind of confirmed. So my one minute is going to be somewhat similar to yours is just digging through as much research as I could before this podcast, just this common trend. So there back around 2000, Dr. Lucia did a bunch of studies. And so I’m looking at one right now where the abstract says these findings suggest that endurance conditioning does not alter the breathing pattern and professional cyclists. There’s been some other recent studies looking at bentyl Ettore efficiency and basically keeps coming up with Yeah, not much we can do about it. What I really got from your review is just how complex this whole system is, and how amazing it is, with all these complexities with all these steps in the process, from getting air from your mouth, to your your muscles, and then getting rid of the carbon dioxide. How effective all these parts are working together when it’s working right, and providing what you need. Which gets to some basically, I’m repeating exactly what you just said, which is the best thing you can do is get out of the way of the system and let it function optimally.
Dr. James Hull 1:26:28
Yeah, you got it.
Chris Case 1:26:30
Trevor Connor 1:26:31
Chris Case 1:26:32
Well, you know, I don’t have all that much to add, really, I think I’ve been lucky in many ways that I’ve never really had to deal with any issues. And I haven’t therefore had to tinker with anything. But it sounds like we’re probably speaking to a lot of people that have issues out there that may be mis diagnosed. Sounds like Trevor probably needs to reconsider his breathing issues, as an example. So I guess I would encourage people to really take in this information and understand what might be going wrong if the if they do have some of these symptoms and reassess how they should treat it because it might really improve their experience on the bike, or as an endurance athlete in general.
Trevor Connor 1:27:23
Great episode. Thank you. That was I thought very informative.
Chris Case 1:27:26
Yeah, thank you, Dr Hull. Whoa, that was great.
Chris Case 1:27:31
That was another episode of Fast Talk. As always, we love your feedback. Email us at email@example.com or record a voice memo on your phone and send it our way. Subscribe to Fast Talk. Wherever you prefer to find your favorite podcasts. Be sure to leave us a rating and review. thoughts and opinions expressed on Fast Talker are those of the individual for Dr. James Hull. Colby Pearrce, Erica Clevenger,, Julie young Neal Henderson. Coach Trevor Connor. I’m Chris Case. Thanks for listening.