Episode 32 | Ask the Expert | Guest: Julie Moore – Respiratory Physiotherapist, Institute of Sport, Exercise and Health
Breathlessness during exercise is something most people attribute to fitness levels. Push harder, get fitter, breathe easier. But what happens when someone is genuinely fit – training consistently, performing well – and still can’t catch their breath in the way they expect? The answer, according to Julie Moore, is often nothing to do with fitness at all.
In this episode of the London Bridge Sports Medicine podcast, Lucie is joined by Julie, a specialist respiratory physiotherapist who works at the Institute of Sport, Exercise and Health alongside Professor Hull, running a respiratory clinic that diagnoses exercise-induced asthma, exercise-induced lung obstruction, and breathing pattern disorders. Today, the focus is on that third category – the one that is most commonly overlooked.
What is a breathing pattern disorder?
A breathing pattern disorder is not a diagnosis in the traditional sense – there is no structural problem with the lungs and no underlying disease. It is a habitual inefficiency in the way someone breathes, developed gradually over time and reinforced by repetition until the body treats it as normal.
“I don’t think anyone breathes perfectly,” says Julie. “We all live in a world where lots of different things might change the way we breathe. If your breathing hasn’t been quite as efficient as it could be, and that happens repeatedly, your body can adapt into an inefficient way of breathing – which is ultimately where it can affect your performance.”
These disorders can co-exist with a medical diagnosis. A patient with asthma whose inhaler seems to be losing effectiveness may actually have a breathing pattern disorder layered on top of their condition – and treating only the asthma leaves half the problem unaddressed.
The key question: is your breathlessness disproportionate?
Everyone gets breathless during hard exercise – that is normal and expected. The question Julie is asking clinically is whether the breathlessness feels disproportionate to the effort being made. Does it feel more uncomfortable than it should? Is there chest tightness or a sense of restriction? Does it feel like the breathing “just isn’t working”?
That sense of mismatch – between perceived effort and actual exertion – is the clinical signal worth investigating.
The diaphragm: why where you breathe matters
The diaphragm is the body’s primary breathing muscle. It sits lower in the trunk than most people imagine – around the bottom of the ribcage, at roughly waist height – and when it contracts properly, it drives air into the lower lungs where the majority of alveoli (the air exchange surfaces) are located, and where blood supply is richest.
The upper chest also participates in breathing, and at high intensity that is appropriate. But for most people in most situations, the majority of the breath should be going into the lower ribcage rather than the upper chest. When this pattern reverses – when the upper chest and the accessory muscles of the neck and shoulders are doing most of the work – breathing becomes both less efficient and more tiring.
Accessory muscles fatigue quickly compared to the diaphragm, which is built for sustained effort. Endurance athletes who over-rely on them are essentially running their breathing on a less efficient engine that will tire before they do.
What good breathing looks like at rest
Julie uses a structured tool called the Breathing Pattern Assessment Tool to evaluate breathing at rest before looking at exercise. The markers of efficient breathing at rest are:
- Nose breathing – at rest, breathing should be through the nose, not the mouth
- Quiet – no audible noise on the in or out breath
- Lower ribcage movement – the lower hand (placed over the belly button area) should move; the upper hand (on the chest) should not
- Breathing rate of 8–12 breaths per minute
- Rhythmical – no extra sighs, yawns, or big catch-up breaths. People who frequently sigh or feel they “can’t get a satisfying breath” are often in a disordered pattern.
Starting at rest matters because it establishes a baseline – and because efficient resting breathing also supports recovery between efforts.
Hyperventilation and performance
Breathing too fast too soon – hyperventilating – is one of the most common and most damaging patterns Julie sees. The counterintuitive truth is that breathing faster does not get more oxygen into the body. Oxygen saturation in a healthy person at rest is already around 98% – there is no room for more.
What excessive breathing does do is deplete carbon dioxide faster than the body can manage. The consequences are wide-ranging and all performance-limiting: reduced blood flow to muscles and brain, heightened sensation of breathlessness, chest tightness, dizziness, light-headedness, and nausea. “All the things that would hamper a performance,” as Julie puts it.
One common contributing factor is ribcage stiffness – often the result of prolonged sitting. If the lower ribcage cannot expand properly, the breath volume cannot increase as exercise intensity rises, and the body compensates by breathing faster instead. Opening up the ribcage is sometimes a necessary precondition for slowing the breath down.
Practical tips for athletes
Nose breathing
Julie’s single most impactful habit change: breathe through your nose as much as feels comfortable. The nose slows the breath naturally, connects better with the diaphragm, and directs air into the right part of the lung. At rest and during low-to-moderate intensity exercise, it is almost always the better choice. At high intensity – or when talking – opening the mouth is appropriate and necessary. The key is not forcing it: over-effortful nose breathing that recruits the accessory muscles is counterproductive.
Focus on the out-breath
When breathless, the instinct is to pull more air in. Julie’s advice is to redirect that attention to the out-breath instead. Extending the exhalation slightly – not dramatically, just a fraction longer – allows the diaphragm to return to its starting position and naturally slows the whole breathing cycle. At high exercise intensity, bringing the rate from 50–60 breaths per minute down to 40 can make a meaningful difference to both comfort and performance.
Body awareness cues
During running, useful cues include noticing whether the shoulders are rising and falling excessively (a sign of accessory muscle dominance), trying to make the breath quieter, and experimenting with in through the nose, out through the mouth. An exercise band wrapped around the lower ribcage can provide useful feedback about whether the lower chest is moving – a technique Julie uses regularly in clinic.
The biggest breathing myth
Asked for the most common misconception she encounters, Julie is clear: “More breathing gives you more oxygen.” It does not. If your oxygen saturation is already at 98%, breathing faster or deeper will not increase oxygen delivery. It will, however, deplete carbon dioxide and trigger all the symptoms described above. The goal is efficient breathing – not maximum breathing.
When to seek help
If breathlessness during exercise feels disproportionate or is affecting performance, the first step is always a GP appointment to rule out any underlying medical cause. If investigations have come back clear, or if existing treatment (such as inhalers) is not fully resolving symptoms, a specialist respiratory physiotherapy assessment is the natural next step.
Julie’s clinic at the Institute of Sport, Exercise and Health accepts self-referrals – no doctor’s letter required. A full respiratory assessment will identify the specific pattern at play and provide a targeted treatment plan.
The bottom line
Breathing is automatic – which is precisely why inefficient patterns can embed themselves without anyone noticing, including the athlete. The good news is that breathing patterns can be assessed, understood, and changed. For athletes who feel their breathlessness is holding them back despite their fitness, the answer may lie not in training harder but in breathing smarter.
Julie Moore is a Respiratory Physiotherapist at the Institute of Sport, Exercise and Health, Tottenham Court Road, London, where she runs a specialist respiratory clinic diagnosing and treating exercise-induced breathing conditions alongside Professor Hull. The clinic accepts self-referrals.
Listen to the full episode below ↓
