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Research · Practices

Slow breathing and breathwork

Pooled trials find breathwork lowers self-rated stress, anxiety and low mood by small amounts, against both inactive and active comparisons. Slow breathing lowered blood pressure about 5.6/3.0 mm Hg in pooled trials, but device-guided breathing did not differ from sham in blinded trials. Hyperventilation before breath-holding in water has preceded drownings.

Add to Bio HackChecked 2026-11-13
Status
A practice, not a regulated product. One device that guides slow breathing with musical tones, RESPeRATE, was cleared by the FDA in 2002 (K020399) as a relaxation treatment for stress reduction and as an adjunctive treatment for high blood pressure, together with other treatments [1].
Also called
slow breathing, slow-paced breathing, resonance breathing, resonant breathing, coherent breathing, paced breathing, 6 breaths a minute, box breathing, square breathing, cyclic sighing, physiological sigh, diaphragmatic breathing, belly breathing, pranayama, breathwork, heart rate variability biofeedback, HRV biofeedback, device-guided breathing, RESPeRATE, Wim Hof breathing, Wim Hof Method, cyclic hyperventilation, holotropic breathwork, inspiratory muscle training, Buteyko, Papworth method
Practiced for
stress, anxiety, calm, mood, blood pressure, heart rate variability, vagal tone, sleep, insomnia, asthma, focus, energy, immunity, inflammation, exercise performance, cold tolerance

Strong several reviews agree · Moderate one review or consistent trials · Limited one or a few small studies · Untested no study in people, listed with what it rests on

Shown to help8

Reported risks3

What people practice it for, and what was found

Shown to help8

Moderate

Stress, against no breathing practice

Shown to lower self-rated stress by a small to moderate amount against inactive controls such as a waiting list, in one meta-analysis.

Compared with inactive non-breathwork controls [2]

The numbers and sources
Effect
Across 12 randomized trials, breathwork lowered self-rated stress against non-breathwork controls (g = -0.35, 95% CI -0.55 to -0.14). In the 7 trials with inactive controls, g = -0.37 (95% CI -0.73 to -0.02, I² 66%) [2]. A meta-analysis of heart rate variability biofeedback, which trains breathing at a slow resonant pace, found effects larger against inactive than active controls, and significant against both [3].
Population
785 adults in 12 trials, nonclinical and clinical samples [2]. 58 randomized trials of heart rate variability biofeedback [3].
Sources
[2], [3]
Caveats
Most trials were at moderate risk of bias, and stress was self-reported by people who knew their group [2]. The biofeedback abstract gives no subgroup sizes [3].
Moderate

Stress and mood, against an active comparison

Shown to lower self-rated stress slightly more than active control conditions. In one trial, 5 minutes a day of cyclic sighing lifted mood more than mindfulness meditation.

Compared with active non-breathwork controls [2]; mindfulness meditation for the same time [4]

The numbers and sources
Effect
In the 5 trials with active controls, breathwork lowered stress by g = -0.26 (95% CI -0.48 to -0.04, I² 0%) [2]. In a remote randomized trial of three 5-minute daily breathing exercises against 5 minutes of mindfulness meditation for a month, breathwork, especially exhale-focused cyclic sighing, produced a greater rise in positive mood (p < 0.05) and a greater fall in breathing rate (p < 0.05). State anxiety and negative mood fell in all groups and did not differ between breathwork and meditation [4].
Population
Participants in 5 trials [2]. 114 adults invited into a 1-month remote trial [4].
Sources
[2], [4]
Caveats
Five small trials [2]. The 1-month trial had no inactive control, participants completed about 18 to 20 of 28 days, and outcomes were self-rated [4].
Strong

Anxiety and depression symptoms

Shown to lower self-rated anxiety and depression symptoms in two meta-analyses, by small amounts for breathwork in general and larger amounts for heart rate variability biofeedback.

Compared with non-breathwork controls, active and inactive [2]; control conditions the source abstract does not describe [5]; inactive and active controls [3]

The numbers and sources
Effect
Breathwork lowered self-rated anxiety (g = -0.32, 20 trials, p < 0.0001) and depressive symptoms (g = -0.40, 18 trials, p < 0.0001) against non-breathwork controls, with moderate, significant heterogeneity [2]. Across 24 studies, heart rate variability biofeedback reduced self-reported stress and anxiety against control conditions by g = 0.83, an effect not changed by whether participants had an anxiety disorder [5]. A wider meta-analysis of the same technique found its largest effects for anxiety, depression and anger, from few studies each [3].
Population
Adults in 20 and 18 randomized trials [2]. 484 participants in 24 studies [5]. 58 randomized trials [3].
Sources
[2], [5], [3]
Caveats
Symptoms were self-rated and nobody can be blinded to breathing training. The biofeedback analysis pooled stress and anxiety together and included some studies without control groups in its within-group estimate [5].
Limited

Blood pressure, resistance breathing training against sham

One trial of 36 adults found 30 daily breaths against high resistance lowered systolic pressure from 135 to 126 mm Hg over 6 weeks. Sham training did not.

Compared with low-resistance sham training [11]

The numbers and sources
Effect
High-resistance inspiratory muscle strength training at 75% of maximal inspiratory pressure lowered casual systolic pressure from 135 to 126 mm Hg (P < 0.01), about 75% of which remained 6 weeks after training stopped, and diastolic pressure from 79 to 77 mm Hg (P = 0.03). Twenty-four hour systolic pressure was lower after training than after sham (P = 0.01). Blood pressure did not change with sham training at 15% of maximum. Brachial artery flow-mediated dilation rose about 45% [11].
Population
36 adults aged 50 to 79 with systolic pressure of 120 mm Hg or higher, 18 per group [11].
Sources
[11]
Caveats
One small double-blind trial using a handheld resistance device. This is strength training of the breathing muscles, not slow breathing [11].
Moderate

Heart rate variability

Shown to raise vagally mediated heart rate variability during, right after and across weeks of slow breathing practice, in one meta-analysis of 223 studies.

Compared with control conditions the source abstract does not describe [12]; mindfulness meditation [4]

The numbers and sources
Effect
Vagally mediated heart rate variability rose with voluntary slow breathing during the session (172 studies), immediately after one session (16 studies) and after multi-session programs (49 studies) [12]. In the 1-month trial of 5 minutes a day, resting heart rate variability and resting heart rate measured by a wrist wearable did not change in any group [4].
Population
223 studies [12]. 114 adults invited into a remote trial [4].
Sources
[12], [4]
Caveats
The meta-analysis abstract gives no effect sizes [12]. Heart rate variability during slow breathing rises partly because breathing itself drives heart rhythm, so a rise in the moment is not a lasting change in resting tone.
Moderate

Asthma, against no breathing training

Shown in a Cochrane review to improve asthma quality of life slightly at 3 months against inactive controls. Asthma symptom scores and FEV1 in liters did not clearly change.

Compared with inactive control groups [15]

The numbers and sources
Effect
Asthma quality of life improved at 3 months (MD 0.42 points, 95% CI 0.17 to 0.68, 4 studies, 974 participants, moderate certainty). Hyperventilation symptoms fell at 4 to 6 months (MD -3.22) but not at 6 months. Asthma Control Questionnaire scores were inconclusive (MD -0.08 over 6 months, 95% CI -0.22 to 0.07). FEV1 in liters was inconclusive (MD -0.10 L, very low certainty), while FEV1 % of predicted improved by 6.88% [15].
Population
2,880 adult outpatients with mild to moderate asthma in 22 trials, 14 of them of yoga breathing [15].
Sources
[15]
Caveats
Trials differed in technique, sessions and outcomes, and most reported their methods incompletely. Adverse effects were not assessed [15].
Limited

Asthma, against asthma education

One trial of 183 adults found physiotherapist breathing training improved asthma quality of life and anxiety more than nurse asthma education at 6 months, not at 1 month.

Compared with nurse-delivered asthma education, to control for clinician attention [16]

The numbers and sources
Effect
At 6 months, breathing training improved asthma quality of life by 0.38 units more than education (95% CI 0.08 to 0.68), with differences in anxiety (1.1 points), depression (0.8) and hyperventilation scores (3.2). No differences were seen at 1 month. Airway physiology, inflammation and hyper-responsiveness did not change [16]. The Cochrane review pooled this comparison from the same single trial [15].
Population
183 adults with asthma and impaired health status in UK primary care [16].
Sources
[16], [15]
Caveats
Three sessions, one trial, single-blind [16].
Limited

Hyperventilation breathwork and inflammation

Small trials of a program combining cyclic hyperventilation, cold exposure and meditation found a blunted inflammatory response to injected endotoxin, and a fall in ESR in spondyloarthritis.

Compared with untrained volunteers [17]; a control period without training [18]

The numbers and sources
Effect
After 10 days of training in meditation, cyclic hyperventilation with breath retention, and cold immersion, 12 volunteers given intravenous endotoxin had higher plasma adrenaline and anti-inflammatory IL-10, lower TNF-alpha, IL-6 and IL-8, and fewer flu-like symptoms than 12 untrained controls [17]. In 24 patients with axial spondyloarthritis, ESR fell over 8 weeks of the program from a median of 16 to 9 mm/hr (p = 0.040) with no change in controls, and hs-CRP did not change [18]. A systematic review of 8 trials of the Wim Hof Method concluded it may reduce inflammation and found mixed effects on exercise performance [19].
Population
24 healthy volunteers [17]. 24 patients with moderately active axial spondyloarthritis and raised hs-CRP [18]. 8 trials [19].
Sources
[17], [18], [19]
Caveats
The breathing was never tested apart from the cold and meditation in these trials. The spondyloarthritis trial was open label [18]. Endotoxin injection is a laboratory model of inflammation, not a disease [17].

Mixed results3

Moderate

Blood pressure, against non-sham controls

Mixed results: pooled trials found blood pressure fell about 5.6/3.0 mm Hg with slow breathing, but device trials showed no effect once manufacturer-linked trials were removed.

Compared with control groups the source abstract does not describe [6]; control groups in 8 device trials, not sham-controlled in most [7]

The numbers and sources
Effect
In 17 randomized trials of slow breathing at 10 breaths a minute or fewer, with or without a guiding device, systolic pressure fell 5.62 mm Hg (95% CI -7.86 to -3.38) and diastolic 2.97 mm Hg (95% CI -4.28 to -1.66), with high heterogeneity [6]. Across 8 trials of the RESPeRATE device, systolic pressure fell 3.67 mm Hg and diastolic 2.51 mm Hg. Excluding the 5 trials sponsored by or involving the manufacturer left no overall effect [7]. The American Heart Association rated device-guided breathing Class IIA for lowering blood pressure in 2013 [8].
Population
People with hypertension, prehypertension or on blood pressure medication in 17 trials [6]. 494 adults in 8 trials, none longer than 9 weeks [7].
Sources
[6], [7], [8]
Caveats
Heterogeneity was high in every analysis [6]. The AHA rating predates the blinded trials in the next block [8][9].
Limited

Sleep

Mixed results: two small trials found better sleep with slow breathing before bed, while a month of 5-minute daily breathwork did not change sleep measured by a wearable.

Compared with social media use for the same time [13]; spontaneous breathing, before and after in the same people [14]; mindfulness meditation [4]

The numbers and sources
Effect
In 64 healthy young adults, 15 minutes of slow-paced breathing each evening for 30 days improved Pittsburgh Sleep Quality Index scores and raised overnight cardiac vagal activity, compared with 15 minutes of social media use [13]. In 14 people with self-reported insomnia, 20 minutes of paced breathing before bed shortened time to fall asleep, cut awakenings and raised sleep efficiency on polysomnography [14]. In the 1-month trial, hours of sleep, sleep efficiency and sleep score from a wearable did not change in any group or differ between groups [4].
Population
64 healthy adults with a mean age of 22 [13]. 14 people with self-reported insomnia and 14 without sleep complaints [14]. 114 adults invited [4].
Sources
[13], [14], [4]
Caveats
Small samples, self-rated sleep in one trial [13], and no randomized control group in the insomnia study [14].
Limited

Exercise performance with hyperventilation breathwork

Mixed results: a systematic review of Wim Hof Method trials found mixed effects of its breathing on exercise performance and on breathing during exercise.

Compared with control conditions the source abstract does not describe [19]

The numbers and sources
Effect
In a narrative synthesis of 9 papers from 8 trials, the effect of Wim Hof breathing on exercise performance was mixed, as were effects on minute ventilation, tidal volume and breathing frequency after exercise [19].
Population
Healthy people and people with medical conditions aged over 14 in 8 trials [19].
Sources
[19]
Caveats
No pooled estimate. Trials were small.

Not shown to help1

Moderate

Blood pressure, device-guided breathing against sham

Not shown to lower office blood pressure more than a sham device or music, in a pooled analysis of blinded trials and a double-blind trial.

Compared with a sham device playing music without pacing the breath [9][10]; music therapy [9]

The numbers and sources
Effect
In individual patient data from blinded, randomized trials with active controls, office systolic pressure differed by 2.2 mm Hg in favor of the control group (95% CI -2.7 to 7.0) and diastolic by 0.2 mm Hg in favor of the device (95% CI -2.8 to 3.1) [9]. In 48 people with type 2 diabetes and hypertension using the device or a sham for 15 minutes a day for 8 weeks, systolic pressure differed by 2.35 mm Hg in favor of sham (95% CI -6.50 to 11.20) and diastolic by 2.25 mm Hg in favor of the device (95% CI -2.16 to 6.67) [10].
Population
Adults with hypertension in 5 eligible trials, 3 with individual data [9]. 48 adults with type 2 diabetes and hypertension in the Netherlands [10].
Sources
[9], [10]
Caveats
All trials were short [9]. The sham used music, which may itself relax, so these trials ask whether slowing the breath adds anything beyond sitting quietly with music.

Protocols studied

Slow breathing trials for blood pressure used 10 breaths a minute or fewer, for at least 5 minutes on at least 3 days a week, for at least 4 weeks [6]. The blinded device trial used 15 minutes a day for 8 weeks with a device guiding the breath below 10 breaths a minute [10]. The sleep trials used 15 minutes of app-paced slow breathing each evening for 30 days [13] and 20 minutes at 0.1 Hz, or 6 breaths a minute, before bed [14].

The 1-month mood trial compared three 5-minute daily practices: cyclic sighing with prolonged exhalations, box breathing with equal inhalation, hold and exhalation, and cyclic hyperventilation with retention, against 5 minutes of mindfulness meditation [4]. Resistance breathing training used 30 breaths a day, 6 days a week, for 6 weeks at 75% of maximal inspiratory pressure [11]. The Wim Hof style program trained people for 10 days in meditation, cyclic hyperventilation followed by breath retention, and cold immersion [17], and ran for 8 weeks in spondyloarthritis [18]. Asthma trials taught yoga breathing, breathing retraining, Buteyko, Papworth or diaphragmatic breathing [15], over three physiotherapy sessions in one trial [16].

Risks

Reported risks3

LimitedCommon

Unpleasant experiences during brief daily breathing exercises

In one trial, 10% of participants reported negative experiences during their daily 5-minute breathing or meditation exercise.

The numbers and sources
How common
Common: between 1 in 100 and 1 in 10 people.
Effect
In an optional debriefing at the end of the 1-month trial, 90% of participants reported positive experiences during the exercises and 10% reported negative experiences related to them [4].
Population
Adults in a remote trial of breathwork and mindfulness meditation [4].
Sources
[4]
Caveats
The figure covers all four groups together, including mindfulness meditation, and comes from an optional questionnaire [4].
LimitedHow often is not known

Blackout and drowning after hyperventilating before breath-holding in water

Case series: New York State recorded 16 fatal and nonfatal drownings in otherwise healthy swimmers that followed intentional hyperventilation, hypoxic training or prolonged breath-holding.

The numbers and sources
How common
How often is not known: the sources give no rate.
Effect
A state health department review of 1988 to 2011 identified 16 drownings that followed dangerous underwater breath-holding behaviors in swimmers with no known medical condition or substance use. Practicing more than one of these behaviors was linked to a higher risk of death. The review was prompted by two healthy young men who became unconscious underwater and died after intentional hyperventilation before submersion [20].
Population
16 swimmers in New York State, 15 of them at pools [20].
Sources
[20]
Caveats
A case series with no denominator. These were swimmers breath-holding underwater, not people doing breathwork on land.
LimitedHow often is not known

Low blood oxygen and alkalosis during cyclic hyperventilation

One small trial measured intermittent respiratory alkalosis and low blood oxygen while trained volunteers practiced cyclic hyperventilation with breath retention.

The numbers and sources
How common
How often is not known: the sources give no rate.
Effect
Practicing the learned techniques produced intermittent respiratory alkalosis and hypoxia and a sharp rise in plasma adrenaline [17]. A review of high ventilation breathwork describes marked changes in conscious experience and in central and autonomic nervous system function, and discusses its safety profile [21].
Population
12 trained healthy volunteers [17]. Studies of high ventilation breathwork [21].
Sources
[17], [21]
Caveats
The trial measured the change and did not report symptoms from it [17]. The review abstract gives no rates [21].

Claims tested and not found

  1. That a breath-pacing device lowers blood pressure beyond sitting with music. Blinded trials against a sham device or music therapy found no difference in office blood pressure [9][10].
  2. That a few minutes of daily breathwork improves sleep. A month of 5-minute daily practice did not change sleep duration, efficiency or score measured by a wearable [4].
  3. That brief daily breathwork raises resting heart rate variability. Resting heart rate variability did not change over a month of 5 minutes a day [4].
  4. That breathing exercises improve lung function in asthma. FEV1 in liters was inconclusive in pooled trials [15], and airway physiology, inflammation and hyper-responsiveness did not change with breathing training [16].

Sources

  1. US Food and Drug Administration. 510(k) premarket notification K020399: Intercure Ltd. RESPeRATE. 2002. https://www.accessdata.fda.gov/cdrh_docs/pdf2/K020399.pdf
  2. Fincham GW, Strauss C, Montero-Marin J, Cavanagh K. Effect of breathwork on stress and mental health: A meta-analysis of randomised-controlled trials. Scientific Reports. 2023. https://doi.org/10.1038/s41598-022-27247-y
  3. Lehrer P, Kaur K, Sharma A, et al. Heart Rate Variability Biofeedback Improves Emotional and Physical Health and Performance: A Systematic Review and Meta Analysis. Applied Psychophysiology and Biofeedback. 2020. https://doi.org/10.1007/s10484-020-09466-z
  4. Balban MY, Neri E, Kogon MM, et al. Brief structured respiration practices enhance mood and reduce physiological arousal. Cell Reports Medicine. 2023. https://doi.org/10.1016/j.xcrm.2022.100895
  5. Goessl VC, Curtiss JE, Hofmann SG. The effect of heart rate variability biofeedback training on stress and anxiety: a meta-analysis. Psychological Medicine. 2017. https://doi.org/10.1017/S0033291717001003
  6. Chaddha A, Modaff D, Hooper-Lane C, Feldstein DA. Device and non-device-guided slow breathing to reduce blood pressure: A systematic review and meta-analysis. Complementary Therapies in Medicine. 2019. https://doi.org/10.1016/j.ctim.2019.03.005
  7. Mahtani KR, Nunan D, Heneghan CJ. Device-guided breathing exercises in the control of human blood pressure: systematic review and meta-analysis. Journal of Hypertension. 2012. https://doi.org/10.1097/hjh.0b013e3283520077
  8. Brook RD, Appel LJ, Rubenfire M, et al. Beyond medications and diet: alternative approaches to lowering blood pressure: a scientific statement from the American Heart Association. Hypertension. 2013. https://doi.org/10.1161/HYP.0b013e318293645f
  9. Landman GW, van Hateren KJ, van Dijk PR, et al. Efficacy of device-guided breathing for hypertension in blinded, randomized, active-controlled trials: a meta-analysis of individual patient data. JAMA Internal Medicine. 2014. https://doi.org/10.1001/jamainternmed.2014.4336
  10. Landman GW, Drion I, van Hateren KJ, et al. Device-guided breathing as treatment for hypertension in type 2 diabetes mellitus: a randomized, double-blind, sham-controlled trial. JAMA Internal Medicine. 2013. https://doi.org/10.1001/jamainternmed.2013.6883
  11. Craighead DH, Heinbockel TC, Freeberg KA, et al. Time-Efficient Inspiratory Muscle Strength Training Lowers Blood Pressure and Improves Endothelial Function, NO Bioavailability, and Oxidative Stress in Midlife/Older Adults With Above-Normal Blood Pressure. Journal of the American Heart Association. 2021. https://doi.org/10.1161/jaha.121.020980
  12. Laborde S, Allen MS, Borges U, et al. Effects of voluntary slow breathing on heart rate and heart rate variability: A systematic review and a meta-analysis. Neuroscience and Biobehavioral Reviews. 2022. https://doi.org/10.1016/j.neubiorev.2022.104711
  13. Laborde S, Hosang T, Mosley E, Dosseville F. Influence of a 30-Day Slow-Paced Breathing Intervention Compared to Social Media Use on Subjective Sleep Quality and Cardiac Vagal Activity. Journal of Clinical Medicine. 2019. https://doi.org/10.3390/jcm8020193
  14. Tsai HJ, Kuo TB, Lee GS, Yang CC. Efficacy of paced breathing for insomnia: enhances vagal activity and improves sleep quality. Psychophysiology. 2015. https://doi.org/10.1111/psyp.12333
  15. Santino TA, Chaves GS, Freitas DA, et al. Breathing exercises for adults with asthma. Cochrane Database of Systematic Reviews. 2020. https://doi.org/10.1002/14651858.cd001277.pub4
  16. Thomas M, McKinley RK, Mellor S, et al. Breathing exercises for asthma: a randomised controlled trial. Thorax. 2008. https://doi.org/10.1136/thx.2008.100867
  17. Kox M, van Eijk LT, Zwaag J, et al. Voluntary activation of the sympathetic nervous system and attenuation of the innate immune response in humans. Proceedings of the National Academy of Sciences. 2014. https://doi.org/10.1073/pnas.1322174111
  18. Buijze GA, De Jong HMY, Kox M, et al. An add-on training program involving breathing exercises, cold exposure, and meditation attenuates inflammation and disease activity in axial spondyloarthritis: A proof of concept trial. PLoS One. 2019. https://doi.org/10.1371/journal.pone.0225749
  19. Almahayni O, Hammond L. Does the Wim Hof Method have a beneficial impact on physiological and psychological outcomes in healthy and non-healthy participants? A systematic review. PLoS One. 2024. https://doi.org/10.1371/journal.pone.0286933
  20. Boyd C, Levy A, McProud T, et al. Fatal and nonfatal drowning outcomes related to dangerous underwater breath-holding behaviors: New York State, 1988-2011. MMWR Morbidity and Mortality Weekly Report. 2015. https://pubmed.ncbi.nlm.nih.gov/25996093/
  21. Fincham GW, Kartar A, Uthaug MV, et al. High ventilation breathwork practices: An overview of their effects, mechanisms, and considerations for clinical applications. Neuroscience and Biobehavioral Reviews. 2023. https://doi.org/10.1016/j.neubiorev.2023.105453

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