What if the way you breathe is silently holding you back?

In this powerful episode of The Art & Science of Breathing, we sit down with Dr. Aashish Vyas, consultant in respiratory medicine and head of a Severe Asthma Centre, to explore what elite athletes, children, and everyday people all get wrong about their breath - and how it affects everything from performance and sleep to mental health and longevity.

Whether you’re a health nerd, breathwork coach, athlete, parent, or just someone who’s ever felt breathless walking up the stairs, this conversation will change the way you think about your lungs.

 

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Transcript:

Patrick Obolgogiani (00:04.042)
Aashish, you've been a medical doctor in respiratory medicine for 30 years now. I'm curious to hear what drew you towards that field in the first place.

Aashish Vyas (00:17.134)
I don't know. I've always wanted to be a doctor. It's really strange, Patrick. I since the age, I can remember being 8-year-old and being lined up in two lines. All the kids, all the boys wanted to be footballers. And the teacher came to me and said, what do you want to do? And I just said, I wanted to be a medic. I don't know where I said that from, but I just did. it's always, you know, as young children, you always want to be astronauts and stuff like that.

but I've always been drawn back to that passion and it was really amazing that I got into university to do this career. I've done loads of different things. I wanted to be an obstetrician in the past. It was one of my first career processes, but I had an amazing consultant in my first job who inspired me to be a physician.

And from there onwards, I fell in love with respiratory medicine. The ability to focus on well-being through your breath is kind of like, seems simple, everyone breathes. You need to breathe to live. It's a process that we do and we're aware of. We're aware of it when we're exercising a lot, but not everyone does it efficiently. was kind of like that process. also, just to back story, my father had

severe asthma. when we were growing up, Dad was in and out of hospital a lot. He was intubated in intensive care. So suppose probably psychologically it probably had an impact on me. But yeah, it's been an, I can't really pinpoint a moment in time apart from that eight year old's initial discussion with the teacher that really pushed me forward.

Patrick Obolgogiani (02:07.671)
Yeah. I imagine also, as I mentioned, having personal experience of what it's like when it's difficult breathe plays a lot, at least in my case, that helps. I'm curious, like, given that there's been probably some progress also in how we understand and treat different respiratory conditions, what's been the biggest change, if you think back, like, to when you started as a physician to now in 2025?

Aashish Vyas (02:13.419)
Hmm.

Aashish Vyas (02:38.591)
So, science is amazing. That's what I've discovered. If there's anything I've discovered from being a medical student to where I am now, is that actually trusting good science is really important. so, I've come from an era where when I first qualified and, you know, we had...

individuals who have severe asthma or COPD and people would accept that that's their life. They would be on steroids, really obese because of steroids, develop diabetes, sleep apnea and stuff like that. And now if I look at the intervention of science and especially the medications, have kind of like precision medicine that actually takes this most severe

individuals with death-defying disease and actually makes through simple injections with very little side effects makes their life's normality from a breathing perspective. And that I see that in all aspects of you know you look at cancer treatments where once upon a time people used to have chemotherapies and and nowadays biological agents, monoclonal antibodies have revolutionized some parts of treatment. I think what's really interesting currently is

involvement in technology. So stepping outside medicine to understand how tech and understanding of what normality is and whether there's subclinical disease and whether you can at a younger age understand maybe limitations you may have and actually work with them before needing to go on medications may be important. So I think one of the things that we've never explored in huge amounts is technology.

within respiratory medicine, surely we've had bronchoscopies to look inside lungs, CT scans, NMR scans, those are diagnostic tools, but we've not really ever had tools which facilitate outcome in personal life. We've now got Apple Watches, if you look at the Apple Watch, the amount of probable data that's gone in to find that mindfulness where you take your deep breath in, hold your breath and breathe in and out for a minute every hour.

Aashish Vyas (05:05.642)
which actually slows everything down. think, so in my life I've seen medicine change dramatically from where it was, where it was very reactive, where it was very limited to the future. I'm slightly envious of the next generation because the medicine that they will undertake I hope will be more preventative than treatment wise but I think the instigation of, I don't know, the...

the science around medication, which reduces side effect profiles, also technologies which inform the general population of how to stay healthier. It's going to be really important, I think, going forward.

Patrick Obolgogiani (05:49.172)
Yeah, I can imagine my, as you probably recall, my previous life was in the field of personalization for commerce. And I guess, you know, part of that premise was always like, it's something you can take also into the world of healthcare and start personalizing. And now it feels like we're going to moving towards that direction where there's more inputs that you can feed into an algorithm to derive what is the right personalized output, whether it's as you mentioned, medicine or actual.

more technological interventions or even behavioral interventions that are tailored to you. So, yeah.

Aashish Vyas (06:22.219)
So historically medicine has been about being told what to do, it? You know, need an operation, you need this, but actually, it's your life, isn't it? It's your choice, it's your ability to understand. And most individuals are intelligent enough if you're given data or you're able to understand data effectively and you're given it in a usable form to actually make sensible decisions.

Patrick Obolgogiani (06:27.924)
Hmm.

Aashish Vyas (06:51.669)
for yourselves. And you know, we do that, you know, when I see my patients in my clinics, always, you know, part of that discussion or even at the start of discussion, we always say that just because we can do stuff as physicians for them, that's not always the right thing for those individuals. At the end of the day, it's a personal choice, it's the life you lead and such like. So my hope and aspiration is as time goes on.

that we have a bit more ability to be pre-informed as individuals because I'm a patient as well. You know, I'm maybe a doctor but outside my care processes and my interest processes are outside of respiratory medicine. If it was something else, I would be that patient and I would like to have the ability to understand the illness and the process around how I can make recovery occur better if there's something gone wrong.

Yeah, so I think you're right. I personalisation of healthcare is important for everyone.

Patrick Obolgogiani (07:57.575)
I want to go deeper into the technology in a moment, but maybe yeah, please

Aashish Vyas (07:59.188)
And I would go one deeper. Yeah. I would go one more deeper rather than just knowing when you're poorly, knowing when you're well, what it means to be well. So we, know, mean, individuals who, yeah, exactly. So individuals who do like, 10Ks or doing couch to 5K, kind of like, you know, have watches, tell them heart rates and stuff like that. But actually understanding, you know,

Patrick Obolgogiani (08:12.71)
Yeah, what well looks like.

Aashish Vyas (08:27.018)
how much you can push yourself safely and what to do to try and get yourself better would be an amazing thing, wouldn't it? You can imagine the impact on longevity and well-being, you know, because being healthy is part of not just for today, it's where you are in 20, 30 years' time. The healthier you are now today, the likelihood is the healthier you are going to be, less dependent on other people when you're 70 and 80 years old, for example.

Patrick Obolgogiani (08:55.731)
Yeah, it's like the gradient of decline, you can change both the curvature of the gradient and the level at which you start the decline. it's a good point. I thought actually, because you're one of the best people to ask some of these basic questions about defining a few things which are thrown out there, but there are sometimes like ill-defined, including breathlessness and a few others. you know, let it, think NHS writes the severe asthma and breathlessness.

complex muscle unit, maybe we start with just defining what those are. What is, in practice, asthma? How do you define that?

Aashish Vyas (09:36.915)
So the first thing is asthma is not a single disease. Asthma is multitude of different pathways within the body that go wrong. It's an inflammatory process. The way to look at it is an inflammation or a wildfire in your lungs. The lungs are angry and red. And rather than feeling pain, so if you hit your thumb with a hammer, it gets swollen and you get pain. But rather than having pain, your lungs twitch.

but your lungs are swollen, they very often exude kind of like nutrients and fluid. So you have a cough, which is productive of mucus sometimes when you've got exacerbation. But even at steady state, if you're an asthmatic, your lungs are red and inflamed. There are multiple different types of asthma. So we call them phenotypes. So the way that patients present and the types of, have patients who are allergic, patients who have no allergic component to the asthma, but are

are for example exercise induced or are viral induced and they have different internal pathways which lead to the same road if you like of inflammation and twitch in the lungs. So the way to... so if you have an asthma attack your airways really shut down, they narrow. So and if you go back to basic physics if you half the diameter

of a cylinder, the resistance to airflow in that increases to the power of four. So by just narrowing your airways, the amount of difficulty in breathing becomes really severe and the amount of energy you use up in breathing, the potential for exhaustion becomes more significant. Now if you've got chronic asthma or low-level asthma, you just work harder than everyone else and you're more tired.

and you're able to achieve less physically and in a day-to-day manner. the panacea for everyone is to have normal, large, open airways all the time. So from our perspective, when we see patients with asthma, what we're trying to do is just ensure that the airways are non-twitchy and the inflammation is gone. And the best way to look at asthma for anyone is narrowed, inflamed, twitchy airways, which are reactive to inhaled...

Aashish Vyas (12:03.783)
particles.

Patrick Obolgogiani (12:07.014)
I think often, at least in my personal experience, you kind of correlate usually wheezing in your lungs with asthma. But is it that way? like is wheezing always asthma and vice versa is asthma always with wheezing sounds or not always?

Aashish Vyas (12:23.496)
So it's difficult, it? So the most significant asthma acute attack, and we talk about life-threatening asthma, your wheeze disappears because your airways are so tight. The reason you wheeze is flow through the airway, which is normally laminar, becomes turbulent, and you produce noise. It's a bit like a read-on-the-wind instrument. You press it down, you narrow it, and you produce turbulent flow. You produce sound.

And very much what wease is, is narrowing of your airways to pretty sound. But actually your lungs are quite complicated pieces of tree. So I always say to my patients, think about your lungs as an upside down tree. You have your trunk, which is your trachea. You have the big branches that go to the left and right lung. And then you've got the middle sized branches, which go to the upper lungs, middle side, middle lungs and lower lobes. And then they branch and branch and branch until you end up with the terminal airways.

and the leaves which are the alveoli and the alveoli are important because that's where the job of the lungs is done. Oxygen goes into your bloodstream and oxygen is important because it's basically the battery for everything we do. Whether we think, whether our heart beats, whether our kidneys work, everything. So wheeze occurs very often when your large airways are done but we do have patients who just get breathless and they seem to have more peripheral, more

distal asthma and that distal asthma very often doesn't cause as much of a wheeze. It's what we in respiratory medicine call the silent zone. It's hard to investigate but we know it exists and we know response to treatment does improve the outcomes.

Patrick Obolgogiani (14:09.112)
Makes sense. So it basically means that wheezing probably increases the chance of having asthma, but the fact that you don't have it doesn't mean that you don't have the asthma condition in your lungs, basically. And the side notes, you know this already, but obviously the alveoli reading about them in the first place some time ago kind of had like these magical little things that are transforming CO2 into oxygen and vice versa was like what inspired the name of the company. So that's really cool.

magical things we have inside ourselves.

Aashish Vyas (14:39.749)
Yeah.

Aashish Vyas (14:43.622)
Absolutely. the importance about asthma is that, you know, it's not purely a child's disease. It occurs at different times in your life. My oldest patient today, who's had first time asthma diagnosis was 92. The average onset of asthma is in early middle age or in your elite 30s. And children do have asthma and they grow out of it. So asthma is a different thing.

And then patients are different. Some patients sense and perceive asthma much more severely, and some patients are what we consider low senses of asthma. So they can have really severe asthma symptoms and they perceive it as normal. But it's just that process that we need to look at. Just a second.

Aashish Vyas (15:44.902)
Sorry about that, just the lights went out. So yeah, so I think just going back to your asthma, personal perception of breathlessness is really important in asthmatics. And very often as medics, we look at severity. And actually some of that severity is defined by people's perceptions of what their asthma is. So we can get patients who we consider severe asthmatics.

initially because they're on steroids all the time, but actually when you look at it, the lung physiology and stuff like that is not severe and actually education around that is important. But then the more worrying side of it is that the people who sense and perceive their asthma, that's not severe and it is. So actually having an ability to assess that yourselves is really important. And currently it's, you know, we use things like peak flow machines and such like, which...

Patrick Obolgogiani (16:25.87)
Mm.

Aashish Vyas (16:38.48)
have their uses but it's not the right thing for everyone because as we say asthma occurs in a variable state in the lungs. So some people the large airways shut down and some people it's more peripheral. These individuals very often don't wheeze but get breathless and quite limited in what they can do. you know, and that's again where we need the ability for individuals to understand and assess.

what's going on in themselves a bit more effectively than we currently do. the ability to have technology and be involved in that's great.

Patrick Obolgogiani (17:19.118)
Maybe you mentioned the word breathlessness. That's another word that's thrown out quite easily. People are like, oh, I became breathless. I was like, know, walking up the stairs. And I think a lot of people correlate that with basically being, you know, not fit. But it feels like at least in your clinic, which I'm happy to talk about in a moment, you know, we have athletes that are, have breathlessness, despite being at the peak of their performance in their athletic pursuit. So again, how do you even define breathlessness?

Aashish Vyas (17:49.893)
So everyone gets breathless. Breathlessness is normal. If you're an elite athlete and you finish a marathon, you're a marathon runner, they kind of fall to the floor. They're exhausted, they run out of all nutrients, they've got high lactate and their respiratory rates are huge. So breathlessness, first thing people need to know is breathlessness is normal.

but it can be limiting in individuals. And one of things that we always talk about in athletes and young individuals is whether your breathlessness is disproportionately more significant to your physicality. So if you feel you can keep on going but it's your breathing that stops you doing exercise, then that's something that we need to realign and assess.

Sometimes it isn't, sometimes breathlessness is because of deconditioning. So if you've been really unwell for a while, you don't have to have respiratory disease, as you exercise your muscles are weaker, you have to carry your skeletal body, you kind of like go from an oxygen enriched environment in your muscles and your heart and such like to an oxygen poor environment, a lactate high environment, and you start getting breathless. So breathlessness is a multi...

A of reasons for it. Your lungs are one of the most predominant causes, but muscle fatigability is one. The functionality of your heart is another. Psychology is another. You and I know that sometimes when there is a moment of importance in your life, you kind of feel that your breath is uncontrolled. Or you cut, you know, but when there's a moment of importance and you still your breath, you control your breath.

everything else improves. So breathlessness is a multitude of things and it's very different for everyone that comes and sees us there. and what the important thing for clinics like ours is to understand what is physiological breathlessness. So actually there's no particular disease process, it may be a conditioning issue, a biomechanical issue. what I mean by biomechanical issue, breathing is complex procedure.

Aashish Vyas (20:14.071)
you breathe through your nose or sometimes through your mouth, you have to pass this thing called your vocal cords, your voice box, which is the, if you like, the door, the entrance to your lungs, and it needs to be fully open, not shut down, because if it is, then it becomes hard to breathe. And then you need to have a coordination of your in-breath to your diaphragmatic breathing, and your diaphragm's a big muscle, so they have to work effectively in coordination. So there's a lot that can go wrong.

And actually sometimes just resetting how you breathe, functionality, there's nothing wrong with your lungs, but your voice box is narrowing, your breathing pattern is asynchronous and helping that and to understand that occurring is really important. And at the moment we're limited by physiotherapy and assessments when people are breathless. We don't actually have that, the...

the portable technology to define that at the moment, but we do understand there are symptoms for that. And then obviously there's pathological breathlessness, which is related to disease processes such as asthma, COPD, fibrosis of the lungs, and related to cardiac disease. And then there is psychological breathlessness, which is really important because actually...

Coordination of your breathing and delivery of efficient oxygen to your body is really important to deliver outcome.

Patrick Obolgogiani (21:46.39)
Yeah, I'm curious because you.

Aashish Vyas (21:47.647)
I'm not sure the answer to your question is what breathlessness is, because it's not about feeling. I think for everyone it's just about feeling breathless, isn't it? You feel breathless. But actually there's a multitude of causes and actually it's a different thing for different people. It's like daffodils and roses, it's the flowers.

Patrick Obolgogiani (21:51.318)
Yeah.

Patrick Obolgogiani (22:07.469)
Yeah, makes sense. Maybe one thing that could help even more pinpoint kind of what we're talking about, like you have the elite breathlessness clinic, where I believe you have both pro athletes and kind of more weekend warriors. If we maybe talk about both, like, I'm not sure if you can name names, but if you could give an example of someone, maybe the sport they did and what was the kind of, what did it look like when they walked into your door and what happened next?

Aashish Vyas (22:38.339)
So, elite teams are really very careful about who we talk about and don't know. But what we do do, so for example, we do loads of processes in our elite breathlessness clinic. We do screening. So for example, we screen for some of the most significant Premier League teams in our country. The reason we screen for them is that there was a really seminal paper

by John Dickinson, who's a professor of physiology in South England, showing that one in ten Premier League footballers have subclinical asthma. So they don't know they've got asthma, they've got amazing engines they can play, but actually John did the study with his team and actually by doing basic assessments, picked them up, treated them and actually their performance improved significantly. And one of the things I was asked by one of the Premier League teams next to us is

what happens if their performance improves and actually one of things we discovered was when actually within John's paper was that actually the performance was improved and actually there was a 20 % improvement in some of those individuals. So actually by just treating something that they didn't even sense but was there was limiting how hard they could work and they were becoming more exhausted because they working hard to breathe. By correcting that

actually their ability to play for longer and harder was improved. But also some of the feedback they got and we get now from our screening programmes is people feel fresher and more clear of thought. had one of our players saying that he just feels less exhausted and able to make more decisions with regards to his final ball and such like at 85 or 90 minutes.

that there's a huge impact in our screening programs. So one of things we do is screening programs at the Leap, but we also look after individuals who have episodes of breathlessness. Sometimes they feel that there is more in the engine than their breathlessness allows, and therefore we assess that, we understand, and we assess whether it's the biomechanics of breathing, i.e. the lungs are grey, the heart's grey, but the voice box is shutting down, this is called...

Aashish Vyas (24:58.816)
induceable laryngeal obstruction or there's an asynchronicity of their breathing pattern. And we have to use quite complex processes and real-time physiotherapy and cardiopulmonary exercise testing to assess that at the moment. But things like plethysmography and new technologies to assess breath-to-breath variations will be really important to understand that going forward.

I think we then also assess people with exercise-induced asthma. We do quite a lot of work around that and then obviously there's a group of individuals who have huge amounts of deep conditioning so we assess that as a cause of breathlessness. our clinics are for all. We look after individuals from British Olympics, British athletics.

Paralympians, the Paraswim teams, the UK Swim teams, we've got Premier League teams and we do a lot of work with our Yorkshire and Lancashire Croquet as well.

Patrick Obolgogiani (26:08.298)
Amazing. What about like someone who's not an elite athlete, but they're maybe, uh, you know, trying to run once, twice a week, maybe go to the gym. Um, if you think about an average person like that, I'm sure, including myself, we still don't always breathe optimally. Like when, when people come to you, what are the, some of the, the challenges that then probably affect their wellness and health long-term if they don't, don't change? Like what are the

That's a key challenge to see when it comes to people's breathing.

Aashish Vyas (26:42.698)
So I'm going to take a personal process in that. I'm going to talk about myself for a few seconds. So I've got exercise-induced asthma and I've had it since childhood really. And even through my junior medical training course, I didn't realise it because I don't wheeze. I don't really wheeze. I used to run and I used to think I'm just exhausted. And I couldn't do a 5K without having a stitch and being absolutely shattered.

Patrick Obolgogiani (27:07.22)
Mm.

Aashish Vyas (27:12.191)
you know, cycling okay, I could swim okay, but I was always limited by my physicality. And I put myself into a study when I was a research reg and I did a spirometry for the first time, you know, and this has now been qualified for quite a few years. And I found that I had very severe obstructive airways disease, but no symptoms of it. And I went to see the logo, you know.

one of my colleagues who then started with inhalers and now I take inhalers on a regular basis. But realistically, I don't have exacerbations, I don't have any symptoms, one of the first things I noticed within the year, I was running long distances and I do a Sunday run for two hours and my breathing was never limited. It's my fatigue ability and my age and my physicality now that I...

I truly understand that limits me more than anything else. So it's really interesting, know, the kind of people that come to see us, it's, know, we have individuals who want to run better and want to be faster and fitter. So they want things like VO2 tests and VO2 max tests and assessments from their respiratory or their cardiac perspective to see how far they can do and what they can do further. We have individuals who

So one of things that you always need to be aware of is that when you exercise regularly, you chew up nutrients and you know, so we all think about hydration and stuff like that, but nutrition and nutritional replacement and management is important. And also your physical health. So you and I know that, you know, whether you're an elite athlete or someone who exercises regularly, sometimes

You live in a precipice between being really fit and healthy and becoming unwell quickly and such a life. So part of the process is that we ensure is that our individuals, when they come and see us, are nutritionally replete and don't over-exercise, know, and don't have fatigueability due to that. And that's not where the breathlessness comes from. But a large proportion of our individuals come to us with breathlessness and they sometimes are symptomatic. by just...

Patrick Obolgogiani (29:24.392)
Hmm.

Patrick Obolgogiani (29:29.085)
Right.

Aashish Vyas (29:36.894)
having a discussion with them. The most important thing that you do as a medic is to talk to your patient. That initial consultation is by miles the most paramount thing that you do because you learn loads of things. Effective history, you just let the patient talk, it will give you a diagnosis, nine times out of ten. You understand hopes and aspirations of those individuals and you understand

the best way to support them to get better. And that's the thing that we do. We support individuals to try and get back to where they want to be. So I think from our perspective, we have a multitude of reasons why people come to us. Sometimes they're really symptomatic. They've had a bad infection and they've just not recovered. Sometimes they want to be better. Sometimes they perceive they can be better, but they're limited and they don't understand why, and they feel breathless related to that.

And sometimes it's about fatigue ability and such like. and it's trying to unpick the physiology and the pathophysiology from each other and trying to meld them into a process which works for that individual.

Patrick Obolgogiani (30:51.846)
Yeah, it's beautiful. Maybe then let's talk about Alvius. So we've kind of been dancing around the topic of technology a little bit, partly on purpose. But I think I reached out to you, this is like some time ago already, and you got intrigued. Do you remember like maybe even thinking back now, like what is the thing that attracted you most? Like what was the thing that made you like, I want to learn more. Or maybe even I want to join as an advisor, a medical advisor for these guys.

Aashish Vyas (31:00.434)
Hmm.

Aashish Vyas (31:22.366)
So I think it's one of the next horizons in health and wellbeing. So I'm the head of a severe asthma centre, so we look after the most severe asthmatics in our region. And one of the things we very often find our patients are over-medicated.

And we not only look after the asthmatics, sometimes people have had a diagnosis of asthma because they've got vocal dysfunction and they've been misdiagnosed. So misdiagnosis, then putting on loads of steroids, loads of inhalers, which don't work, but people keep on finding on things. And actually, the most important thing in life is diagnosis. Understanding what's rather than medication. The medication comes secondary to that process.

because actually the right medication has the most impact. But actually is medication the right thing to do? And not in all ways, in all people. So why technology is starting to interest many of us? Is it because it has potentially the ability to do multiple things for an individual and for the clinicians as well. It has the potential to...

support diagnosis. So for people and the clinicians to understand what's before you treat, it has the potential to assess outcome of the things that you implement to make yourself better because it's a sequential process. At the moment we use things like questionnaires. you know, are you using more steroids, are you using more inhalers? But actually having technology demonstrate things are getting better is, is, would be amazing.

because it's actually real-time feedback to that individual. It's more likely to make someone more compliant to their well-being and to the things that they're doing to show them it works. The other thing that technology can potentially do is pick up disease earlier or pick up abnormalities earlier for individuals to correct it in their life without becoming unwell. So one of the things that globally...

Aashish Vyas (33:47.76)
we're struggling with is funding healthcare, aren't we? It's a challenge because technology and because of the drug productions and the medications and people are living longer and because there's more obesity in Western countries and all of this scenario, there's problems. But actually, the question that none of us seem to want to answer or know how to answer is, historically, medicine's been reactive.

disease you treat disease so then it becomes about treatment with drugs predominantly yeah or with surgery or such like but we know from data that there's if you can pick up something early there's potential to correct it so why technology interests me predominantly is is there an ability for technology in individuals but also

on a much more wider healthcare system basis and a global basis to pick up the potential for illness and to correct that early with minimal medication and will that improve healthcare of that individual so they're less reliant on being sick? Yeah? And more able to be physical. The most important thing in life for many of us is to be physically active because if you are physically active you can...

your weight better, you can control your blood pressure better, your heart's more conditioned, your muscles more conditioned. We know the data around anxiety and depression, the more physically active you are, the less you are likely to have psychological ill health. So if we can promote individuals to be able to understand their well-being more effectively, and the only way I can see currently to do that is through the ability to

Patrick Obolgogiani (35:31.983)
Yeah.

Aashish Vyas (35:44.847)
pick it up through technology because it's, you know, and things like AI may help as well. Yeah. But I think that those things are going to be important. So that's why technology interests me. It also interests me because it is a potential way of tracking outcome, whether it's of medication, whether it's of, you know, processes of care that you put in, which are more holistic. And it also allows us to understand whether

how a certain disease process, improving that, potentially has an improvement in the whole well-being of that individual. Because at the end of the day, we're not organs, we? We're not a lung, we're not a heart, we're a human being who has psychological, respiratory and physical needs. And how that impacts on you as an individual. So, in a snippet, to me it's part of the next...

processes of trying to improve the wellbeing of an individual but also of a nation if possible.

Patrick Obolgogiani (36:52.548)
I can relate to the mission there. it's like being able to do stuff earlier, catching and really giving independence and control is something I'm really excited about. And I can think back of what it was like for me. And what I imagine it's like for lot of parents in the world as well is like that the unknowing is the difficult.

Maybe going into more detail here, with, yeah, please.

Aashish Vyas (37:21.05)
So I'll do this question for you then.

Aashish Vyas (37:26.458)
No, no. So I was doing that question. If we know that 10 % of footballers are asthmatic and don't sense asthma, the question is how many young children out there who struggle with sport and exercise due to breathlessness actually could we intervene in early because we don't have the ability to find issues? And if we improve their outcomes early on in life?

what would that look like for them, but also for the nation as a whole with regards to healthy well-being individuals who are able to provide a better outcome for your nation with work, with health, with regards to longevity, less utilisation of healthcare, more productiveness within the workforce, but also individuals who are able to contribute to all the other...

social and art form processes that are important for us as communities and individuals.

Patrick Obolgogiani (38:31.875)
Hmm. Actually that brings a thought like I would love to hear your thoughts. I've been thinking about this, like, you know, this old, you know, three pillars of health. have exercise, sleep and nutrition. And typically the way it's portrayed, which I think is to a large extent true is the keystone habit within those three, three is usually exercise because when you exercise, then you actually want to eat better. It just feels that way. You kind of want to have a salad rather than a burger after a run.

And then when you eat well, they actually sleep better because you've done the exercise, eat well. so it becomes this nice feedback loop. But I actually wonder like, the more I explore this world of breathing, whether the actual keystone habit that could trigger the first one is actually breathing because it seems like very often the difficulty people have with taking the first run is that they feel like, I can't even breathe. Well, if you can train your CO2 tolerance and like the basic breathing stuff.

So that then you run becomes easier, or at least feel the perception of it is easier. Maybe that could be the kind of the keystone habit that leads to exercise, which then leads to better nutrition and that leads to better sleep. Just curious to hear what are your thoughts on that.

Aashish Vyas (39:43.386)
So it's really important, it's the one thing that we have real control over, don't we? The way we breathe effectively. How our heart beats, we can help it by conditioning and by exercising, but you need to be able to breathe and your muscles need to be active. The way your kidneys function is about your hydration, but we don't have the control of that. As an organ, your skin...

and your breathing are the two things that we probably have more control over and the ability to optimize more than anything else. And actually, you're quite right. So you take someone who has obstructive sleep apnea, whose oxygen saturations fall significantly in nighttime, who has abnormal sleep-disordered breathing. They are tired in the daytime, their memory is poor, their functionality is poor, they get up.

heartburn, they're more likely to have metabolic disturbances like diabetes, yeah, they have less ability to concentrate, you know. So actually that pathophysiology related to sleep-disturbed breathing at night time demonstrates if you can correct that, what actually is achievable. And actually it gives you an indicator of having effective functional breathing and how important

delivery of oxygenation to the mitochondria in your body, wherever they are in your body, is really important because actually having effective breathing and effective gas exchange actually fuels everything you do. So it is actually, if you want to exercise, the more efficient your breathing is, the more efficient the delivery of oxygen into your end organ targets is.

the more you're going to be able to exercise, more you're going to be physical. If you have effective breathing at night...

Aashish Vyas (41:48.184)
and throughout your sleep patterns you're probably going to be more refreshed when you wake up. So we know that asthmatics get tired because we go through a circadian pathway within our breathing so there are times in the early hours of the morning where our airways are tighter and narrower and we're more symptomatic to being symptomatic. That's why asthmatics very often wake up at night and coughing and wheezing early hours of the morning. So actually you're quite right. Actually

Effective breathing is really important and you know, history tells us that. You know, just because we're in this era of modern medicine and science, you you go back generations and you know, over a thousand years and the importance of breathing in yoga and to the whole well-being is still practiced to this day because we understand that...

the core of your well-being very often is related to how you breathe effectively and efficiently. And I think you're right, I think, you know, those three pillars are driven by the effectiveness. It's about... So, take a... If you take a deep breath now, yeah, and you take two or three deep breaths, what happens? Your heart rate comes down, yeah?

Patrick Obolgogiani (42:51.936)
Hmm.

Aashish Vyas (43:15.233)
you feel more relaxed, your muscles are less tense, you feel a bit more alive, and if you have your hands in your pulse, you'll see your heart rate is lower, you're more calmer, your whole process is more efficient. And therefore you then you put that into a process whereby it's throughout your day, throughout the 24 hours that you have, then...

Actually, can imagine what physiologically, how important that will be to you as an individual. Having lower heart rates, being calmer, being more effective. And we know that actually having effective breathing improves metabolic function, improves the core activities within your body. So actually, it's probably one of the most important things to focus on.

Patrick Obolgogiani (43:51.552)
Hmm.

Patrick Obolgogiani (44:10.529)
That's fascinating. Can you talk more about that? Like, what do you mean? How does it affect the metabolic function?

Aashish Vyas (44:17.857)
So we know that, so this data isn't there, so most of data comes through pathophysiology. So you look at individual stuff, for example, you have look at people that have sleep, disorder, breathing and night time. And because they have adrenaline surges, because they become hypoxemic on a regular basis, they have hypertension. They have the adrenal corticoid.

adrenal axis is affected. You know that they have increased heartburn and the impact on acid secretion is impacted. We know that there is a potential for increased diabetes in patients with obstructive sleep apnea and so now some of that may be due to lethargy and tiredness and obesity. We understand that but there also seems to be an independent factor within that which is related to the sleep disorder, breathing, the hypoxemia that individuals have. So we know that there are

Patrick Obolgogiani (45:14.241)
Hmm. Interesting.

Aashish Vyas (45:16.97)
pathways and processes that we patients go through that undoubtedly impact on them and on their well-being, which is related to abnormal breathing patterns. So one of things that we see in our patients, for example, you can see the ability because you work hard with inducible laryngeal obstruction, this is where your voice box shuts down.

you get coughing, you get increased nervous activity, you get the ability not to breathe effectively, you get chest pain, and you get adrenaline surges within them and there's a cortisol imbalance. There's a cortisol imbalance in patients with asthma. Now that may be effective because if you've got severe asthma, you're on and off steerwards a lot orally if you're on the severe spectrum. So there are pathways and there are probably pathways that we still don't know about which lead to lethargy and tiredness and fatigability in this.

population but we know that this is part and parcel of that process. We know that people with chronic lung disease for example have anxiety and depression. Now some of that may be related to the fact that they've got chronic disease but that chronic disease is driven by a respiratory component. Some of that may be due to isolation because they've got severe disease they can't socialise and some of that may be related to lack of physicality. But there is also a question is whether that whole

Patrick Obolgogiani (46:41.695)
Hmm.

Aashish Vyas (46:44.873)
dysfunctional breathing, the impact and delivery of effective gas exchange is impacting on their ability to function and what that is having at a metabolic rate within their bodies.

Patrick Obolgogiani (47:01.108)
Yeah, that's fascinating. I remember reading at some point that how the oxygen is basically driving the metabolism when we eat. And I'm just wondering if anyone studied actually like the impact of the way you breathe to the way you digest food. Do know much if anyone studied that kind of thing or like, does it matter at all the way we breathe during eating?

Aashish Vyas (47:20.829)
Yes, some of that's outside my knowledge base to be very honest with you Patrick, but in fairness we know, so for example we know that people with chronic lung disease get more breathless when they eat, because you get blood diversion to your gut and actually that removes, because your oxygen levels are lower, that removes

Patrick Obolgogiani (47:28.383)
Sure.

Aashish Vyas (47:50.656)
blood to your vital organs so you you're still going more after food. And we know that in fairness that inability to breathe effectively also impacts on your digestion and your capabilities of digesting effectively. And also we know that people with severe lung disease have respiratory cacaxia so they work so hard to breathe that they consume, they're in a positive catabolic state.

So they chew up more energy than they can take in orally. So they are actually at a point where they are continuously in a starvation mode. So we know that, you know, we know looking at it that processes of activity which cause breathlessness may have an impact on your nutritional status. You know, we know that the more harder you work,

the more nutrients you break up. So when you look at athletes, have processes, don't they? They replenish not only vitamins, but they replenish minerals like magnesium and potassium and such like in their diet because they sweat it out, they work hard. But that's all about working hard. And some of that is related, if you've got respiratory disease, to the ability that you're just having to physically work hard to breathe.

Patrick Obolgogiani (49:17.853)
Yeah. Yeah, super fascinating. It's like everything impacts everything in our body. But seems like this could be one of those levers, as you mentioned, we have control over, which then helps all those other things underneath that. Maybe one thing we haven't discussed, but I thought might be interesting to just touch on at least briefly is the the COVID and impact it had because I read somewhere that

what's called a long COVID which I actually don't know how it's defined, but it's, guess, the things that are the impact of what COVID had on people, but then it continues having symptoms, particularly when it comes to respiration. And I'm just curious to hear, like, have you seen that still ongoing, even now in 2025? And if yes, like, what are the ways people can combat that, like, to live a full life when they have it?

Aashish Vyas (50:11.046)
Yeah, gosh that's difficult isn't it. So my unit, so we run a respiratory high dependency unit. At my hospital when COVID occurred we, as part of department health assessment, we had some of the lowest death rates. So we had a unit whereby people were not intubated but non-invasively ventilated. Some of my team did some of the seminal work around.

what pressures people needed and the oxygenation delivery to keep people alive through those acute COVID periods, especially before the vaccine became available. And we noted that COVID was a systemic disease process. So people had blood clots a lot in the first wave where the bloods were thickened and we were looking at anticoagulation pathways and such a lot. We knew that people had severe confluence.

shadowing very often being asymptomatic, but then they became symptomatic within their lungs. knew from the data that was coming out China that people had heart disease. So we knew COVID was not a lung disease, but a systemic disease affected nearly every organ, predominantly through an inflammatory process, which caused huge amounts of damage, including your central nervous system. I think what we were not prepared for was a sequelae of COVID.

We were thinking about people with fibrotic lung disease or impacted myocardiums, but actually the outcome of long COVID and the impact of that on many individuals has been documented over many years. It's fair to say that the investigations, the follow-ups, the diagnosis of long COVID has not

probably been where it needs to be globally. I don't think people who've had long COVID have had a fair shot. I don't think nuns have been put into the definition of it, the causation of it, the treatment of it, the accessibility to treatment of different presentations of it. And I think therefore, especially in our country, you you look at the world around you, people have struggled with outcomes.

Aashish Vyas (52:33.457)
I think there's been an undoubtedly psychological outcome of COVID, both acutely and chronically. I think many people have never witnessed the potential of losing life and their own life at an early age through no fault of their own, but by picking something up. I think people have psychologically been scarred by the impact of it and of being so unwell. And I don't think there's been much help for those.

So long COVID in many ways is a multifactorial thing to many people. There are definitions of it, but I think people interpret it in different ways. I think people interpret it as a sequelae of that pandemic, whether they were badly impacted or the impact it's had on their wellbeing after that. And I think, but there are undoubtedly people who have increased fatigability, cardiac dysarrhythmias, who've got significantly

Patrick Obolgogiani (53:08.988)
Mm-hmm.

Aashish Vyas (53:32.818)
breathlessness in the presence of normal lung physiology. And one of things we have to understand about physiology that we undertake, it is limited. know, the lung physiology that we take in modern medicine doesn't give you all the answers. So it's wrong to think that you come to a lung function unit and you do some glowing testing and it will give you a diagnosis.

because there is undoubtedly a cohort of patients, it will not give you a diagnosis, but you see patients who are symptomatic and clinically have a disease process, which a physiology does not prove. In the vast majority, it will do that. It will give you an idea of diagnosis, may give you an idea of severity as well, but not in everyone. And we know that we've had individuals with normal lung physiology, for example, but when they've done helium MRs and stuff like that, they've shown...

significant vascular abnormalities affecting gas exchange. So I think when you extrapolate that into the long COVID process, there is undoubtedly a group of individuals that struggle with fatigability, which is muscle and oxygen delivery and delay to death. There's individuals who have developed abnormal breathing patterns, so breathing pattern disorders, which our physiotherapists have worked with to try and resynchronize how they breathe.

Patrick Obolgogiani (54:52.474)
Hmm.

Aashish Vyas (54:57.455)
So actually the physiology is normal, but actually when you look at the way they breathe, it's become abnormal. And that's because they've had an acute viral insult, or maybe a secondary bacterial insult to their lungs, which has rearranged how they breathe normally. rather than having an expansion of their lungs and a lowering of their diaphragm, which produces a huge vacuum within your lungs to suck air in, you've become asynchronous. So your breathing's become abnormal.

Patrick Obolgogiani (55:14.224)
Hmm.

Aashish Vyas (55:25.763)
And the only way we've been able to do that and understand that currently is by our physio seeing them. And we know that after viral insults, sensitization, development of disease, post-like asthma increase. So I think in people with that, and then there's the whole issue of brain fog, fatigability, poor sleep, and there are more unknown questions. So now a few years down the line,

Patrick Obolgogiani (55:40.036)
Right.

Aashish Vyas (55:53.861)
We don't see patients currently being admitted into our high dependency units, high intensive care units with acute COVID. The presentation of long COVID is less frequent to our front door, so we don't see as much of it. I think people have rehabilitated, a lot people have improved, not everyone, but significant people have had time for the body to recover. The body does recover itself, which is a miracle that it performs on a regular basis. So I think...

Patrick Obolgogiani (56:07.546)
Mm-hmm.

Patrick Obolgogiani (56:12.484)
Yeah.

Patrick Obolgogiani (56:20.836)
Amazing.

Aashish Vyas (56:23.897)
I think we see less long COVID coming through the front door. There's no doubt about it. think individuals have found long COVID units where they've tried to find practitioners. And I think there is a proportion of people who have given up so they don't come and see clinicians anymore because there is very little data, there's very little treatment options, and actually there's very little for them to access to help them currently.

Patrick Obolgogiani (56:40.409)
Right.

Aashish Vyas (56:52.494)
And the question realistically is a lot of us don't know exactly what pathophysiology we're trying to sometimes deal with because there's so many symptoms in some far patients.

Patrick Obolgogiani (57:03.46)
Yeah, I mean, I sensed when you started talking about COVID, there was this sadness in your voice. I can only imagine what those years were like.

Aashish Vyas (57:05.84)
I mean the secrecy of it. The secrecy of it has been...

Aashish Vyas (57:16.462)
Yeah. So honestly, those, were initially scary because we were going into the respiratory concerns and our nurses in particular, our physios in particular, doing secretion management. So we just did not know where we were going into. and, and, you know, we all, mean, I made sure my rules were sorted and stuff like that because I didn't know what was going on and the world and we, PPEs were desperate and stuff like that. And actually in hindsight,

Patrick Obolgogiani (57:17.646)
your perspective.

Aashish Vyas (57:46.257)
People like myself were well protected because we had, you know, even dealing with acute COVID patients, we had masks and gloves and such like it was our bus conductors, our porters, you know, the people who dealt with our day-to-day populations without any protection who were really at risk, you know, and it was poor. It was a disease that impacted the poor more than anyone else because you live in the housing together, you live on top of each other, you have to take public transport.

You don't have the luxuries of working from home very often. So those individuals had high infective burden exposure. So there is a sadness in the world because it shows a disparity within people who are vulnerable and who aren't. It also, there is sadness because actually as clinicians we try to do the best we can, but I think as soon as the acute phase went away, those individuals who are sometimes and continue to be impacted haven't probably been

treated as well as they should have done. And some of them always feel that some, it feels sometimes that there is a population globally that have been left behind.

Patrick Obolgogiani (58:58.201)
Maybe to end on a more positive note, if you think about someone who's listening who, let's imagine they don't have any respiratory disease, they're generally healthy, maybe a little bit out of shape as most of us are. But what is your advice for them when it comes to, if you think about like, nutrition, we all have these kind of clear guidelines like eat vegetables, eat enough protein, there's like pretty clear guidelines. Everyone knows kind of roughly what to do, the question is, do we actually do it?

But I think with breathing, it's a bit less clear, like what does good look like? If you could just kind of design almost like a protocol for a normal human out there, like what would that look like from a breathing perspective?

Aashish Vyas (59:41.081)
Gosh. So live well, that's the most important thing. Yeah? We've got finite time in the world, live well, yeah? Physically and mentally and spiritually, live well. I think that's really important, isn't it? So I think, but the question then is what does live well look like to you and I and to anyone else out there? Because we have all different ideas of what living well is and we have different proportions of our spirituality.

Patrick Obolgogiani (59:48.748)
Ha ha.

Aashish Vyas (01:00:09.487)
psychological well-being and a physical well-being. I think understand your body is really important because we are all made of different physiological stuff. know, ectomorphs, endomorphs, know, some of us are never meant to be skinny models, and some of us are going to carry a bit more bulk, but that's your life, but you can do stuff that other people can't.

You can move boulders for example where other people struggle with that, you have a strength in there. So I think what I would suggest is to understand what your physicality is. So we now have things like Apple watches that give you heart rates, that you can do an ECG on, tell you abnormal heart rhythms and stuff like that. Actually we have mindfulness in our watches and our phones, so we're moving that way. We have patches which talk...

talked to you about your glycemic well-being. Actually, we went through this initially, didn't we? We talked about how important breathing was to centre you. We did that two or three deep breaths in. What does that do to you? How do you feel after you've slowed everything down, you've taken two or three deep breaths in, you found your pulse rate reduced, you found the muscle tension reduced in your body, you found that there was more clarity of thought, you felt more relaxed. Those are all physiological...

that go on in your body, which effective breathing allows you to do. So actually, if we can have technology that allows us to understand how to control your breathing, how to make your breathing the central pivotal part of where you are, almost it's your yoga teacher with you all the time. Now don't think you probably can do it through a wristwatch because you need something on your chest.

which is non-intrusive but allows you to be effective. But I think if we can do that, even if it's not all the time, it may allow us to control ourselves. Imagine you're really head up, you've had a confrontation and your watch goes off saying, you need to slow your breathing down. What happens when it does that and you listen to it? What does that do to you? What does that do to confrontation? What does that do to you? And what does that then look like in the evening? Are you still...

Aashish Vyas (01:02:35.79)
kind of like angry or have you calmed down because you've been able to stop that earlier? What does that do to you long term being able to do that? What does being able to breathe effectively, so we all breathe, but do we all breathe effectively? And I don't know the answer to that. I would argue that my clinical experience is that not all of us breathe as well as we should do. Even the best of us don't. There are times when we can breathe more cohesively, more coordinated.

So the question then becomes, is if we can understand how to breathe more effectively, does that allow us to exercise more efficiently? Does that allow us to be more calmer at times? Does that allow us to be centered more? And does that allow us to be well at this moment in time? And if you're well at this moment in time, and you can carry that on for five, ten, fifteen, twenty years time, what does that do to your brain?

What does that do to your heart? What does that do to your blood pressure? What does that do to your kidney function? And I go back to the yogis, know, of all... To me, they understood something very kind of like essential to well-being, that actually yoga is a part of many people's lives because it allows you to center your ability around your breath pattern.

and your breath pattern then allows you to centre your physicality and your wellbeing. And it's not just about improving your wellbeing with regards to exercise, but it's about the whole physical journey and the psychological journey that you go on. So to me, when you're thinking about the future, you're thinking about yourself as an individual, you're thinking about what can we do, what can technology do, what can...

If we can understand how we breathe, how we can improve our breathing, what does that do to you as human being?

Patrick Obolgogiani (01:04:46.006)
I think a beautiful way to start closing. Aashish, thank you so much. Every time I talk to you, I feel like I learn a lot and I'm sure we'll do a round two you at some point. But for now, thank you very much for joining us today. And for everyone listening, we'll be definitely adding a few show notes. You can check, for example, the Elite Breathlesness Lesson Clinic and a bunch of other things we've mentioned there. But thank you Aashish for what you do.

Aashish Vyas (01:05:12.396)
Thank you Patrick, thank you for having me, it's been a pleasure.

Patrick Obolgogiani (01:05:15.712)
Cheers.