Struggling to Breathe

Asthma is on the rise – in 2010 the CDC indicated there are 25.7 million people in the US living with asthma, and they indicated they expect an increase of 15% per decade (1). That’s a lot of people who are struggling to breathe and if your studio is like mine, you’ve seen an increase in singers who are dealing with this issue.

What singers with asthma have shared with me: they struggle to get through phrases, feeling like they are running out of breath. Higher notes feel harder to hit and to sustain. And, when their asthma is active, singing at all can feel like an impossibility.

Asthmatics have differences in breathing patterns, ribcage position and mobility as well as quality of  speaking voice and singing voice.

What is Asthma?

Asthma is defined as a chronic disease in which the airways can be inflamed, constricted and lined with too much mucus during an asthma attack.

The symptoms of asthma can be triggered by a number of stimuli including: pet dander, dust, pollen, tobacco smoke, emotional stress, cold air, exercise, fatigue, infection or food.

Symptoms of an asthma attack include coughing, wheezing, and shallow, fast, labored breathing as well as a rapid heart beat.

Asthmatics also have a greater likelihood of experiencing reflux, rhinosinusitis, sleep apnea, and they are more likely to experience anxiety – much more on this in a bit.

Medical management of asthma includes both bronchodilators and corticosteroids. Bronchodilators are ‘rescue’ inhalers, like Albuterol, used to bring quick relief of the symptoms of an asthma attack. Corticosteroids, like Prednisone, are used to manage the chronic inflammation that many asthmatics experience. As with most medicines, both types of treatment carry risks/side effects. Rescue inhalers can mask an increase in chronic airway inflammation and therefore mask the severity of asthma when they become overused. Corticosteroids can reduce the need for rescue inhalers, but can cause hormone changes, weight gain, glaucoma and bone loss as well as hoarse voice and thrush.

Many singers with asthma know to rinse their mouth out after using an inhaler to help their voice function a bit better.

To be clear, I am not advocating in any way, shape or form, abandoning the medical management of asthma. What I would like to suggest is there are some practices you can engage in that can help you manage your asthma, change your experience of breathing and how you experience your voice.

When I was first researching asthma back in 2008 I was fascinated to see that reflux, sinusitis and anxiety were all factors that were frequently concurrently present. To me, that suggested that a whole body approach was going to be an important one in managing this condition. Diet, stress management, weight, movement and general health all need to be considered in the treatment and management of the disease.

We know the breath is intimately linked to anxiety – when we get anxious the breath becomes higher and shallower. There is no doubt in my mind that feeling like you can’t breathe is an anxiety producing situation! It isn’t clear which came first, anxiety or asthma, and in some ways it doesn’t matter, we know the two go hand in hand. One of my goals in working with singers with asthma is to help them break the cycle of anxiety and breathing.

Working with Asthmatics in the Studio

Here is my action plan for working with an asthmatic in the voice studio. It is built on the following: Awareness, Skill Building, and Implementation. That process is rarely linear but it is a combination of those three areas that helps singers find success.

  1. Do an extensive intake questionnaire so you know from the first meeting what all the factors are in terms of asthma, allergies and acid reflux, anxiety and medications along with how much they are moving throughout the day.
  2.  Complete a breathing assessment in the initial lesson. Asthmatics are classic ‘over-inhalers’, meaning they are taking in more air than they are letting back out (not hard to see how that would impact singing, right?!).
    1. Within the assessment discover the breath ratio and explore mobility of the ribcage. Very often it is ‘stuck’ in the inhale position (called ribcage flare) and part of the work they need to do is to learn how to move the ribcage on the breath in AND the breath out.
  3. Give the singer the task for the week between when they will see you next of observing their breath in different situations – low stress, high stress, hanging out with friends, speaking in public and private situations, while they are singing, in the morning and at night.
  4. In the studio begin the lesson with gauging where the breath is that day. Use the first 5-10 minutes to do some kind of breath work to help balance the breath. ** DO NOT do this if they are symptomatic.
  5. If they are symptomatic begin here. If they are not, do this next, and incorporate it into vocally warming up. Use postures that target the thoracic spine, ribcage and diaphragmatic ability as well as deep relaxation through forward bends, spinal twists and psoas release.

If you have a singer you are working with, or you are a singer with asthma and I would like some support on your journey, don’t hesitate to reach out!

  1. https://www.cdc.gov/asthma/impacts_nation/asthmafactsheet.pdf

Breath Holding

Have you ever wondered if you or one of your singers is a breath holder? It is more common than you might think and can be one of the factors contributing to vocal fatigue, tension and increased effort in producing the voice. While there may be pathology on the cords that contributes to these issues too, many singers will get a clear strobe showing vocal cords that look and seem to function perfectly well, yet they are experiencing issues.

Breath holding can be a long term habit or it can arise as a result of a particularly stressful experience or a change in breathing resulting from an upper respiratory infection. (I write this as someone who was a breath holder as a result of a very stressful time in my life – I was literally holding my breath waiting for the next bad thing to happen, but I resolved it with time, awareness and practice.) How it came to be is almost beside the point, if it is happening we need some strategies to resolve it.

Physiologically, when we hold the breath back, there is a change in the way to vocal cords function, such that they are restricting the airflow. In the people I have worked with I have found there is also a change in the function of the musculature of the upper body that restricts motion of the parts that need to be moving (muscles of respiration, abdominal musculature, joints, tissue of the lungs etc.) – often their ribcage is lacking motion in at least 1 plane. I was also someone who carried a fair amount of constant engagement in my abdominals and needed to find ways to release those so I could turn on my reflexive core.

How do you identify breath holding in a singer? For one, you can watch the ribcage and abdomen while they breathe – always ask yourself is there movement and what is the quality of it? Do this for both the inhale and the exhale. I like to assess breath while the person is just breathing, while they are speaking and while they are singing. What you may hear (you probably won’t hear all of this in one voice, but you might hear a combination of these things) is an audible intake of air, a glottal at the beginning of a word, a quality of pushing to the voice, a phrase ending with lots of vocal fry and sometimes that little puff of air coming out after they’ve finished the phrase. The person might report that their throat is sore, it feels tight and the voice just feels plain effortful. I was that person with the extra effort going on, especially at a tessitura that put me near the passaggio, D5-G5.

The solution comes from a whole body approach that uncovers stress response patterns and creates an exhalation that is free. Using awareness practices we can ask students to begin to notice their breath in stressful situations. We can all relate to watching something like a down-to-the-wire sporting event moment where we hold our breath in response, or watching a movie where a character is about to meet his untimely end and we know it is coming but he doesn’t. What do we do in those situations? We hold our breath. If they are breath holding in response to stress, simply raising their awareness and remembering to keep breathing is a huge step in the right direction.

We can begin with breathing practices of yoga to give us some information about our breathing patterns. These practices are particularly valuable when taking time to explore and assess your habits. Breath Ratio is a great place to start. Then move into extending the inhale and exhale to both be long and smooth – always staying in your pure range – where there is no pain, strain or compensation. When the body fights the extension of either, that’s your edge and you want to work within that range rather than trying to push past it.

However, I haven’t encountered too many pieces of music where you can get 2 or 3 solid measures of rests in between each phrase AND we need to be able to phonate while we exhale, not just exhale. So we have to be able to incorporate breathing and singing.

Using a 10 minute practice that combines breath and physical motion, targeting the muscles of the torso can do wonders in liberating the breath prior to singing. Then, moving into singing phrases out of context to implement the new breathing patterns and slowly decreasing the length of time you are taking to inhale between phrases until the body can do so in a liberated way has been a solid approach for the voices I’ve dealt with.

If you are interested in exploring your breath more, set up a free 30 minute consult and let’s talk about how to get your breath flowing more freely!

Head, Shoulders, Neck and your Voice

Physically, you need your larynx to be aligned just right for your breath to flow optimally and your voice to sound at its potential.

However, what do you you a lot every day? Type on the computer, drive, play piano or other instruments, hold children, carry heavy bags, slump in a chair…any of those sound familiar? Each of those activities pulls your head in front of your shoulder line, adding weight to your neck and pulls your arms out in front of you, putting your arms and shoulders into internal rotation, pulling your shoulder blades away from your spine.

The result? Tight upper chest muscles, weak rhomboids,  a neck that is strained by an additional 10 lbs for every inch that the head sits forward, a voice that isn’t set up to let little muscles do little work and big muscles to do big work, breath that can’t flow freely and posture that looks like this:
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OW!  I’m giving a bit of an extreme example, but you get the point. Though you are primarily concerned about your voice, the long term effects of this position are a bit grim. This misalignment is linked to impingement of nerves in the neck, migraines, eye tension, breathing problems, endocrine issues as well as rotator cuff injuries.

Your situation might not be at a point where you feel pain in your neck and shoulders, but if you don’t address it now, it will get there. If you aren’t sure if your upper chest is tight, try palpating just below your collarbone from your sternum out toward your shoulder and see if you feel some pain. That’s one of your pec muscles – in an extreme situation, you might feel the pain radiate through to the muscles around your shoulders in the back. Then, extend your arms out wide and notice what you feel down your inner arm. You will feel how tight the inner arm is.

Honestly, I was shocked when I did both of these things at just how much sensation (sounds nicer than pain, right?) I felt across the top of my chest and all the way down my inner arm and into my fingers. I often have neck pain. The combination of a water skiing accident as a child and being rearended in my twenties with my head turned over my left shoulder left me with my 2nd cervical vertebrae out of alignment. My neck muscles spasmed after giving birth to my second and in the last two years the pain would sometimes get pretty intense, feeling like my head was in a vice and all I wanted to do was close my eyes and lie down. My vocal symptoms included not being able to sing the really, really high notes that I had been easy before.

Fortunately, I started exploring things through my yoga practice and have managed to keep the pain and tension at a minimum, re-finding some high notes and making my life much, much better.

Here are a few things you can do and your voice, neck and shoulders will thank you for it.

First, find your hyoid bone in your neck and imagine it moving back and slightly up, pulling your neck and head back with it.

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Then, cup the back of your head with your hand and press the head back into your hand.

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This will get you on the road to moving your head and neck back into alignment. It will probably feel pretty foreign at first and you’ll have to develop a sense of how it feels when it is in the right place so you can be aware of when it isn’t.

Taking it to the next level to really create a long term remedy involves some great yoga-based stretches that I’ll share in another post. Together, these go a long way to undoing tension and pain in the neck to help your voice function at its best!