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The breathing thinking functioning (BTF) approach (Leaflet 1)

Patient information A-Z

The information given below is designed to help you manage your stable long-term breathlessness. If your breathing is getting worse, or you are experiencing breathlessness as a new feeling, it is important to seek medical advice from your GP.


Breathlessness can be a difficult symptom to live with, but there are ways you can reduce its impact on your life. Sometimes, the ways we try to cope can unfortunately worsen the feeling. An important first step is to understand how breathlessness develops. This understanding can then lead to you finding ways to help your breathing.

The breathing, thinking, functioning model

The breathing, thinking, functioning model
Diagram showing the three areas: Breathing, Thinking, Functioning (BTF)

The sudden and distressing sense of breathlessness is very useful when there is an immediate threat to survival, such as suffocation. A threat to survival needs to cause a rapid emotional response, such as terror, that leads in turn to a coping behaviour such as breathing quicker and deeper, and running away. However, when people have chronic conditions that affect the heart and lungs, this coping behaviour is less helpful and can cause development of emotions and behaviours that actually make the breathlessness worse.

The control of breathing is complex, and so too are the mechanisms which cause us to feel breathless. How the feeling of breathlessness is created is not yet fully understood. However, we know that breathlessness can impact on our thoughts, the way we breathe, and how we go about our daily activities.

We have highlighted these three areas as ‘Breathing’, ‘Thinking’, and ‘Functioning’. In each of these areas, specific unhelpful emotions or behaviours develop and lead to three linked vicious cycles that prolong and worsen the feeling of breathlessness.

1. Breathing

Being breathless can often lead to the development of an inefficient breathing pattern. We feel like we need to ‘get more air’ so take big breaths in. We tend to pant, with small breaths coming in and out of only the top part of our chest, with our shoulders hunched. The muscles that support breathing, particularly around your neck and shoulders are over-used in an attempt to pull more air in. This increases the effort of breathing and makes it less efficient.

In conditions like chronic obstructive pulmonary disease (COPD), there is not enough time for the lungs to empty when breathing fast. The next breath in starts before the lungs have fully emptied. This causes breaths to stack on top of each other, which makes the chest over-expanded and makes the breathing feel even less comfortable. This leads to an increase in the effort needed to breathe and makes recovery longer.

There are things that can help improve breathing. These include breathing techniques, cooling the face with a fan or cold flannel, and finding a comfortable position.

2. Thinking

Feelings of breathlessness almost invariably lead to a sense of anxiety or panic. The areas of the brain involved in the feelings of breathlessness also process our emotions. Feeling anxious or frightened will directly increase breathlessness. This well-recognised vicious cycle can lead to panic, and faster breathing. When we are anxious, muscle tension increases, which makes breathing more difficult.

Things that can be helpful include learning to relax, gradually slowing your breathing, and finding a calm state of mind. You can try the relaxation tracks on our website

3. Functioning

Breathlessness is an unpleasant sensation. Therefore, it is natural to try to avoid it by reducing our activity levels. However, this leads to all our muscles becoming weaker. These weakened muscles use oxygen less efficiently and are not able to do their job as well, which makes the breathlessness worse. Our family and carers try to help by doing the activities that we might otherwise have done, thereby further reducing our activity.

It can help to understand that getting moderately breathless by being active is not harmful and can actually improve breathlessness over the longer-term. Regular exercise or walking more can also help.

Contacts and further information

Other leaflets in this series will go through these techniques in a bit more detail.

For further help or advice contact the Breathlessness Intervention Service on 01223 274404 09:00 (9am) to 17:00 (5pm) Monday to Friday.

We are smoke-free

Smoking is not allowed anywhere on the hospital campus. For advice and support in quitting, contact your GP or the free NHS stop smoking helpline on 0800 169 0 169.

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Contact us

Cambridge University Hospitals
NHS Foundation Trust
Hills Road, Cambridge

Telephone +44 (0)1223 245151