Breathing during a panic attack: what helps and what doesn't

What to do during a panic attack

1. Stay where you are, if it is safe, and sit down if you can.
2. Breathe out first, slowly, through pursed lips, as if blowing on hot soup. Let your shoulders drop.
3. Breathe in gently through your nose for a count of about 4, then out for about 6. Keep the breaths soft and low in your tummy, not big gulps at the top of your chest.
4. Remind yourself that this is a panic attack, that it is not dangerous and that it will pass. Most last between 5 and 20 minutes.
5. Carry on breathing slowly until it settles, then rest before you get up.

If you have chest pain and you are not sure it is panic, especially if it is your first attack, you are older or you have a heart condition, call 999. It is always better to be checked.

Why breathing matters in panic

Panic and breathing feed each other. When you panic, you breathe fast and from the top of your chest. That blows off carbon dioxide, which causes tingling, light-headedness, a tight chest and a feeling of not getting enough air. Those sensations feel like proof that something is badly wrong, so the panic grows. Slowing your breathing, and especially lengthening the out-breath, breaks that loop. See carbon dioxide and over-breathing.

The trap is that “take a deep breath” can make things worse if it means big gulps of air. Slow matters more than deep.

Why not a paper bag?

Breathing into a paper bag was once standard advice, on the idea that rebreathing your own carbon dioxide would correct it. It can work, but it also lowers your oxygen. An emergency doctor reported three deaths in people who were given a paper bag for what was thought to be anxiety, but who actually had low oxygen or a heart attack. Slow, gentle breathing raises carbon dioxide safely without that risk.

What the research shows

Breathing retraining has long been part of cognitive behavioural therapy (CBT) for panic disorder. A 2018 analysis of 72 trials with 4,064 people tried to work out which parts of CBT matter. It found that breathing retraining made treatment more acceptable, with fewer people dropping out, but added only a small amount to how well treatment worked. The most effective ingredient was interoceptive exposure: practising bringing on the feared body sensations in a safe way until they lose their power.

A US trial of 41 people with panic disorder compared four weeks of breathing training, guided by a device that measured carbon dioxide in the breath, with four weeks of cognitive training. Both reduced panic symptoms by a similar amount, and in the breathing group the improvement followed the rise in carbon dioxide levels back to normal.

We grade the evidence for breathing exercises on their own as weak. They are a sensible first thing to try in the moment, and a useful part of treatment, but not a treatment on their own.

Getting help for panic attacks

If you have repeated panic attacks, or you are avoiding places because you fear having one, talk to your GP or refer yourself to NHS Talking Therapies in England. CBT for panic disorder works well, and you will usually learn breathing techniques as part of it. You may also find stress and anxiety and breathing pattern disorder helpful.