Breathing during panic: what actually helps and why a paper bag is not the answer

“Just tell me how to breathe.”

I hear this from almost everyone who comes to me because of panic attacks. It usually arrives with a kind of urgency, as though there were a correct combination of inhales and exhales that stops an attack, and I keep it in a drawer. I understand where it comes from. When it feels during an attack as though you are running out of air, breathing is the only thing in your body you can move on purpose. Everything else – the heart, the sweating, the shaking, that sense that you are about to collapse – happens without asking you.

The answer is both simpler and more annoying than people want. Breathing does help, but not in the way it is usually taught. And the paper bag someone saw in a film and now carries in a handbag is not the solution – in some situations it is dangerous.

What actually happens to your breathing during panic

When the alarm goes off, the body prepares blood for the muscles. Part of that preparation is faster, deeper breathing. That makes sense if you have to run from something. It makes no sense if you are sitting in a meeting or standing at a checkout, because the muscles never use that oxygen.

The result is hyperventilation: you breathe more than your body needs. The mistake almost everyone makes here is assuming this is about oxygen. It is not. You have plenty of oxygen during an attack; blood saturation is practically always normal. What changes is carbon dioxide.

Carbon dioxide is not merely waste. It regulates the acidity of your blood. When you blow off too much of it by breathing too fast, the blood becomes more alkaline – we call this respiratory alkalosis. And this is where what people describe as “the most frightening part” begins.

Why it feels as though you are running out of air when you have too much

Alkalosis does three things you feel immediately.

First, the blood vessels in the brain narrow. Blood flow through the brain can drop by roughly a third. Hence the dizziness, the blurred vision, the sense of things receding, and that unreal feeling I wrote about in the piece on what happens in the brain during anxiety.

Second, calcium binds more tightly to proteins in the blood, which makes nerves more excitable. Hence the tingling in your fingers and around your mouth, and the cramping in your hands.

Third – and this is the treacherous one – under alkalosis haemoglobin holds onto oxygen more tightly and releases less of it to the tissues. The Bohr effect, named after the Danish physiologist who described it in 1904. So: there is plenty of oxygen in your blood, and the tissues get less of it. The body reads this as a shortage of air and tells you to breathe even more deeply. Which worsens the alkalosis. Which increases the feeling that you are running out of air.

That is a loop. And it is exactly why the advice “take a deep breath” often does harm.

Where the paper bag idea came from

The logic was reasonable. If the problem is too little carbon dioxide, let the person breathe their own exhaled air back in and recover it. The idea is at least seventy years old and, through films and television, settled into general knowledge so firmly that even someone who has never had an attack knows it.

The physiology is not wrong. A bag really does raise blood CO₂. The trouble is everything else.

Why the bag is not recommended

The first and most serious reason is diagnostic. Breathlessness, chest tightness and the sense of not getting enough air do not belong to panic alone. A pulmonary embolism starts the same way. So can a heart attack, an asthma flare, a collapsed lung. If you put a bag over the face of someone who genuinely does not have enough oxygen, you reduce the little they are getting. The medical literature describes cases where this ended in death – people given a bag on the assumption that “it is only panic”, when in fact they were having an infarction or an embolism.

The second reason is that in a healthy person the bag works less well than it appears to. Measurements have shown that a paper bag gives you a relatively small rise in CO₂ and, at the same time, a noticeable drop in oxygen – not quite the combination you were after.

The third reason is psychological, and it is the one I see most often in my room. The bag becomes a talisman. The person will not leave the house without it, and this entrenches the panic: the body’s message is “without the prop, this would have been terrible”. The same mechanism that narrows a life in catastrophising is at work here too.

So I do not recommend it. Not as first aid, and not as a tool for home.

What to do instead: less air, not more

If the problem is that you are breathing too much, the answer is to breathe less. Not deeper – less.

In practice that means a slower rhythm, a shallower inhale and a longer exhale. Concretely: breathe in through the nose, count to four. Breathe out through slightly parted lips, count to six. Do not fill your lungs to the top. Do not pull hard. If it feels as though you are not getting enough air, that is precisely the false signal your body is sending – and this rhythm is what slowly settles it.

Why the longer exhale? During exhalation the parasympathetic influence on the heart increases. Heart rate falls on the out-breath and rises on the in-breath. Lengthen the exhale and you spend more time in the part of the cycle that slows the heart. Measurably, this shows up as greater heart rate variability. A rhythm of around six breaths a minute is where this effect is largest for most people.

Ten such cycles take about a minute and a half. That is enough to notice a difference. It is not enough to make the attack disappear – and it is important to say so in advance, or you will declare the exercise a failure.

Two details I frequently correct. Breathe with your belly, not your chest: if your shoulders rise on the in-breath, you have pulled too much again. And do not count fast. Under stress people count so quickly that “four” is gone in a second and a half, and then wonder why nothing helps.

When to practise, so that it works at all

The biggest mistake is trying slow breathing for the first time in the middle of an attack. Working memory is narrowed then, your hands are shaking, you cannot remember the counting. An exercise you have never done while calm will not come to you in panic.

So: five minutes a day when you do not care. After coffee in the morning, on the bus, before sleep. The goal is not relaxation – the goal is for the rhythm to become so familiar that your body finds it without your help. When you then use it during an attack, you are not using a technique, you are using a habit.

In studies where people had their exhaled carbon dioxide measured during training and shown back to them, improvement was most closely tied to the rise in CO₂ – not to how relaxed they felt. Elegant evidence that the mechanism runs through respiratory chemistry rather than through “calm”.

Three sentences worth keeping to hand

Alongside the rhythm, it helps to have an explanation ready for yourself. Not reassurance – an explanation. “I am not running out of air, I have too much of it.” “The tingling is calcium, not a stroke.” “My body is doing exactly what it was built for, only at the wrong moment.”

These sentences are not magic. But they are something that interrupts the second in which a sensation gets translated into “I am dying”. I wrote about how a thought can be separated from an event in the piece on cognitive defusion.

Where this comes apart: when breathing becomes a safety behaviour

Now for the part that argues against what I have written so far.

If you use slow breathing in order to prevent a catastrophe, you have simply swapped the bag for your breath. The difference is in the relationship, not in the technique. “I am breathing so that I will not collapse” is a safety behaviour, and in the long run it feeds panic, because the body never gets the chance to learn: the attack passed on its own, without my intervention.

Some research groups have for this reason removed breathing techniques from panic disorder protocols. Comparisons have shown that exposure to bodily sensations works as well or better, and that breathing exercises can even worsen the outcome for some people – precisely because they become a crutch. I wrote about the road in the other direction in the piece on the symptom as a message.

My dividing line is simple. Breathing as a daily exercise that lowers general arousal: yes. Breathing as a fire extinguisher you will not leave the house without: no. If the thought of simply sitting an attack out makes your chest tighten, we are in the second case.

When breathing is not the main player at all

There is also a group of people for whom respiratory chemistry is not the consequence but the trigger. The psychiatrist Donald Klein proposed that some people have an oversensitive “suffocation alarm” – a brain mechanism that monitors CO₂ and fires at levels that mean nothing to anyone else. This explains why inhaling air enriched with carbon dioxide reliably triggers an attack in these people and not in healthy volunteers. For them, the advice “add some CO₂” is especially misplaced.

And there are people whose main problem is not breathing at all, but lack of sleep keeping the nervous system on permanent standby. I wrote about that in the piece on arousal and insomnia. If you are sleeping five hours, every breathing exercise will work badly.

What about a doctor

If the attack was your first, if the chest pain was crushing and spread outwards, if you are over forty, smoke, have raised blood pressure, or have recently had surgery or been immobile for a long time – this is not material for a breathing exercise, it is material for an examination. Panic disorder is diagnosed only once physical causes have been ruled out, and a therapist cannot do that.

The same applies if the attacks follow a fixed pattern: always after a meal, always on exertion, always with the same medicine. Panic is capricious and likes to appear without order; a pattern that repeats with military precision more often points to a physical cause. The thyroid, heart rhythm disturbances and low blood sugar can imitate an attack well enough that the difference is invisible at first glance. I set this out in more detail in the piece on when to see a psychiatrist first.

What to remember

During a panic attack you are not short of oxygen – you are short of carbon dioxide, because you are breathing too much. The feeling of suffocation is the result of that loop, not its cause.

The paper bag is a bad idea: it raises CO₂ too little, lowers oxygen too much, and if a heart or lung problem is behind the symptoms, it is dangerous. It has no business being in your bag.

What helps is the opposite of what panic tells you: less air, not more. In for four, out for six, around six breaths a minute. Practise every day while calm, or there will be no exercise to reach for during an attack.

And watch your relationship to it. As long as breathing is a tool, it is useful. When it becomes the condition for leaving the house, it has turned into a new form of avoidance – and that is the moment to talk to someone about it.