Typically, when people first begin to experience shortness of breath or dyspnea on exertion (DOE), they either find ways to modify the activities that cause them discomfort, or they simply avoid them altogether. While this may seem like the safest and most reasonable course of action, lowering your activity level can worsen the situation, causing you to become weaker and shorter of breath over time, until even life’s simplest tasks, like showering or getting dressed, can become difficult thanks to that miserable SOB (shortness of breath).

Let’s use stair climbing as an example. In our small town of New York City, our subway steps are not built for comfort. Rather, they are designed for efficiency, which here in New York City means “space-saving.” As a result, they are usually longer, higher, and steeper than the stairs in most people’s homes or even those you might encounter in a restaurant or movie theater. Add to this scenario, a mob of type-A New Yorkers during rush hour, and the situation more closely resembles the running of the bulls than a daily commute. Patients frequently tell me that they don’t take the subway anymore because they can no longer climb the stairs. Instead, they take the bus or taxi, or Access-A-Ride, (but that’s a whole ‘nother story, altogether).

Again, using our stair-climbing example, think about how much less activity a person will get if they switch from taking the subway to taking the bus. Let’s say they usually commute to work five days per week and have two flights of stairs going to work and two flights coming back home. That’s 20 flights of stairs per week—80 flights per month—and nearly 1000 flights per year.

It isn’t hard to imagine that if you climb 1000 fewer flights of stairs this year than you did last year, your body will naturally (or more accurately, unnaturally), become less conditioned, and you will likely experience an increase in your shortness of breath. Incidentally, these negative adaptations to inactivity can happen even if you don’t have a pulmonary disease.

Now, here is a concept that is very important to understand. The inability to climb stairs can be affected by many factors including shortness of breath, cardiovascular disease, muscle weakness or fatigue. It can even be caused by anxiety, which, incidentally, is both increased by shortness of breath and increases shortness of breath (another vicious cycle we want to break). Or it can be cause by osteoarthritis or spinal stenosis or something else altogether.

But, as you become more deconditioned, one consequence is that your body does not use oxygen as efficiently. As a result, you then start to feel short of breath at lower levels of activity. Then, you start to avoid those (even lower level) activities, and so on and so forth. Again, this is called the dyspnea cycle or dyspnea spiral and our goal is to help you break that cycle by teaching you more effective breathing techniques—and teaching you how to exercise most effectively every time, so that your body becomes more efficient at using oxygen and you, more fit and less short of breath.

For many people, their symptoms can get so bad that the activity doesn’t seem possible or worth the effort anymore. Depending upon where you live and the resources available to you, this scenario can drastically limit the things you can do, the places you can go, and the people you can see. We will also discuss some of the challenges of portable oxygen use later in the book.

Some of my patients can map out the city by where there are steep (or in some cases, not so steep) inclines or hills. Others can map out the city based on where there are places to sit down and rest, and still others, by the availability of public restrooms. They take the easier routes whenever possible and avoid hills like the plague. But as you might have guessed, all the muscles that they use to walk uphill become deconditioned, and they now start to feel short of breath at even lower levels of activity (e.g., walking on flat surfaces). Sound familiar?