Settle: A Gentle Nose-Low-Slow Breathing Practice Sheet for Long COVID

Long COVID · Practice-informed · Practice-informed

A one-page breathing sheet. Step 1 is nose-low-slow breathing: breathe in gently through the nose, let the breath drop low into the belly or lower ribs, and let the out-breath be slow and a little longer, for 3 to 5 minutes once or twice a day. Step 2 is optional and later: in for about 4 seconds and out for about 6, roughly 5 to 6 breaths a minute. It includes a stop box and a practice log with before and after calm ratings. No trial has tested either step in Long COVID. Slow-breathing trials in other groups found benefit for stress and mood but no reliable change in resting heart rate variability, so the sheet is framed as a small optional skill and not a treatment.

Underlying mechanism: Nose-Low-Slow Breathing with Optional Resonance Breathing for Long COVID

What it helps with

  • Giving the client a simple, low-risk way to settle the alarm that can be used when already calm.
  • Keeping the practice optional, with a clear stop rule if dizziness, tingling or anxiety appears.
  • Showing the client what suits them through before and after calm ratings that are not a score to chase.
  • Offering a little more structure later without requiring it, because a fixed slow rate did about as well as an individually found rate in a recent trial.

How clinicians use it

  • Teach Step 1 in Session 3 and practise it for two to three minutes in the room, seated or reclined.
  • Frame it as settling the alarm and not as a cure, and do not promise changes in fatigue or heart rate variability.
  • Offer Step 2 in Session 5 only if Step 1 feels familiar and comfortable, and drop counted breathing if it feels like effort.
  • Tell the client they can skip the practice if breathing attention is hard for them.

Clinical Implementation Guide

  1. Practise Step 1 in the room for two to three minutes and agree 3 to 5 minutes once or twice a day.
  2. Review the calm ratings next session and ask what suits the client.
  3. Offer Step 2 only if Step 1 feels familiar, and say it can wait.

What the worksheet looks like

Settle: A Breathing Practice Sheet — worked example
DayStep 1 or 2MinutesCalm before (0 to 10)Calm after (0 to 10)
MonStep 1345
TueStep 1435

Clinical cautions

Never use breath holds, forced breathing or deep over-breathing. Stop and return to normal breathing if the client feels dizzy, lightheaded, tingly or more anxious. Take extra care with asthma, COPD, dysautonomia such as POTS, panic or a trauma history in which attention to breathing is distressing, and make the resonance step optional every time. This tool does not diagnose any condition and is not a substitute for individual face-to-face therapy or for emergency crisis support.

References

  1. Minjoz, S., Jeanne, R., Pellissier, S., & Hot, P. (2026). Psychophysiological effects of heart rate variability biofeedback versus sham biofeedback: A randomized controlled trial. Biological Psychology, 206, 109254. https://doi.org/10.1016/j.biopsycho.2026.109254.
  2. Sumińska, S., Rynkiewicz, A., & Szulczewski, M. (2026). Resonance frequency versus fixed 0.1 Hz breathing in HRV biofeedback: A four-week randomized comparison. Scientific Reports, 16(1), 22630. https://doi.org/10.1038/s41598-026-53333-6.
  3. Lehrer, P. M., & Gevirtz, R. (2014). Heart rate variability biofeedback: How and why does it work? Frontiers in Psychology, 5, 756. https://doi.org/10.3389/fpsyg.2014.00756.

Copyright and use in research

© 2026 Dr Richard Pomfret and Third Wave Therapy Tools. May be used in research with the author and site cited. Version 1.1, approved 21 October 2026, revised as the evidence develops.

Suggested citation (APA 7th edition): Pomfret, R. (2026). Steady Ground: A stepped, measurement-led psychological protocol for adults with Long COVID (Version 1.1) [Therapist guide and worksheets]. Third Wave Therapy Tools. https://thirdwavetherapytools.com/

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Steady Ground

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