Breathing Techniques and Meditation for Health Care Workers During COVID-19
Phase: NA
Conditions: COVID-19 Infection
Sponsor: M.D. Anderson Cancer Center

 
 
2020-0483 
 
 
Rev. August 19, 2020 
 
Breathing Techniques and Meditation for Health Care Workers During COVID-19 
PI: Santhosshi Narayanan MD  
Collaborators: Jegy Tennison, Yisheng Li, Balachundhar Subramaniam MD Dave Balachandran MD Smitha 
Mallaiah MS 
Senior Authors: Lorenzo Cohen PhD Eduardo Bruera MD   
Introduction:  
Pranayama is a term used to describe breathing techniques that are an integral part of yoga practice. 
Numerous studies have shown the benefit of yoga in healthy volunteers and cancer patients. (1,2, 3,4, 5, 
6, 7) The benefits range from decreasing inflammation as evidenced by reduction of inflammatory 
cytokines to improvement in immune system as evidence by increasing non-killer/NK cells. (8) In our 
own studies, we have shown evidence of yoga improving chemotherapy-related cognitive dysfunction 
and reducing anxiety in cancer patients and caregivers in addition to improving both their quality of life. 
(1,9) The pandemic COVID-19 has created chaos and distress for the entire world, especially for 
healthcare workers. Here we suggest a series of 3-minutes breathing or pranayama practices followed 
by 2 minutes of meditation – overall 5 minutes to complete. The purpose of this study is to determine 
the effects of web-based breathing techniques and meditation on lung health and building resilience 
among health care workers dealing with the COVID-19 pandemic.  
 
AIMS: 
Primary Outcome:  
To demonstrate the feasibility of a short pranayama or breathing techniques and meditation during 
Covid-19 pandemic. Feasibility will be defined as recruitment of 50 participants to the study within 2 
months and acceptance of the study defined as more than 50% of participants perceive the intervention 
as useful.  
Secondary Outcomes:  
1. 
To determine the adherence to the practice assessed as at least 50% of participants  implement 
the intervention for 3 or more times in a week by the end of week 1/day 7 (+ 3 days) 
2. 
To determine the change in resilience, perceived stress and psychological impact from day 0 to 
day 28 as measured by the Brief Resilient Coping Scale (BRCS), Perceived Stress Scale (PSS4), and COVID-
19 Stress among health care workers questionnaire 
3. 
To determine the changes in breath holding time measured weekly for 4 weeks 
4. 
To determine the differences in breath holding time between those who are adherent and those 
who are not adherent to the practice 
 
 

 
 
2020-0483 
 
 
Rev. August 19, 2020 
 
Background/Rationale:  
  
Current COVID-19 climate and stress on health care: 
COVID-19 is a war-like situation where health care workers (HCW) are faced with unprecedented 
challenges with the novel coronavirus global pandemic. Studies have been done examining previous 
experience with disease outbreaks and pandemics such as MERS-CoV and Ebola management and its 
effect on HCWs. (10,11) These studies suggested that although HCW’s ethical obligations propelled them 
to continue with their jobs, their perceived levels of stress were higher than normal. As a consequence, 
these HCW’s were also more likely to suffer from long term psychological effects.   
 
While the health care community has been exemplary under this enormous pressure, many health care 
workersare showing early signs of burnout in terms of anxiety, fear, ethical dilemma due to risks 
associated with coronavirus spread,  in the setting of limited resources such as medical and personal 
protective equipment. (12) To minimize the long-term negative effects of the intense stress, fear, and 
anxiety HCWs are experiencing at the moment, it is important to support them with wellness tools.  One 
such non-pharmacological and easily adaptable tool is a time-tested behavioral program that can help to 
build resilience, and that is yoga and meditation. Numerous studies have been conducted indicating the 
effectiveness of yoga and meditation as effective strategies to manage stress. In addition, there is a 
growing body of literature suggesting that even short-term meditation improves measures of attention 
and well-being. 
  
Breathing techniques: 
COVID-19 results in multiple respiratory symptoms and those with prior respiratory conditions are more 
vulnerable to infection with SARS-CoV-2 (the virus that causes COVID-19 disease). As such, learning 
techniques that help to improve lung capacity, volume and function may play a role in decreasing risk 
and simultaneously lowering stress levels. A short powerful stroke of exhalation and inhalation in quick 
succession with contraction of abdominal and diaphragmatic muscles helps to make full use of 
diaphragm and abdominal muscles in breathing. It also aids in removal of secretions from the bronchial 
tree, clearing up respiratory passages and the alveoli.  
 
Studies have shown improved ventilatory functions in the form of lowered respiratory rate (RR), and 
increases in the forced vital capacity (FVC), forced expiratory volume at the end of 1st second (FEV1%), 
maximum voluntary ventilation (MVV), peak expiratory flow rate (PEFR-lit/sec), and prolongation of 
breath holding time. (6,7) These practices have also led to increases in parasympathetic tone and 
decreases in sympathetic activation.  Importantly, participants engaging in yogic breathing practices 
report reduced stress, better quality of life, and improvement in multiple physiological and biological 
outcomes.  “Dog breathing” is one such yogic breathing technique that has been shown to improve lung 
volume and capacity, helps to reduce stress, and is relatively easy to learn and perform compared to 
other complex breathing/pranayama techniques requiring more extensive training and practice. The 
“Dog breathing” practice and meditation that will be tested in this pilot study were designed by 
Sadhguru, a Yogi and founder of Isha Institute of Inner Sciences. (13) The reason for choosing these 
practices are that it is short (less than 5 minutes), readily available free of cost, with clear instructions.  
 
Methods: 
  
Enrollment: 

 
 
2020-0483 
 
 
Rev. August 19, 2020 
 
MD Anderson Email will be used for advertisements at the hospital. Recruitment will also involve word of 
mouth, announcements, and flyers on social media and official websites of MD Anderson. 
 
Interested participants will receive a link where they can confirm their interest in the study and get 
detailed information of the study procedures. If they are interested in participating after receiving the 
email, they will be directed to REDCap where they will be asked a few screening questions to ensure 
study eligibility. Participants who are eligible will be directed to an electronic consent form. They will be 
enrolled into the study following submission of the evaluation of the consent process. Participants will 
be informed that their decision to participate or not to participate is entirely voluntary. Participants will 
have the ability to discontinue their participation at any time. 
 
Study Population:  
All employees at the University of Texas MD Anderson Cancer Center are eligible to participate.  
 
Inclusion Criteria: 
Participants must be able to read and understand English. 
Must be employed at MD Anderson Cancer Center.  
 
Exclusion criteria  
Epilepsy  
Brain tumor  
Brain aneurysm 
Pregnant or trying to get pregnant 
Brain bleeding in the past 1 year  
>70 years of age 
Recent abdominal surgery and not cleared to exercise 
 
Study Procedures: 
Subjects will be sent a link to the video with instructions. They will also be requested to maintain weekly 
activity logs to document their daily practice. A survey will be completed at study recruitment, before 
receiving the video link, and then again 1, 2, 3, and 4 weeks after starting the breathing practices.   
 
Intervention:  
The practice will consist of a 3-minute breathing practice followed by a 2-minute meditation. The 
participants will be encouraged to practice at least once a day and ideally more often, especially first 
thing in the morning, anytime they are feeling stressed or have time to take a 5 minutes break from 
work during the day, and at the end of the day. 
 
Participants will be instructed to start the practice when somewhat hungry or have empty stomach.  It is 
not ideal to do these practices after meals. To begin, sit in a comfortable position where your spine is 
straight and your abdomen is not compressed. Some options include:  
• 
An upright seated cross leg position  
• 
A seated position on a chair with your feet flat on the floor, resting your hands on knees, palms 
facing down. 
 
Step 1: Shawna kriya (Dog breathing) 

 
 
2020-0483 
 
 
Rev. August 19, 2020 
 
To perform Dog breathing, lengthen your spine, inhale lifting your diaphragm by pushing your 
chest/ribcage out, keep your hands on your knees with palms facing downwards elongating your hands, 
open your mouth wide and stick your tongue out as far as it can go. 
Start panting the way a dog pants. All of the breathing will take place from the mouth while doing Dog 
breathing. Do not force any muscles to contract while abdomen will automatically contract during 
exhalation when you will pant like a dog. The inhales and exhales during Dog breathing or Panting Dog 
Breath should be even in depth, time and force. Participants will be instructed to do this practice for 21 
breaths.  
Step 2: Dog breathing with tongue rolled upwards  
Fold your tongue backwards as much as you can. Now inhale and exhale in the same way you did for 
Dog breathing. The mouth is opened wide; the tongue is rolled backwards to its maximum. Inhale and 
exhale through constriction in the throat and make the sound ‘HHHHHAAAA’ while exhaling as 
demonstrated in video. You will feel the touch of air in your throat. Participants will be instructed to 
perform this practice for 21 breaths. 
• 
While performing this practice, participants will be instructed to take a 15- 20 seconds break if 
feeling dizzy. 
• 
Participants will be instructed to not stress the body or overdo the exercise beyond capacity. 
Step 3:  Participants will be instructed to close mouth, inhale fully and simply sit for 30-60 seconds in full 
inspiration. After 30-60 seconds, exhale with a constriction in pit of throat and relax.  
Upon completion of breathing techniques, participants will be instructed to sit in meditation for 2 
minutes or longer with eyes closed. Participants will be instructed to not judge their thoughts, to be an 
observer, and just let their thoughts pass by without focusing on anything.  
 
If you feel short of breath, or unable to perform the practices please do not continue with the practice. 
Please contact your doctor for further medical attention and notify the study team.  
 
Video link of the practice is as follows-  
https://www.youtube.com/watch?v=lP1Y1bk1YgU 
 
Measures:  The following measures will be completed during the course of 4 weeks through a REDCap 
data base   
 
Adherence: Participants will keep a record of when they practiced each day to report in the survey how 
many times a day and how many days a week participant practiced for each of the 4 weeks.  
 
Breath holding time: At baseline and the end of each week, participants will count how many seconds 
they can hold their breath at one time. Participants will be asked to use the stopwatch on their 
smartphones to time breath holding. They will first empty their lungs as much as possible with an 
extended exhale pulling in their diaphragm using abdominal breathing. They will then inhale fully 
extending their diaphragm out and start timing how many seconds they can hold their breath. After a 2-

 
 
2020-0483 
 
 
Rev. August 19, 2020 
 
minute rest period they will repeat and record the second number. They will record both numbers at end 
of each week and report the results in the survey.  
 
Meditation perception questionnaire (including perception of usefulness): At the end of each week, 
participants will be asked 7 questions regarding their perception of practice such as feeling more peaceful, 
hopeful, relaxed, in more control of life, if they noticed improvement in their breathing, if they found the 
practice useful, and if they will continue to engage in the practice. We used this questionnaire in our 
previously published meditation study (14) and added 2 questions.  
 
Global Symptom Evaluation (GSE): The GSE has 2 parts and participants will only complete part 2. (15) 
Part 2 consists of 5 questions that evaluate whether participating in the study was worthwhile, whether 
they would participate in the study if they had to do over again, whether they would refer the study to 
others, and whether it had a positive or negative impact on quality of life. The answers consist of yes, no, 
and uncertain. We will only use the second part of GSE (Modified GSE Questionnaire) and it will only be 
asked at the end of the study. These questions will help determine if participating in the study was 
burdensome or beneficial to the participants. Participants will complete the questionnaire at the end of 
the study at week 4, or at the time of removal from the study.  
 
Perceived Stress Scale 4 (PSS-4): The PSS will be asked at baseline and the end of the study. (16) The 
questions in this scale ask about participants feelings and thoughts during THE LAST MONTH. In each 
case, please indicate your response by placing an “X” over the square representing HOW OFTEN you felt 
or thought a certain way. 
1. In the last month, how often have you felt that you were unable to control the important things in 
your life? 
2. In the last month, how often have you felt confident about your ability to handle your personal 
problems? 
3. In the last month, how often have you felt that things were going your way? 
4. In the last month, how often have you felt difficulties were piling up so high that you could not 
overcome them? 
The responses include: Never, Almost Never, Sometimes, Fairly Often, Very Often. 
(0 1 2 3 4)  
Lowest score: 0, Highest score: 16. Higher scores are correlated to more stress 
 
Stress among healthcare workers: This measure will be asked at baseline and the end of the study. 
Drawing from published measures that have assessed the impact of pandemics (H1N1) (17) and other 
major national stressors such as 9/11, a 29-item measure was developed to assess COVID-19 specific 
psychological distress (e.g., fear, anxiety and depressive symptoms), and financial and social disruptions. 
Items also assess resiliency factors such as social support, perceived benefits under times of stress, and 
ability to manage stress. Responses are provided in a Likert like scale (from 1 to 4) where participants are 
asked to rank statements from “strongly disagree” to “strongly agree.” The measure provides a total score 
summary that indicates the degree to which the COVID-19 pandemic has negatively impacted the 
participant. Items that tap into resiliency are reverse scored. In addition to the summary score, based on 
psychometric analyses upon collection of the data, the scale is expected to yield 5 subscale scores: COVID-
19 Specific Distress; Disruption to Daily Activities and Social Interactions; Financial Hardship; Perceived 
Benefits; and Perceived Stress Management Skills. These answers may not change over time, and may 
even worsen with time depending on the pandemic effect such as number of cases and burden on health 
care organization.   

 
 
2020-0483 
 
 
Rev. August 19, 2020 
 
 
Brief Resilient Coping Scale-BRCS: The BRCS will be asked at baseline and the end of the study. The BRCS 
has four items. (18) The participants are asked to select one option for each statement to indicate their 
level of disagreement or agreement with each item on a 5-point Likert-type scale, ranging from 1 
= strongly disagree to 5 = strongly agree 
1. I look for creative ways to alter difficult situations 
2. Regardless of what happens to me, I believe I can control my reaction to it 
3. I believe that I can grow in positive ways by dealing with difficult situations 
4. I actively look for ways to replace the losses I encounter in life 
 
Demographic information includes age, gender, race, ethnicity, occupation, marital status, COVID status, 
directly managing patients with COVID (Yes/No), work location, and h/o respiratory disorder (type, 
medications on daily basis or as needed). At the end of study, we will also ask the participants if they 
tested positive for COVID during the study time.  
 
 
Statistical Considerations: 
 
Sample Size Justification:  
This study is being conducted with HCWs who are currently at the forefront of pandemic management. 
Due to overwhelming response and willingness to participate in the study, we decide to increase our 
accrual from 50 to 100. The increased sample size will allow for increased precision or power in 
assessing both the primary and secondary objectives, When the sample size is 100, a two-sided 95% 
confidence interval (CI) for the proportion of perception of the intervention as usual using the large 
sample normal approximation will extend 0.098 from the observed proportion for an expected 
proportion of 0.500. In addition, a sample size of 100 will have 80% power to detect a difference in 
mean of 0.283 standard deviation (SD) unit between baseline and a time point after baseline, using a 
paired t-test with a 0.050 two-sided significance level. Attrition is unlikely in our study setting given that 
the participants are HCWs during the pandemic of COVID-19. However, in the unlikely case of a 10% 
attrition, a resulting sample size of 90 (=100*0.9) will have 80% power to detect a difference in mean of 
0.299 SD unit between baseline and a time point after baseline, using a paired t-test with a 0.050 two-
sided significance level. In both scenarios, the detectable effect size is considered medium.  
 
 
Data Analysis:   
Baseline characteristics of participants will be recorded. Continuous data will be presented as means ± 
standard deviation or median (interquartile range) depending on the distribution of the data and 
assessed with a parametric paired t-test or non-parametric Wilcoxon signed rank test for the changes 
between time points, as appropriate. Normality will be assessed with the Shapiro-Wilk test.  Categorical 
data will be presented as frequencies and percentages and assessed with a chi-square or Fisher’s exact 
test, as appropriate.  SPSS will be used for all analyses with two-sided p-values < 0.05 considered 
statistically significant.    
Feasibility will be defined as recruitment of 50 participants to the study within 2 months and acceptance 
of the study defined as more than 50% of participants perceive the intervention as useful. Adherence 
will be assessed using data from how often participants complete their breathing techniques. This will 
be reported as the percentages of completed activities out of the total required per protocol. 

 
 
2020-0483 
 
 
Rev. August 19, 2020 
 
Exploratory regression analysis for adherence to protocol for various outcomes is also planned. Protocol 
adherence for the study has been defined as participation in the intervention for more than 3 days in a 
week. Participant perception will be measured using a survey.  Continuous and dichotomous data will be 
reported and assessed in a similar fashion as above.   
Given the continuous nature of the scale, differences between scores will be assessed with a paired 
parametric or non-parametric t-test.  In the absence of randomization, unadjusted and adjusted linear 
regression will be utilized in order to account for differences that persist.  Our primary analyses will be 
assessed using intention-to-treat principles.  In order to assess whether there are differences between 
baseline and at various intervals, we will employ the use of paired t-tests as appropriate.   
 
For the analyses of the changes of variables over time (starting from baseline), we will also use linear 
mixed-effects models. 
 
Risks:  
 
The risk to the subject is minimal as intervention involves breathing techniques based on yoga and 
meditation.  
 
Potential physical risks of the study interventions:  
The interventions offered in this study are simple and only involves meditation and breathing practices.  
Participants may feel light headed for a short period of time. As such, there are no physical risks 
expected with these interventions.  Similarly, by assessing stress or well-being measures, we do not 
anticipate any risk of physical harm to any of the research subjects.   Hand held spirometer is easy to 
use. The twenty participants selected for this extra measure will be nurses, physicians or respiratory 
therapists who report knowing how to use the spirometer.  
Potential psychological risks:   
It is possible that there could be psychological or emotional risk to subjects in this study if they were to 
become aware of their performance in assessments and more so than they would be if they were not 
participating in the study.  Subjects will not be given the scores of their assessments, but if they were to 
become aware of a decline in their performance this could be stressful or disconcerting to the subject.  
For additional counseling regarding any psychological or emotional distress stemming from this, 
participants will be referred to Employee Assistance Program (EAP) at the request of the subject. 
Data security and privacy:  
Risk of breach of confidentiality:   
As with any research study, there is a small risk associated with a breach of confidentiality.  All research 
staff for this trial has been extensively trained in how to handle confidential data and how to minimize 
the possibility of this risk. To mitigate this risk, electronic data and that on paper will be kept in 
confidential, locked file cabinets and secure offices and/or on password-protected computers.  Subjects 
will also be assigned a unique study ID to minimize this risk.    
Privacy:  
 

 
 
2020-0483 
 
 
Rev. August 19, 2020 
 
All efforts will be taken to ensure participant privacy. All study interactions such as follow up 
assessments will be completed electronically or via the phone. Throughout the study, only the minimum 
required information will be collected, assuring participant privacy during the study protocol.  
 
Data collection will occur only on password-protected computers secured or in REDCap directly. Data 
collected will be limited to only the minimum necessary to accomplish the stated research purposes. 
 
No individual identifier will be obtained from the company other than the email for sending surveys. 
Each subject will be assigned a study-specific ID number.  A crosswalk between the participants and 
their study IDs will be maintained on password-protected computers by members of the research team. 
At no time will this crosswalk be shared outside the study team.  
 
All data would be directly entered into REDCap database and at the completion of the study all 
identifiable will be deleted and data analysis will occur using only the participant's study ID, to further 
ensure confidentiality of their responses.  
 
 
References:  
 
 
1. Chandwani KD, Thornton B, Perkins GH, et al. Yoga improves quality of life and benefit finding in 
women undergoing radiotherapy for breast cancer. J Soc Integr Oncol. 2010;8(2):43–55. 
2. Mustian KM, Sprod LK, Janelsins M, et al. Multicenter, randomized controlled trial of yoga for 
sleep quality among cancer survivors. J Clin Oncol. 2013 Sep 10;31(26):3233–3241. 
doi:10.1200/JCO.2012.43.7707. Epub 2013 Aug 12. 
3. Narayanan S, Francisco, R., Lopez, G., Chaoul, M. A., Meegada, S., Liu, W., Mallaiah, S., Milbury, 
K. & Cohen, L. Role of yoga across the cancer care continuum: From diagnosis through 
survivorship. Journal of Clinical Outcomes Management. 2019;26(5):p. 219-28 
4. Infante JR, Peran F, Rayo JI, et al. Levels of immune cells in transcendental meditation 
practitioners. Int J Yoga. 2014;7(2):147-51 
5. Kochupillai V, Kumar P, Singh D, Aggarwal D, Bhardwaj N, Bhutani M, et al. Effect of rhythmic 
breathing (Sudarshan Kriya and Pranayam) on immune functions and tobacco addiction. Annals 
of the New York Academy of Sciences. 2005;1056:242-52 
6. Chandla SS, Sood S, Dogra R, Das S, Shukla SK, and Gupta S. Effect of short-term practice of 
pranayamic breathing exercises on cognition, anxiety, general well being and heart rate 
variability. Journal of the Indian Medical Association. 2013;111(10):662-5. 
7. Joshi LN, Joshi VD, and Gokhale LV. Effect of short term 'Pranayam' practice on breathing rate 
and ventilatory functions of lung. Indian journal of physiology and pharmacology. 
1992;36(2):105-8 
8. Rao RM, Telles S, Nagendra HR, , et al. Effects of yoga on natural killer cell counts in early breast 
cancer patients undergoing conventional treatment. Comment to: recreational music-making 
modulates natural killer cell activity, cytokines, and mood states in corporate employees 
Masatada Wachi, Masahiro Koyama, Masanori Utsuyama, Barry B. Bittman, Masanobu 
Kitagawa, Katsuiku Hirokawa Med Sci Monit, 2007; 13(2): CR57-70. Med Sci Monit. 
2008;14(2):LE3-4. Brooks M. COVID- 19: ‘Striking’ rates of anxiety, depression in Healthcare 
workers. Medscape. March 26,2020. Retrieved from:  
https://www.medscape.com/viewarticle/927581 

 
 
2020-0483 
 
 
Rev. August 19, 2020 
 
9. Biegler KA, Chaoul MA, Cohen L. Cancer, cognitive impairment, and meditation. Acta Oncol. 
2009;48(1):18-26 
10. Khalid I, Khalid TJ, Qabajah MR, Barnard AG, Qushmaq IA. Healthcare Workers Emotions, 
Perceived Stressors and Coping Strategies During a MERS-CoV Outbreak. Clin Med Res. 
2016;14(1):7–14. doi:10.3121/cmr.2016.1303 Retrieved from: 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4851451/ 
11. Paladino L, Sharpe RP, Galwankar SC, et al. Reflections on the Ebola Public Health Emergency of 
International Concern, Part 2: The Unseen Epidemic of Posttraumatic Stress among Health-care 
Personnel and Survivors of the 2014-2016 Ebola Outbreak. J Glob Infect Dis. 2017;9(2):45–50. 
doi:10.4103/jgid.jgid_24_17 Retrieved from: 
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5452550/  
12. Lai J, Ma S, Wang Y, et al. Factors Associated With Mental Health Outcomes Among Health Care 
Workers Exposed to Coronavirus Disease 2020. JAMA Netw Open. 2020;3(3):e203976. 
doi:10.1001/jamanetworkopen.2020.3976 Retrieved from: 
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2763229?utm_campaign=artic
lePDF%26utm_medium%3darticlePDFlink%26utm_source%3darticlePDF%26utm_content%3dja
manetworkopen.2020.3976 
13. Isha foundation: https://www.innerengineering.com/sadhguru 
14. Narayanan S, Reddy A, Lopez G, Liu W, Wu J, Liu D, et al. Randomized Feasibility Study of 
Meditative Practices in Hospitalized Cancer Patients. Integrative cancer therapies. 
2020;19:1534735420909903. 
15. Guyatt GH, Feeny DH, Patrick DL. Measuring health-related quality of life. Ann Intern Med. 
1993;118:622-629. 
16. Cohen, S., Kamarck, T., & Mermelstein, R. (1983). A global measure of perceived stress. Journal 
of Health and Social Behavior, 24, 385-396 
17. Matsuishi K, Kawazoe A, Imai H, Ito A, Mouri K, Kitamura N, et al. Psychological impact of the 
pandemic (H1N1) 2009 on general hospital workers in Kobe. Psychiatry and clinical 
neurosciences. 2012;66(4):353-60. 
18. Kocalevent RD, Zenger M, Hinz A, Klapp B, and Brahler E. Resilient coping in the general 
population: standardization of the brief resilient coping scale (BRCS). Health and quality of life 
outcomes. 2017;15(1):251