Breathe Right Nasal Strips: Not for Most Athletes

Affiliations: Fred Hatfield PhD FISSA, President, International Sports Sciences Association, Davie, Florida.
Acknowledgments:Arnie Baker (reviewer), Will Hopkins (editing), Rob Roach (reviewer).
Correspondence: drsquat=AT=aol.com (Fred Hatfield)
Date: March 1997

Summary. Breathe right nasal strips have little or no effect on the amount of air that passes through your lungs, or on the amount of oxygen you can extract from the air during exercise. Performance of and recovery from maximal endurance exercise by normal healthy adults under normal laboratory conditions also appears to be unaffected. A study showing that nasal dilation can reduce heating of the brain during exercise needs to be repeated with Breathe Right strips while athletic performance is monitored under various conditions. My recommendation: the strips are silly for most athletes, but they may work when high body temperature reduces performance.
Reviewers' comments
 Comment

Background

A Breathe Right nasal strip is like a Band-Aid with a flexible backbone that holds the nostrils open when the strip is stuck across the bridge of the nose. In 1993 permission was granted the manufacturer to market the strips as a device for reducing or eliminating snoring. By 1995 the strips had found their way into the locker rooms of national footballers, and by 1996 athletes from other sports were also using them.

Jerry Rice, all-pro wide receiver for the San Francisco 49ers professional football team, is quoted at the Breathe Right website as saying:

Before, I would be congested at times, but after I put the strip on, I went out there and I was breathing well. I was recuperating faster. Around the fourth quarter when you've got other players getting tired, I'm just getting my second wind.

Testimonials like this give the impression that the strips are so good, it's almost not worth doing the research. But it's too easy for athletes to deceive themselves or others about performance enhancement. Only properly controlled research will give a trustworthy answer to the question of whether the strips really work. The research to date is largely preliminary, but I think it is worth reviewing.

Literature

Reviewed herein are two studies reported in peer-reviewed journals, four studies presented in abstract form at annual meetings of the American College of Sports Medicine, and the contents of several pages at the Website of the manufacturer of Breathe Right nasal strips.

Findings

White and Cabanac (1995) were the first to report effects of nasal dilation that could affect performance. In this study, the nostrils were dilated by the use of small hooks attached to an elastic cord frame while untrained subjects exercised on a cycle ergometer in a room at 28°C and 28% relative humidity. Core temperature measured on the ear drum rose significantly less under the dilated condition (by 0.4°C per hour at 150 Watts). Removal of heat from cranial arteries by increased airflow through cranial sinuses was proposed as a possible mechanism. There were no effects on ventilation (rate at which air passes in and out of the lungs) or oxygen consumption.

The remaining studies in this review have been performed with Breathe Right nasal strips. It is clear that these strips can also have physiological effects. Used at night they reduce snoring, mouth dryness, and daytime sleepiness (study reported at Breathe Right web site). They appear to achieve these effects by increasing the cross sectional area of the nasal airway, thereby diverting air flow from the mouth to the nose (study reported at Breathe Right web site). But can these effects impact on physical performance?

In an anonymous undated study reported in brief at the Breathe Right website, 20 college football players performed 40-yard sprints at 3-min intervals up to 25 times. The players ran one set of sprints with the strips and one without. The report includes detail of methods, but the results aren't stated, and the discussion or conclusion consists of the following: "The results of this study indicate that athletes doing repeated sprint activity may benefit from using Breathe Right nasal strips improvement will likely be directly related to the increase in nasal cross-sectional area produced by the strips." [sic]

Other studies have found no effect of the strips on performance. Trocchio et al. (1995) studied 16 college-age male athletes in a progressive test to maximum effort on a cycle ergometer. There were no significant differences in peak oxygen consumption or peak workload with and without the nasal strips.

Huffman et al. (1996; abstract only) performed a placebo-controlled trial of the effects of the nasal strips on metabolic and respiratory responses during exercise. They randomly assigned five non-athletes to ride a bicycle ergometer to exhaustion on separate days using three different treatments: a Breathe Right strip, plain tape (the placebo), or nothing.. The subjects were told that two kinds of strip were being tested. The Breathe Right strip and the plain tape were applied while the subject's eyes were closed, so they did not know which was which. No significant differences were found in breathing or in oxygen consumption between the three trials. When asked which of the strips they preferred, one subject chose Breathe Right, two chose the placebo, and the other two had no preference. In another study with the same subjects, Quindry et al. (1996; abstract only) investigated whether the strips had any effect on post-exercise recovery. Again, no differences were found.

Papanek et al. (1996; abstract only) conducted a study to determine the effects of the strips on sprint performance and recovery of nine men and five women of college age. The investigators included tests for perceived exertion and perceived breathing effort, and ran all sprints on the same day, with 16 min of rest between sprints. The design appears to be an improvement on that of the study reported at the Breathe Right site. There were no significant differences between treatments (mouthpiece, nasal strips, or placebo) on any variables.

Clapp and Bishop (1996) conducted a study to determine the effects of the nasal strips on ventilation and oxygen consumption during treadmill running at speeds and grades that increased until subjects (12 moderately trained healthy males?) reached peak effort. The subjects completed an exercise bout with and without a nasal while wearing a mouthpiece. There were no significant differences between the two conditions at any stage of the 30 min of exercise for either ventilation or oxygen consumption (see Table).

	ventilation at 0% grade	ventilation at 7% grade	peak ventilation	peak oxygen consumption
nasal strip	16.4 ± 3.6	22.3 ± 4.7	70.8 ± 22.0	3.2 ± 1.1
no strip	15.8 ± 3.8	22.3 ± 4.5	70.7 ± 22.0	3.3 ± 1.1
Data are mean ± SD; all units are L.min-1.

These studies spurred Daniel Cohen, chief executive officer of CNS Inc. (the manufacturer of the strips), to claim that "accurate research results cannot be expected from studies that do not measure nasal cross-sectional area". Apparently, in those studies where nasal cross-sectional area was not measured (all the studies with negative findings), the strips did not dilate the nostrils! He also claimed that "we've heard from NFL and college trainers all over that for players with congestion, the intangibles are immeasurable [sic]: less congestion, fewer headaches, better focus and improved concentration." As yet, no data have been provided to support this statement.

Conclusions

It's clear that Breathe Right strips have little or no effect on breathing or performance in properly designed studies under normal conditions in healthy subjects. On the other hand, prolonged exercise in the heat could be enhanced by the use of these strips.

Further Research

The work of White and Cabanac (1995) needs to be repeated with Breathe Right strips, but the subjects should be competitive athletes exercising under various challenging conditions. Placebo-controlled trials of the strips with athletes suffering from asthma, allergies, or colds resulting in nasal obstruction would also be worthwhile, especially in conditions where these athletes are likely to overheat. Subjective responses, as well as objective measures of performance, need to be studied.

References

Clapp, A. J., and Bishop, P. A. (1996). Effect of the Breathe Right external nasal dilator during light to moderate exercise. Medicine & Science in Sports & Exercise, 28(5), S88.

Huffman, M. S., Huffman, M. T., Brown, D. D., Quindry, J. C., and Thomas, D. Q. (1996). Exercise responses using Breathe Right external nasal dilator. Medicine & Science in Sports & Exercise, 28(5), S70.

Papanek, P. E., Young, C. C., Kellner, N. A., Lachacz, J. G., and Spirado, A. (1996). The effects of an external nasal dilator (Breathe Right) on anaerobic sprint performance. Medicine & Science in Sports & Exercise, 28(5), S182.

Quindry, J. C., Brown, D. D., Huffman, M. S., Huffman, M. T., and Thomas, D. Q. (1996). Exercise recovery responses using the Breathe Right nasal dilator. Medicine & Science in Sports & Exercise, 28(5), S70.

Trocchio, M., Wimer, J. W., Parkman, A. W., and Fisher, J. (1995). Oxygenation and exercise performance-enhancing effects attributed to the Breathe Right nasal dilator. Journal of Athletic Training, 30, 211-214.

White, M. D. and Cabanac, M. (1995). Physical dilation of the nostrils lowers the thermal strain of exercising humans. European Journal of Applied Physiology, 70, 200-206.

I'm intrigued by the notion that nasal strips might have an effect on core body temperature. Core temperature can rise significantly at maximal exertion, even when not under conditions of high temperature. At the 1997 International Cycling Symposium held just a couple of weeks ago in Colorado Springs, Peter Keen, Chris Boardman's coach, showed how Chris cooked to 40°C in his one-hour world record.

The psychological component of a competitive setting hasn't been addressed in this review. When one is on the starting line of an aerobic endurance event, the perception that one can breathe fully might affect the psychological readiness to compete (though the ability to ventilate at high volumes would be unchanged.)

What about the difference, if any, between sports where athletes breathe through their mouths--running, road cycling, X-country skiing--and sports where a mouth guard might limit ventilation, such as football? But for most athletes, most of the time, I am tempted to say that if the strips helped, we wouldn't do our VO₂max tests with those clothespins on the nose.

If you have a partial nasal obstruction due to a cold or allergy, the strips may provide an increase in space sufficient to increase nasal breathing. That might make you feel a bit better, but it won't improve endurance performance. If you're really stuffed up, they won't make any difference. Try an over-the-counter decongestant.

Dr. Hatfield has done an admirable job debunking Breathe Right strips, the latest myth in performance enhancement for otherwise healthy athletes. Does this mean these they are useless? Absolutely not! Athletes sleep, which means that sleeping male athletes annoy people with their snoring. Breathe Right strips seem to relieve snoring in some cases.

As Dr. Hatfield suggests we still have a lot to learn about these strips and their effects on people with known respiratory limitations. And the exciting possibility of enhanced brain cooling by increasing nasal airflow has possible public health as well as performance enhancement implications.

At one point I thought of asking the author to change the title of this review to Breathe Right strips: open your mouth and say "nah!", to emphasize that you can get enough air through your mouth for any form of exercise. But it's too early to be that definite. If the strips reduce heating of the brain, they might well enhance the performance of endurance athletes or team athletes competing in hot conditions. --Will Hopkins

Andrea Fuller, PhD candidate
Department of Physiology, University of the Witwatersrand, South Africa. 127ANDY=AT=chiron.wits.ac.za.
April 97. Edited from a message on the Sportscience email list, 1 April 97.

This review dispels the notion that Breathe-Right strips enhance breathing during exercise. However, Dr Hatfield suggests that these strips may still prove to be useful to athletes in the heat, because they may enhance brain cooling. He cites a recent article by White and Cabanac (1995), in which cyclists' nostrils were physically dilatated by an elastic cord frame attached to two hooks that flared the nostrils. At the end of exercise ear-drum temperature was 0.2°C lower than in the control condition.

One must be careful in assuming that these results provide evidence of brain cooling. The issue of selective brain cooling in humans has been hotly debated over the past decade (those interested should see the opposing viewpoints of Cabanac, 1993, and Brengelmann, 1993). The issue is difficult to resolve because it is difficult to measure brain temperature directly. Some investigators have questioned the validity of ear-drum temperature as a measure of brain temperature. The debate has not been resolved by the few studies in which brain temperature and ear-drum temperature have been measured simultaneously in humans undergoing brain surgery.

Hence, the results of White and Cabanac show only that nasal dilatation lowers the temperature of the ear drum. Even if the cooling they observed was present throughout the brain, it could be argued that it is not physiologically significant. Breathe Right nasal strips probably increase nasal opening to a lesser extent than the apparatus used by White and Cabanac, so the cooling would be even less. It is also important to realize that any brain cooling via the nose would not occur in conditions of high air temperatures and relative humidity.

White, M. D. and Cabanac, M. (1995). Physical dilatation of the nostrils lowers the thermal strain of exercising humans. European Journal of Applied Physiology, 70, 200-206.

Cabanac, M. (1993). Selective brain cooling in humans: "fancy" of fact? FASEB Journal, 7, 1143-1147.

Brengelmann, G. L. (1993). Specialized brain cooling in humans? FASEB Journal, 7, 1148-1153.