Ready, Set…Hold Your Breath?!

This viral (pun-intended) myth has infiltrated (again, pun-intended) numerous social networks, including my mom’s inbox and my aunt’s WhatsApp. So what is the truth, you might ask? Well, continue reading as we parse through the evidence to determine the validity behind the infamous and (pseudo)scientific hold your breath test.

What is the myth?

The hold your breath test is a way to self-diagnose COVID-19. If you can hold your breath for 10 seconds without coughing or discomfort, you do not have any fibrosis in your lungs, and therefore are not infected with COVID-19.

Where did this myth come from?

The exact source of this myth is a mystery, which, by the way, is part of the problem, making this unsourced health advice. Nonetheless, the first appearance of the hold your breath test dates back to early March, to a post widely shared on social media platforms such as Facebook. While different variations exist, the post reads:

New coronavirus may not show signs of infection for several days. How can [you] know if [you’re] infected? By the time [you develop] a fever and/or a cough and go to the hospital, [you] may have 50% fibrosis… Taiwanese experts provide a simple self-monitoring that we can do every morning: Take a deep breath and hold it for more than 10 seconds. If you do this successfully without coughing and without discomfort, without anxiety or chest tightness, it shows that you do not have fibrosis and generally indicates no infection. Check yourself every morning in an [environment with fresh air].1

Thus, the post purports that if you can pass the hold your breath test, you do not have pulmonary fibrosis, and therefore are not infected with COVID-19 as pulmonary fibrosis is an alleged early sign of COVID-19.

Who is propagating the myth?

The uncertainty and wide-spread fear from the COVID-19 pandemic has served as a perfect breeding ground for the circulation of pseudoscience, including the hold your breath test. In fact, to its readers, the rationale behind the hold your breath test is more than compelling. First, the idea of self-diagnosing the coronavirus is extremely appealing; it gives us a sense of control (a self-test that we can do daily to determine our COVID-19 status) during such uncontrollable times. Secondly, the posts regarding the hold your breath test tactfully increase their seeming credibility through integrating convincing scientific concepts such as pulmonary fibrosis in addition to newer versions that cite institutions such as the Stanford University or the Stanford Hospital Board as a source of their claim.2

Indeed, despite Stanford’s rapid response on Twitter3 denying its association to the hold your breath test, in addition to their interview with CNN,2 condemning the post as “dangerous,” not affiliated with Stanford Medicine, and containing inaccurate information, the myth continued to circulate through email chains, WhatsApp groups, and social media platforms such as Facebook and Twitter.4

Why is it wrong?

The claim regarding the hold your breath test consists of two parts: 1) early symptoms of COVID-19 include symptoms of pulmonary fibrosis; and 2) the hold your breath test is a test of pulmonary fibrosis. Thus, the myth claims that if you can pass the hold your breath test, you do not have pulmonary fibrosis and therefore are not infected with the COVID-19.

So, let’s take a closer look at each part and see what the science tells us:

Part 1: Early symptoms of COVID-19 include symptoms of pulmonary fibrosis.

The post claims that fibrosis of the lungs (i.e., pulmonary fibrosis – which occurs when lung tissues become thick and scarred, affecting the lung’s capacity to expand and bring in oxygen)5 is an early sign of the coronavirus, that precedes the onset of known symptoms such as cough or fever. This claim is inconsistent with the current evidence-based guidelines from sources such as the CDC,6 Canada.ca,7 and Up-to-Date,8 as no current evidence exists to support pulmonary fibrosis as an early sign of COVID-19.

While it may be true that severe cases of COVID-19 can lead to pneumonia,8,9 and severe cases of pneumonia can lead to Acute Respiratory Distress Syndrome (ARDS),10 which can (rarely) cause pulmonary fibrosis,10 it is not true that pulmonary fibrosis is an early symptom of COVID-19. Pulmonary fibrosis (PF), if seen amongst those with COVID-19, would develop days to weeks after the early signs and symptoms of the coronavirus, including fever, fatigue, and cough. As such, the hold your breath test, which is contingent on PF being an early symptom of COVID-19, is false.

Part 2: The hold your breath test is a test of pulmonary fibrosis.

Furthermore, regardless of whether PF is indeed an early sign of COVID-19 (though it isn’t), the hold your breath test cannot be a way to self-diagnose COVID-19, as it is not a valid measure of pulmonary fibrosis.

The viral post claims that, “If you do [the hold your breath test] successfully without coughing and without discomfort, without anxiety or chest tightness, it shows that you do not have fibrosis.”  It may be true that if someone has pulmonary fibrosis, they may experience shortness of breath, which might make it difficult for them to hold their breath for 10 seconds without experiencing discomfort. However, as explained by numerous infectious disease experts,2,9,12 one’s ability to hold their breath is a crude measure of one’s degree of shortness of breath and irritated airway. Numerous other conditions can impact one’s ability to hold their breath2,11 such as congestive heart failure, asthma, allergic reactions, and infectious processes. For that reason, the hold your breath test is an invalid measure of PF as it is not specific to PF and lacks meaningful clinical utility.

In summary, the science tells us that the hold your breath test is not a way to self-diagnose COVID-19. This is because 1) pulmonary fibrosis is not an early sign of COVID-19; and 2) even if it were, the hold your breath test is not a valid measure of pulmonary fibrosis.

What are the ramifications of our misunderstanding?

But you might now ask, what really is the harm of the hold your breath test? What’s so bad about people choosing to take a 10-second deep breath every day?

Well, you’re right. Theoretically, there is no direct harm caused by people choosing to engage with the hold your breath test. However, the dangers of this myth are associated with the false sense of reassurance that the test can provide, which can lead to a lack of appropriate care and management. For example, individuals infected with COVID-19 may choose to wait in seeking medical help because they can still pass the hold your breath test. More critically, individuals may also believe that they are not infected with COVID-19 because they passed the hold your breath test (which would be the vast majority, given that 80% of the COVID-19 cases are mild),13 and inadvertently fail to engage in appropriate self-isolation and/or quarantine. These potential outcomes of the hold your breath test are alarming, especially during a time when our collective effort in managing the coronavirus outbreak and #flatteningthecurve is of utmost importance.

As such, my ask to you – our readers – is to utilize the excellent evidence-based tools created by our healthcare providers, instead. One resource that I’ll highlight (as I take my leave) is a self-assessment tool published by the government of Canada: https://ca.thrive.health/covid19/en, which can help assess your COVID-19 symptoms in addition to providing your with appropriate next steps based on your residing province.14

Summary

The hold your breath test, which has infiltrated our inboxes and social media, is not a way to self-diagnose COVID-19 as pulmonary fibrosis (PF) is not an early sign of COVID-19. Even if it were, the hold your breath test is simply not a valid measure of PF. Furthermore, while it may be true that individuals with severe cases of COVID-19 can develop PF as a complication of pneumonia, this undoubtedly will be days to weeks after their initial presentation of COVID-19 symptoms including fever, cough, and fatigue. Finally, while individuals with severe symptoms of COVID-19 may develop shortness of breath and fail the hold your breath test, many individuals with COVID-19 will have mild cases of the disease and pass the test with flying colours. This cumulatively renders the hold your breath test invalid and without meaningful clinical value. 

BUST OR NO BUST:

Myth: The hold your breath test is a way to self-diagnose COVID-19. If you can hold your breath for 10 seconds without coughing or discomfort, you do not have any fibrosis in your lungs, and therefore are not infected with COVID-19.
Results: BUST. The hold your breath test is not a valid way to self-diagnose COVID-19. Myth-meter = 20/100 truthfulness.

Written by Lucia Juehea Lee

References

1. Facebook (2020). Retrieved from https://www.facebook.com/photo.php?fbid=10215919821285399&set=a.1701316689743&type=3&theater (accessed 21 April 2020).
2. Elassar, A., CNN. (2020). One dangerous coronavirus ‘self-check test’ is circulating on social media. Here’s why you should avoid it. CNN. Retrieved from https://www.cnn.com/2020/03/16/us/coronavirus-myths-debunking-holding-breath-10-seconds-trnd/index.html (accessed 21 April 2020).
3. Stanford University on Twitter. (2020). ‘Misinformation about COVID-19 symptoms and treatment falsely attributed to Stanford is circulating on social media and in email forwards. It is not from Stanford. Official information from Stanford is available at healthalerts.stanford.edu. Twitter. Retrieved from https://twitter.com/Stanford/status/1238327187155156992 (accessed 21 April 2020).
4. Link, D., USA Today. (2020). Coronavirus fact check: Is your holding breath a test for COVID-19? USA Today. Retrieved from: https://www.usatoday.com/story/news/factcheck/2020/03/22/coronavirus-fact-check-your-holding-breath-test-covid-19/2891572001/ (accessed 21 April 2020).
5. Mayo Clinic staff. (2018). Pulmonary fibrosis – Symptoms and causes. Mayo Clinic. Retrieved from https://www.mayoclinic.org/diseases-conditions/pulmonary-fibrosis/symptoms-causes/syc-20353690 (accessed 21 April 2020).
6. CDC. (2020). Coronavirus Disease 2019 (COVID-19) – Symptoms of Coronavirus. Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html (accessed 21 April 2020).
7. Government of Canada. (2020). Coronavirus disease (COVID-19): Symptoms and treatment. Canada.ca. Retrieved from https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/symptoms.html?topic=tilelink (accessed 21 April 2020).
8. McIntosh, K. (2020). Coronavirus disease 2019 (COVID-19): Epidemiology, virology, clinical features, diagnosis, and prevention. UpToDate. Retrieved from: https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19-epidemiology-virology-clinical-features-diagnosis-and-prevention?search=covid%2019&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H4141359801 (accessed 21 April 2020).
9. Reuters. (2020). False claim: Doctors offer advice for preventing COVID-19, symptoms like coughing and fever indicate pulmonary fibrosis, fibrosis is detectable by holding your breath for 10 seconds, drinking water every 15 minutes repels coronavirus. Reuters Fact Check. Retrieved from https://www.reuters.com/article/uk-factcheck-covid-advice-self-test-drin/false-claim-doctors-offer-advice-for-preventing-covid-19-symptoms-like-coughing-and-fever-indicate-pulmonary-fibrosis-fibrosis-is-detectable-by-holding-your-breath-for-10-seconds-drinking-water-every-15-minutes-repels-coronavirus-idUSKBN2142B6 (accessed 21 April 2020).
10. DynaMed. (2018). Acute Respiratory Distress Syndrome (ARDS). DynaMed. Retrieved from https://www.dynamed.com/condition/acute-respiratory-distress-syndrome-ards (accessed 21 April 2020).
11. Ahmed, A. & Graber, M.A. (2020). Evaluation of the adult with dyspnea in the emergency department. UpToDate. Retrieved from: https://www.uptodate.com/contents/evaluation-of-the-adult-with-dyspnea-in-the-emergency-department?search=evaluation%20of%20the%20adult%20with%20dyspnea%20in%20the%20emergency%20department&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H4 (accessed 21 April 2020).
12. Faheem Younus, MD on Twitter (2020). ‘Myth #3: If you can hold your breath for ten seconds without discomfort, you don’t have COVID. Wrong: Most young patients with Coronavirus will be able to hold their breaths for much longer than 10 seconds. And many elderly without the virus won’t be able to do it.’ / Twitter. Twitter. Retrieved from https://twitter.com/faheemyounus/status/1239705900908253190 (accessed 21 April 2020).
13. Wu, Z., McGoogan, J.M. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention. JAMA 2020; 323: 1239–1242.
14. Government of Canada, Thrive Health. (2020). Canada Self-Assessment Tool and App. Thrive Health. Retrieved from https://ca.thrive.health (accessed 21 April 2020).