Patients with PH experience high psychological distress,¹ symptom burden,^2,3 and low quality of life,⁴ which is exacerbated by the coronavirus disease 2019 (COVID-19) pandemic. Current evidence suggests that psychological distress, such as depression and anxiety, are underrecognized and underdiagnosed, which means that symptoms are often untreated or under-treated by healthcare professionals.⁵ Inadequate management of anxiety or depression can have unfavorable influences on PH self-management and needed social support system. Despite advances in PH management, patients continue to struggle in symptom self-management, and this can have untoward consequences on mental and physical health. An integrated review of psychosocial and behavioral interventions and assessments indicates that complementary health approaches such as gentle breathing and mindfulness can reduce stress in patients with PH and be integrated into PH care settings.⁶

Stress experience is characterized by heightened awareness of perceived threat (real or imagined), often accompanied by exaggerated sympathetic outflow and diminished parasympathetic connection. Mindfulness practice is the most well-known and well-accepted modality of complementary health approaches among adults with cancer^7,8 and is beginning to gain traction in the PH community.⁹ One can learn simple mindfulness practice and incorporate it into daily living activities to enhance the relaxation response. The relaxation response experience is the critical defining characteristic of parasympathetic outflow that can facilitate the body's innate ability to counteract chemical and physiologic sequela of chronic stress. Our physical body is fully capable of harnessing the parasympathetic state, as demonstrated by reduced heart rate and respiratory rate. Qualitatively measured, patients with PH who received complementary health approach interventions described their deep relaxation experience as a sense of "time lost," "sleep like," and "body disconnectedness."¹⁰ Learning how to reach this state of relaxation using complementary health approaches can allow the stressed physical body to recover and recuperate.

Mindfulness practice can be an invaluable tool to temper our stress response. Mindfulness is the practice of training your body and mind to engage in full awareness by focusing attention, thoughts, and feelings in the present moment.¹¹ Studies have shown that mindfulness practice in PH (such as mindfulness-based stress reduction) had a positive impact in reducing anxiety among those who adhered to the method.⁹ Progressive muscle relaxation practice among patients with PH post-hospital discharge reduced depression and anxiety.¹² A multi-component integrative therapy program called Urban Zen Integrative Therapy was associated with reducing the severity of pain, anxiety, fatigue, and dyspnea symptoms in patients with PH.⁴ Mindfulness practice can be learned and practiced by anyone with the essential requirements of curiosity, interest, and the willingness to try. With a clear understanding of the basic concepts of mindfulness and regular mindfulness practice, one can gain comfort and confidence.

The practice of gratitude, either in thoughts or verbal expression, can shift our state of being from worry to calmness. Simply put, this practice is an extension of the mindfulness practice. In addition to bringing awareness to your current thoughts, feelings, and sensations, we focus more on the positive aspects of what we notice. Because our minds automatically default to a negative thinking mode, we have to make a conscious effort in this practice. Positive thinking will gradually become a routine, replacing habitual negative thinking with frequent and more extended practice sessions.

• Concept 1: Start with 5 minutes of practice a day and increase the duration as you are comfortable. Although research information is limited with respect to the amount of time recommended for physiologic effects, clinical benefits appear to be dose dependent. Incorporating the practice in the early part of your day is optimal because your mind is least likely to be influenced by the day's events.
• Concept 2: Your mind will wander, and when it does, bring your attention back to the present moment. Your ability to focus will increase with time and practice.
• Concept 3: Mindful breathing practice may be the simplest way to begin. In this practice, you pay attention to the flow of air as you breathe slowly in and out. Engage and observe with all your five senses to enhance your ability to focus.
• Concept 4: Body-awareness meditation practice is another approachable mindful practice. In this practice, you pay attention to each body part systematically. You may start with your feet on the floor and move to the top of your head.
• Concept 5: Cultivate loving kindness toward yourself, your body, and your practice. The practice may be challenging at first. You will get better and feel more at ease once you spend less time judging yourself. Notice how you feel after each practice. The experience of relaxation, albeit short, can be a strong motivator to continue.

With daily practice, mindfulness can become a way of being that is incorporated into daily activities such as mindful breathing, mindful walking, mindful eating, and mindful listening. Being fully present (or aware) in everything you do requires practice, which means that one gains comfort and competence. First, recognize that our minds naturally wander. When yours does, you bring it back to the present moment by focusing on physical sensation at that moment, such as body-awareness meditation, which may be the easiest way to begin the practice. In this method, you pay attention to the physical body sensation and give each body part your full awareness and understanding (Figure 1).

Figure 1

Similarly, when practicing mindful breathing, you provide full attention to the details of breathing, such as the quality of the airflow, chest expansion, and abdominal rises and falls. Adopting mindfulness practice through regular practice can move our thinking into the present moment, which slowly lessens unhelpful or negative thoughts. Through the conscious awareness of the present moment, rather than what happened in the past and what may occur in the future, we become less preoccupied with things that we cannot change. This methodical conscious control of thinking in this state of being can lessen stress and anxiety.

Using a readily available mindfulness app can be an excellent introduction to the practice for a novice practitioner. Many mindfulness apps provide various practice modules according to the participant's level of prior exposure and available time. The key is the consistency of the approach. Through the practice of mindfulness, one can invoke a relaxation response that produces calmness and clarity. Additionally, a community of support through friends and colleagues is critical in promoting and encouraging the practice.

Table 1: Provider and Patient Resources

	Name	Web Address	Description
Fact Sheet	Mindfulness for Those with COPD, Asthma, Lung Cancer, and Lung Transplantation13	https://www.thoracic.org/patients/patient-resources/resources/mindfulness.pdf	A helpful, downloadable PDF for patients that is part of the American Thoracic Society Patient Education Information Series.
Mindfulness Apps	Insight Timer	https://insighttimer.com	The app has 8,000 free guided-meditation modules for basic subscription. You can select meditation programs based on your availability.
	Headspace	https://www.headspace.com	The app is free, offers the basics of meditation and mindfulness, and is perfect for beginners. The Headspace Plus subscription is $12.99 per month and offers more selections. There are free subscription options for full-time students or health care professionals.
	Calm	https://www.calm.com	There is a limited free version of the app and a free 7-day trial of the premium version. After that, premium will cost you $70 a year, or a little less than $6 a month.
Podcasts	The Mindful Healers Podcast	https://podcasts.apple.com/us/podcast/mindful-healers-podcast-dr-jessie-mahoney-dr-ni-cheng/id1542538851	Hosts Dr. Jessie Mahoney and Dr. Ni-Cheng Liang teach mindfulness to create radiant health.
	Breathe Easy Podcasts: "Integrative therapy in respiratory disease: mindfulness practice during COVID-19 - Part 2"	https://www.thoracic.org/about/ats-podcasts/integrative-therapy-in-respiratory-disease-mindfulness-practice-during-covid-19-part-2.php	Host Nina Bracken and guest Dr. Ni-Cheng Liang discuss mindfulness practice during the COVID-19 pandemic.
Web Resources	Massachusetts General Hospital Benson-Henry Institute for Mind Body Medicine	https://bensonhenryinstitute.org	Dr. Herbert Benson was one of the earliest pioneers in the field of mind body medicine. The site offers information and guided meditation.
	The Ohio State University Wexner Medical Center Integrative Medicine	https://wexnermedical.osu.edu/integrative-complementary-medicine	The site offers information about integrative practice in general, including specific information about mindfulness practice.
	UCLA Mindful Awareness Research Center	https://www.uclahealth.org/marc/body.cfm	The UCLA Mindful Awareness Research Center also provides free access to mindfulness practice.
Books	The Miracle of Mindfulness: An Introduction to the Practice of Meditation		Written by Thich Nhat Hahn, a Zen master, this book offers gentle anecdotes and practical exercise as a means of learning the skills of mindfulness: being awake and fully aware.
	Mindfulness for Beginners: Reclaiming the Present Moment and Your Life		Written by Dr. Jon Kabat-Zinn, a teacher, scientist, and clinician, this is a book that you can use as a collection of reflections and practices; as an illuminating and engaging start-to-finish read; or as an unfolding "lesson-a-day" primer on mindfulness practice.
	The Book of Joy: Lasting Happiness in a Changing World		Written by Dalai Lama and Desmond Tutu, this book answers the question "How do we find joy in the face of life's inevitable suffering?"

References

1. Von Visger TT, Kuntz KK, Phillips GS, Yildiz VO, Sood N. Quality of life and psychological symptoms in patients with pulmonary hypertension. Heart Lung. 2018;47:115-21.
2. Matura LA, McDonough A, Carroll DL. Symptom Interference Severity and Health-Related Quality of Life in Pulmonary Arterial Hypertension. J Pain Symptom Manage 2016;51:25-32.
3. Matura LA, McDonough A, Carroll DL. Symptom Prevalence, Symptom Severity, and Health-Related Quality of Life Among Young, Middle, and Older Adults With Pulmonary Arterial Hypertension. Am J Hosp Palliat Care 2016;33:214-21.
4. Von Visger TT, Thrane SE, Klatt MD, et al. The Impact of Urban Zen Integrative Therapy on Symptoms and Health-Related Quality of Life for Patients with Pulmonary Hypertension. J Palliat Med 2020;23:703-11.
5. Pfeuffer E, Krannich H, Halank M, et al. Anxiety, Depression, and Health-Related QOL in Patients Diagnosed with PAH or CTEPH. Lung 2017;195:759-68.
6. Von Visger T, Lee D, Lyons A, Chang YP. Integrated Review of Psychosocial and Behavioral Health Assessments and Interventions in Pulmonary Hypertension. Nurs Res 2020;Dec 1:[Epub ahead of print].
7. Reich RR, Lengacher CA, Alinat CB, et al. Mindfulness-Based Stress Reduction in Post-treatment Breast Cancer Patients: Immediate and Sustained Effects Across Multiple Symptom Clusters. J Pain Symptom Manage 2017;53:85-95.
8. Kenne Sarenmalm E, Mårtensson LB, Andersson BA, Karlsson P, Bergh I. Mindfulness and its efficacy for psychological and biological responses in women with breast cancer. Cancer Med 2017;6:1108-22.
9. Tulloh RMR, Garratt V, Tagney J, et al. A pilot randomised controlled trial investigating a mindfulness-based stress reduction (MBSR) intervention in individuals with pulmonary arterial hypertension (PAH): the PATHWAYS study. Pilot Feasibility Stud 2018;4:78.
10. Von Visger TT, Thrane SE, Klatt MD, Chang YP, Happ MB. Deep Relaxation Experience with Complementary Urban Zen Integrative Therapy: Qualitative Thematic Analysis. West J Nurs Res 2020;Nov 27:[Epub ahead of print].
11. Kabat-Zinn J. Jon Kabat-Zinn, PhD. Bringing mindfulness to medicine. Interview by Karolyn A. Gazella. Altern Ther Health Med 2005;11:56-64.
12. Li Y, Wang R, Tang J, et al. Progressive muscle relaxation improves anxiety and depression of pulmonary arterial hypertension patients. Evid Based Complement Alternat Med 2015;2015:792895.
13. Liang NC, Von Visger T, Devereaux A. Mindfulness for Those with COPD, Asthma, Lung Cancer, and Lung Transplantation. Am J Respir Crit Care Med 2020;202:P11-P12.

Clinical Topics: Cardiovascular Care Team, COVID-19 Hub, Sleep Apnea, Pulmonary Hypertension and Venous Thromboembolism

Keywords: Meditation, Quality of Life, Activities of Daily Living, Mindfulness, COVID-19, Autogenic Training, Exploratory Behavior, Self Care, Respiratory Rate, Patient Discharge, Depression, Heart Rate, Social Support, Anxiety, Sleep, Delivery of Health Care

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