POTS and Asthma: Why Shortness of Breath Isn’t Always What It Seems

Many of the POTS patients we see arrive with an asthma diagnosis already in their chart, and an inhaler in their bag that doesn’t seem to do much. Some have been told their shortness of breath is anxiety. Others have been through pulmonary testing that came back normal and left them with more questions than answers.

If that sounds familiar, you’re not imagining the pattern. POTS and asthma do overlap more than chance would predict, and POTS also produces breathlessness that looks like asthma without being asthma at all. Sorting out which one you’re dealing with, or whether it’s both, changes how you’re treated.

How Common Is the Overlap?

In the large patient surveys that informed the 2019 NIH expert consensus on POTS, roughly one in five people with POTS reported a diagnosis of asthma, well above the rate in the general adult population. Asthma sits on that comorbidity list alongside migraine, irritable bowel syndrome, Ehlers-Danlos syndrome, and mast cell activation syndrome (MCAS).

Why would a heart-rate condition travel with a lung condition? A few threads connect them:

• Mast cells. Mast cells release histamine and other inflammatory mediators. They’re central to allergic asthma, and overactive mast cells are also a feature of MCAS, which is itself common in POTS. Patients with the “trifecta” of POTS, EDS, and MCAS often have reactive airways as part of the picture. (We explore that cluster in our Trifecta article.)
• Connective tissue. In hypermobility conditions like EDS, the same collagen differences that affect joints and blood vessels can affect airway and chest wall mechanics.
• Autonomic imbalance. The autonomic nervous system regulates airway tone as well as heart rate. When it’s dysregulated, breathing can be affected in ways that don’t show up on a standard spirometry test.

When “Asthma” Is Actually POTS

Here’s the part that gets missed. Shortness of breath is one of the most common POTS symptoms, and in many patients it has nothing to do with the lungs.

When someone with POTS stands up, blood pools in the legs and abdomen, and less returns to the heart. The body compensates with a racing heart, and, in a significant subset of patients, with faster, deeper breathing. Research from Dr. Julian Stewart’s group at New York Medical College found that a distinct variant of POTS is driven by this postural hyperventilation: when patients stood, their carbon dioxide levels dropped, their blood vessels constricted, and their cardiac output fell. When researchers corrected the CO2, the circulation normalized.

Low CO2 from over-breathing produces its own unpleasant symptoms: air hunger, chest tightness, lightheadedness, tingling in the hands and face, and a sense of panic. It feels like you can’t get a full breath. It feels, in other words, like asthma, or like an anxiety attack, and it’s frequently labeled as one or the other.

Some clues that breathlessness may be POTS-related rather than asthma:

• It’s positional: worse standing or walking slowly, better lying down
• It arrives with a racing heart and lightheadedness rather than wheezing or coughing
• Spirometry and peak flow are normal, even during symptoms
• Rescue inhalers don’t help much, or make the heart racing worse
• It’s worse in heat, after meals, or during hormonal shifts (see our post on heat intolerance and dysautonomia)

Why It Matters Which One It Is

Albuterol and similar rescue inhalers work by stimulating beta-receptors to open the airways. Those same receptors speed up the heart. For a patient whose breathlessness is actually POTS, a rescue inhaler may do nothing for the breathing and quite a lot for the tachycardia, in the wrong direction. Patients sometimes describe feeling shaky, jittery, and worse after using one, and then conclude their “asthma” is severe when it may not be asthma at all.

The reverse error matters too. If true asthma is present and gets dismissed as “just your POTS,” real airway inflammation goes untreated. Many patients have both, and both deserve a plan.

“An inhaler that doesn’t help isn’t a useful treatment no matter what the diagnosis is- and that information is a good sign that we need to both look for something that causes similar symptoms like POTS, and change the treatment plan to something that does help.”
— Dr. Alicia Hart

Sorting It Out

A thorough evaluation usually includes:

• A careful history of when breathlessness occurs: posture, heat, exertion, meals, allergens, time of day
• Reviewing any prior pulmonary function testing, and ordering it if it hasn’t been done
• Assessing for MCAS and allergic triggers, since treating mast cell reactivity can improve both airway and autonomic symptoms
• Looking at the whole autonomic picture: hydration status, blood volume, heart rate response to standing, sleep, and nervous system regulation

From there, management is individualized. For POTS-driven breathlessness, that may include volume and electrolyte support, compression, pacing, breathing retraining to counter the hyperventilation pattern, and nervous system regulation strategies. For patients where true asthma coexists, we coordinate so that airway treatment doesn’t aggravate the autonomic symptoms, and vice versa. Where MCAS is part of the picture, addressing mast cell reactivity often helps both.

A note on breathing exercises, which are often recommended for both conditions: they can be helpful, but for some people with asthma, slow-breathing or breath-hold techniques can increase anxiety or air hunger rather than ease it. If an exercise makes you feel worse, that’s information, not failure. We adjust.

You’re Not Overreacting

Breathlessness that doesn’t respond to treatment is frightening, and being told it’s anxiety when you know something physical is happening erodes trust in your own body. The connection between POTS, mast cells, and the airways is real, increasingly documented, and treatable when it’s properly identified.

If you have POTS and breathlessness that no one has fully explained, we’d be glad to help you sort it out. Contact us to schedule a consultation with Dr. Alicia Hart.

Dr. Alicia Hart, ND, specializes in complex chronic conditions including POTS, EDS, MCAS, and ADHD. Her integrative approach combines herbal therapies, lifestyle support, and medication management, with a focus on nervous system regulation.

Peer-Reviewed Research and Further Reading

• Vernino S, Bourne KM, Stiles LE, et al. Postural orthostatic tachycardia syndrome (POTS): State of the science and clinical care from a 2019 National Institutes of Health Expert Consensus Meeting, Part 1. Autonomic Neuroscience. 2021;235:102828.
• Shaw BH, Stiles LE, Bourne K, et al. The face of postural tachycardia syndrome: insights from a large cross-sectional online community-based survey. Journal of Internal Medicine. 2019;286(4):438-448.
• Stewart JM, Pianosi P, Shaban MA, et al. Postural Hyperventilation as a Cause of Postural Tachycardia Syndrome: Increased Systemic Vascular Resistance and Decreased Cardiac Output When Upright in All Postural Tachycardia Syndrome Variants. Journal of the American Heart Association. 2018;7(13):e008854.
• Prevalence of mast cell activation disorders and hereditary alpha tryptasemia among patients with postural orthostatic tachycardia syndrome and Ehlers-Danlos syndrome: A systematic review. Annals of Allergy, Asthma & Immunology. 2025.