Buffering the Mile High Advantage: A two-step process to improve in-game NBA performance at altitude

Denver and Utah consistently rank among the best homecourt advantages in the NBA. There has even been research suggesting the road teams shoot a lower free throw percentage at altitude. Talking to NBA athletes about playing on the road at altitude, they often describe feeling out of breath, especially the first few minutes they are on the court. Less total oxygen available at altitude leads to hypoxia — lower levels of oxygen in the blood.

In this post I will discuss:

  1. The impact of altitude on basketball performance
  2. In-game strategies I have used to help NBA athletes perform at altitude

It is common practice in the NBA to have a hard session, immediately upon arrival with the thought of “getting used to the altitude.” However, research has shown it can take up to 6 days to acclimatize in Denver. The density of the NBA schedule doesn’t allow this to happen, as teams will fly in most often within 24 hours of the game. 

Two Strategies for Game Day Performance

This past season, we played Utah and Denver on back-to-back games. We landed in Denver at 2am. This left approximately 17 hours until tip off.  Given the constraints, our staff utilized a two-step process to maximize performance. 

Step 1: Coach our athletes' breathing

Ventilation allows for the exchange of O2 and CO2, we are driven to keep O2 levels high for survival. Hypoxia corresponds to a linear decrease in VO2 max (see p. 541 of Exercise Physiology by Brooks, Fahey, and Baldwin). Efficiency drops and athletes are operating at a higher percentage of their maximum workload. Hypoxia causes athletes to hyperventilate, this increases O2 consumption and decreases CO2 levels.

To realize the impact of hyperventilation, we must look at the connection between O2 and hemoglobin. Hemoglobin is the transporter molecule that is bound to oxygen. The Oxyhemoglobin dissociation curve (ODC) describes how blood carries and releases oxygen via its relationship with hemoglobin.

As a result of the drop in CO2, Hyperventilation shifts the ODC curve to the left.

Oxygen Dissociation Curve

Hyperventilation is a double-edged sword; It does increase oxygen levels; however, it increases how tightly hemoglobin binds to oxygen (Brooks, Fahey & Baldwin, 2019). This left shift in the graph means it takes a lower concentration of oxygen for hemoglobin to liberate O2 in the tissues.

Restoring the O2 / CO2  relationship by decreasing hyperventilation is paramount.  We aimed to educate our athletes on controlling their breathing rate and depth. Slow, deep breathing (6 breath cycles per min for 5 min) at altitude has been shown to significantly increase blood oxygen, without the negative secondary consequences of hyperventilation.

An easy to learn breathing technique is square or box breathing.

Box breathing

Source: bsu.edu

If you want to look more into breathing strategies to improve athletic performance, I recommend looking into Oxygen Advantage.

Step 2: Use of supplemental oxygen

There is conflicting research regarding the benefit of supplemental oxygen for athletic performance at altitude. Some research supports using it, while others question its impact. Ultimately, our staff choose to use it in-game for recovery periods.

I can’t stress enough, that you MUST get step #1 down first. The key with supplemental oxygen at altitude is to first control ventilation. If you don’t and you inhale a ton of oxygen all at once, you might get the opposite impact of what you want (remember the ODC curve)?

The breathing sequence we taught to our athletes on the pregame and on the bench was:

  • 3 cycles of box breathing
  • 1 inhalation with supplemental oxygen
  • 3 cycles of box breathing
  • Repeat two times

This roughly equates to 6 min of controlled breathing.

Products like Boost Oxygen, now make supplemental oxygen that is in small canisters and relatively inexpensive.


  • Altitude leads to hyperventilation which impacts the ratio of O2 to CO2 in our bodies
  • First control your breathing rate
  • There may be some value to supplemental oxygen (IF breathing slowed FIRST)