BREATHING EXERCISES

• Also called as ventilatory training.• An aspect of management to improve pulmonary status and

to increase a patient’s overall endurance and function during daily living activities.

• They are fundamental interventions for the prevention or comprehensive management of impairments related to acute or chronic pulmonary disorders.

• Simply, Breathing exercises are designed to retrain the muscles of respiration, improve ventilation, lessen the work of breathing, and improve gaseous exchange and patient’s overall function in daily living activities.

• Depending on a patient’s underlying pathology and impairments, exercises to improve ventilation often are combined with medication, airway clearance, the use of respiratory therapy devices, and a graded exercise (aerobic conditioning) program.

Goals of Breathing Exercises andVentilatory Muscle Training

1. • Improve or redistribute ventilation.2. • Increase the effectiveness of the cough mechanism and promote airway

clearance.3. • Prevent postoperative pulmonary complications.4. • Improve the strength, endurance, and coordination of the muscles of

ventilation.5. • Maintain or improve chest and thoracic spine mobility.6. • Correct inefficient or abnormal breathing patterns and decrease the work

of breathing.7. • Promote relaxation and relieve stress.8. • Teach the patient how to deal with episodes of dyspnea.9. • Improve a patient’s overall functional capacity for daily living,

occupational, and recreational activities.10. Aid in bronchial hygiene---Prevent accumulation of pulmonary secretions,

mobilization of these secretions, and improve the cough mechanism.

Indications of breathing exercises1. Cystic fibrosis2. Bronchiectasis3. Atelectasis4. Lung abscess5. Neuromuscular diseases6. Pneumonias in dependent lung regions.7. Acute or chronic lung disease8. COPD 9. For patients with a high spinal cord lesion/ Deficits in CNS: spinal cord injury,

myopathies etc.10. Prophylactic care of preoperative patient with history of pulmonary problems 11. After surgeries (thoracic or abdominal surgery)12. Airway obstruction due to retained secretions.13. For patients who must remain in bed for an extended period of time.14. As relaxation procedure.

Guidelines for Teaching Breathing Exercises

• If possible, choose a quiet area for instruction in which you can interact with the patient with minimal distractions.

• Explain to the patient the aims and rationale of breathing exercises or ventilatory training specific to his or her particular impairments and functional limitations.

• Have the patient assume a comfortable, relaxed position and loosen restrictive clothing. Initially, a semi-Fowler’s position with the head and trunk elevated approximately 45, is desirable. By supporting the head and trunk, flexing the hips and knees, and supporting the legs with a pillow, the abdominal muscles remain relaxed.

• Other positions, such as supine, sitting, or standing, may be used initially or as the patient progresses during treatment.

• Observe and assess the patient’s spontaneous breathing pattern while at rest and later with activity.

• Determine whether ventilatory training is indicated.• Establish a baseline for assessing changes, progress, and• outcomes of intervention.• If necessary, teach the patient relaxation techniques. This

relaxes the muscles of the upper thorax, neck, and shoulders to minimize the use of the accessory muscles of ventilation.

• Pay particular attention to relaxation of the sternocleidomastoids, upper trapezius, and levator scapulae muscles.

• Depending on the patient’s underlying pathology and impairments, determine whether to emphasize the inspiratory or expiratory phase of ventilation.

• Demonstrate the desired breathing pattern to the patient.• Have the patient practice the correct breathing pattern in a

variety of positions at rest and with activity.

PRECAUTIONS:

• When teaching breathing exercises, be aware of the following precautions:

1. Never allow a patient to force expiration. Expiration should be relaxed or lightly controlled. Forced expiration only increases turbulence in the airways, leading to bronchospasm and increased airway restriction.

2. Do not allow a patient to take a highly prolonged expiration. This causes the patient to gasp with the next inspiration. The patient’s breathing pattern then becomes irregular and inefficient.

3. Do not allow the patient to initiate inspiration with the accessory muscles and the upper chest. Advise the patient that the upper chest should be relatively quiet during breathing.

4. Allow the patient to perform deep breathing for only three or four inspirations and expirations at a time to avoid hyperventilation.

CONTRAINDICATIONS:• Increased ICP• Unstable head or neck injury• Active hemorrhage with hemodynamic instability or hemoptysis• Recent spinal injury• Empyma• Bronchoplueral fistula• Flail chest• Uncontrolled hypertension• Anticoagulation• Rib or vertebral fractures or osteoporosis• Acute asthma or tuberculosis• Patients who have recently experienced a heart attack.• Patients with skin grafts or spinal fusions will have undue stress

placed on areas of repair.

• Bony metastases, brittle bones, bronchial hemorrhage, and emphysema are contraindications for undue stress to the thoracic area.

• Verify that patient has not eaten for at least one hour. • Severe Obesity • Recent (within one hour) meal or tube feed • Untreated pneumothorax• Chest tubes.

TYPES OF BREATHING EXERCISES:

1. Diaphragmatic breathing 2. Pursed lip breathing 3. Segmental breathing(costal expansion exercise) a)Apical breathing b)lateral costal expansion c)Posterior basal expansion 4. Sustained maximal inspiration (deep breathing)

DIAPHRAGMATIC BREATHING

The semireclining (as shown) and semi-Fowler’s positions arecomfortable, relaxed positions in which to teach diaphragmatic breathing.

•When the diaphragm is functioning effectively in its role as the primary muscle of inspiration, ventilation is efficient and the oxygen consumption of the muscles of ventilation is low during relaxed (tidal) breathing.• When a patient relies substantially on the accessory muscles of inspiration, the mechanical work of breathing (oxygen consumption) increases and the efficiency of ventilation decreases.•Although the diaphragm controls breathing at an involuntary level, a patient with primary or secondary pulmonary dysfunction can be taught how to control breathing by optimal use of the diaphragm and decreased use of accessory muscles.

• GOALS OF DIAPHRAGMATIC BREATHING:• To improve the efficiency of ventilation and oxygenation• Decrease the work of breathing• Increase the excursion (descent or ascent) of the diaphragm• Improve gas exchange and oxygenation.• Diaphragmatic breathing exercises also are used during

postural drainage to mobilize lung secretions.• Reduces work of breathing• Reduces the incidence of post operative pulmonary

complications• Improve ventilation• Eliminates accessory muscle activity • Decrease respiratory rate • Increase tidal ventilation • Improve distribution of ventilation

• PROCEDURE/ TECHNIQUE:1. Prepare the patient in a relaxed and comfortable position in

which gravity assists the diaphragm, such as a semi- Fowler’s position.

2. The patient initiates the breathing pattern with the accessory muscles of inspiration (shoulder and neck musclulature), start instruction by teaching the patient how to relax those muscles (shoulder rolls or shoulder shrugs coupled with relaxation).

3. Diaphragmatic breathing enhance diaphragmatic descent during inspiration and diaphragmatic ascent during expiration

4. Physiotherapist assist diaphragmatic ascent by directing the patient to allow the abdomen to retract gradually during exhalation or by contracting abdominal muscles actively

5. Diaphragmatic descent is assisted by directing the patient to protract the abdomen gradually during inhalation.

6. Place your hand(s) on the rectus abdominis just below anterior costal margin. Ask the patient to breathe in slowly and deeply through the nose.

7. Have the patient keep the shoulders relaxed and upper chest quiet, allowing the abdomen to rise slightly. Then tell the patient to relax and exhale slowly through the mouth.

8. Have the patient practice this three or four times and then rest. Do not allow the patient to hyperventilate.

9. If the patient is having difficulty using the diaphragm during inspiration, have the patient inhale several times in succession through the nose by using a sniffing action This action usually facilitates the diaphragm.

10. To learn how to self-monitor this sequence, have the patient place his or her own hand below the anterior costal margin and feel the movement. The patient’s hand should rise slightly during inspiration and fall during expiration.

11. After the patient understands and is able to control breathing using a diaphragmatic pattern, keeping the shoulders relaxed, practice diaphragmatic breathing in a variety of positions (sitting, standing) and during activity (walking, climbing stairs).

• RE EDUCATION OF DIAPHRAGM:

• As other skeletal muscles, diaphragm also shares the property of skeletal muscle

• Place the index and middle finger below the lower costal margin anteriorly in half lying position over the insertion of diaphragm (central tendon)

• At the end of expiration when diaphragm is relaxed, stretch stimulus is given to the diaphragm to elicit Stretch reflex of the diaphragm and patient is instructed to take breath in.

Resisted diaphragmatic breathing

Manual resistance by therapist over the abdomenPlacing appropriate weight over abdomen in By slightly elevating the foot end of the bed

*procedure- same as breathing ex*CONTRAINDICATIONS- SAME AS BREATHING

PURSED LIP BREATHING• Pursed-lip breathing is a strategy that involves lightly pursing the

lips together during controlled exhalation.• USES OF PURSED LIP BREATHING/ INDICATIONS:• This breathing pattern often is adopted spontaneously by patients

with COPD to deal with episodes of dyspnea. • Improves ventilation• Releases trapped air in the lungs• Keeps the airways open longer and decreases the work of breathing• Prolongs exhalation to slow the breathing rate• Improves breathing patterns by moving old air out of the lungs and

allowing for new air to enter the lungs• Relieves shortness of breath• Causes general relaxation

• It can be applied:- as a 3-5 minutes “rescue exercise” or an Emergency Procedure to counteract acute exacerbations or dyspnea (shortage of air or breathlessness) in COPD and asthma.

• Pursed-lip breathing reduces hyperventilation-induced broncho-constriction.

• PRINCIPLE: Many therapists believe that gentle pursed-lip breathing and controlled expiration is a useful procedure, particularly to relieve dyspnea if it is performed appropriately. It is thought to keep airways open by creating back-pressure in the airways.

• Studies suggest that pursed-lip breathing decreases the respiratory rate and the work of breathing (oxygen consumption), increases the tidal volume, and improves exercise tolerance.

• PRECAUTIONS : • The use of forceful expiration during pursed-lip breathing must be

avoided. Forceful expiration while the lips are pursed can increase the turbulence in the airways and cause further restriction of the small bronchioles.

• Therefore, if a therapist elects to teach this breathing strategy, it is important to emphasize with the patient that expiration should be performed in a controlled manner but not forced.

• PROCEDURE/TECHNIQUE:• Have the patient assume a comfortable position and relax as much as

possible. • Have the patient breathe in slowly and deeply through the nose and

then breathe out gently through lightly pursed lips as if blowing on and bending the flame of a candle but not blowing it out.

• Explain to the patient that expiration must be relaxed and that contraction of the abdominals must be avoided.

• Place your hand over the patient’s abdominal muscles to detect any contraction of the abdominals.

SEGMENTAL BREATHING•Performed on a segment of lung, or a section of chest wall that needs increased ventilation or movement.•It’s questionable whether a patient can be taught to expand localized areas of the lung while keeping other areas quiet. •Hypoventilation does occur in certain areas of the lungs because of pain and muscle guarding after surgery, atelectasis and pneumonia. •Therefore, it will be important to emphasize expansion of problems areas of the lungs and chest wall under certain conditions.

•USES/ INDICATIONS:• post thoracotomy, •trauma to chest wall, •pneumonia, •post mastectomy scar, •post chest radiation-fibrosis.

• ADVANTAGES OF SEGMENTAL BREATHING:• Prevent accumulation of pleural fluid• Prevent accumulation of secretions • Decreases paradoxical breathing• Decrease panic• Improve chest mobility

Lateral costal expansion• This is sometimes called lateral basal expansion and may be done unilaterally or

bilaterally.• The patient may be sitting or in a hook lying position.• Place your hands along the lateral aspect of the lower ribs to fix the patient’s attention

to the areas which movement is to occur.• Ask the patient to breathe out, and feel the rib cage move downward and inward.• As the patient breathes out, place firm downward pressure into the ribs with the palms

of your hands.• Just prior to inspiration, apply a quick downward and inward stretch to the chest. This

places a quick stretch on the external intercostals to facilitate their contraction. These muscles move the ribs outward and upward during inspiration.

• Apply light manual resistance to the lower ribs to increase sensory awareness as the patient breathes in deeply and the chest expands and ribs flare. Then, as the patient breathes out, assist by gently squeezing the rib cage in a downward and inward direction.

• Tell the patient to expand the lower ribs against your hand as he or she breathes in.

• Apply gentle manual resistance to the lower rib area to increase sensory awareness as the patient breathes in and the chest expands and ribs flare.

• Then, again, as the patient breathes out, assist by gently squeezing the rib cage in a down ward and inward direction.

• The patient may then be taught to perform the maneuver independently. He or She may place the hand (s) over the ribs or apply resistance using a belt.

Posterior basal expansion• Deep breathing emphasizing posterior basal expansion is important for the

postsurgical patient who is confined to bed in a semireclining position for an extended period of time because secretions often accumulate in the posterior segments of the lower lobes.

• Have the patient sit and lean forward on a pillow, slightly bending the hips.• Place your hands over the posterior aspect of the lower ribs.• Follow the same procedure as described above.• This form of segmental breathing is important for the post surgical patient

who is confined to bed in a semi upright position for an extended period of time. Secretions often accumulate in the posterior segments of the lower lobes.

Belt exercises reinforce lateral costalbreathing (A) by applying resistance during inspirationand (B) by assisting with pressure along the rib cage duringexpiration.

Right middle lobe or lingula expansion• Patient is sitting.• Place your hands at either the right or the left side of the patient’s chest,

just below the axilla.• Follow the same procedure as described for lateral basal expansion.

Apical expansion• Patient in sitting position.• Apply pressure (usually unilaterally) below the clavicle with the

fingertips.• This pattern is appropriate in an apical pneumothorax after a lobectomy.

*Precautions- same as general*contraindications- same as general

GLOSSOPHARYNGEAL BREATHING• Glossopharynegal breathing is a means of increasing a patient’s inspiratory capacity

when there is severe weakness of the muscles of inspiration. • The first report of GPB was published by Dail in 1951 in patients with poliomyelitis

paralysis.• It is a technique that is performed by using the muscles of mouth, cheeks, lips, tongue,

soft palate, larynx and pharynx to piston boluses of air into the lungs.• The tongue is the main organ of this breathing technique. • The tongue is pushed upwards and backwards forcing the air into the pharynx.• The larynx opens and the air passes into the trachea where it is trapped by closure of

larynx.• This pistoning action is mechanism of each gulp.• A gulp is defined as boluses of air projected into the trachea by pistoning action of the

tongue.• INDICATIONS:• It is taught to patients who have difficulty taking in a deep breath, for example, in

preparation for coughing.• It is used primarily by patients who are ventilator-dependent because of absent or

incomplete innervation of the diaphragm as the result of a high cervical-level spinal cord lesion or other neuromuscular disorders.

• Glossopharyngeal breathing can reduce ventilator dependence • Also can be used as an emergency procedure when a malfunction of a patient’s

ventilator occur.• It also can be used to improve the force (and therefore the effectiveness) of a

cough • It is used to increase the volume of the voice.• Procedure• Glossopharyngeal breathing involves taking several “gulps” of air, usually 6 to

10 gulps in series, to pull air into the lungs when action of the inspiratory muscles is inadequate.

• After the patient takes several gulps of air, the mouth is closed.• The tongue pushes the air back and traps it in the pharynx. • The air is then forced into the lungs when the glottis is opened. • This increases the depth of the inspiration and the patient’s inspiratory and

vital capacities

COUGHING• An effective cough is necessary to eliminate respiratory obstructions and keep

the lungs clear.• Airway clearance is an important part of management of patients with acute or

chronic respiratory conditions.• The Normal Cough Pump• A cough may be reflexive or voluntary. • When a person coughs, a series of actions occurs as follows:• Deep inspiration occurs-------Glottis closes------vocal cords tighten------

Abdominal muscles contract-------diaphragm elevates-------causing an increase in intrathoracic and intra-abdominal pressures-------Glottis opens-----Explosive expiration of air occurs.

• Under normal conditions, the cough pump is effective to the seventh generation of bronchi. (There are a total of 23 generations of bronchi in the tracheobronchial tree.)

• Ciliated epithelial cells are present up to the terminal bronchiole and raise secretions from the smaller to the larger airways in the absence of pathology.

• Factors that Decrease the Effectiveness• of the Cough Mechanism and Cough Pump• The effectiveness of the cough mechanism can be compromised for a

number of reasons including the following:1. Decreased inspiratory capacity2. Inability to forcibly expel air3. Decreased action of the cilia in the bronchial tree.4. Increase in the amount or thickness of mucus.

5. Decreased inspiratory capacity:• Inspiratory capacity can be reduced because of: Pain due to acute lung disease Rib fracture Trauma to the chest Recent thoracic or abdominal surgery Weakness of the diaphragm or accessory muscles of inspiration as a result

of a high spinal cord injury or neuropathic or myopathic disease Postoperatively, the respiratory center may be depressed as the result of

general anesthesia, pain, or medication.

2. Inability to forcibly expel air:• The following factors contribute to a weak cough: A spinal cord injury above T12 and myopathic disease, such as muscular dystrophy,

cause weakness of the abdominal muscles, which are vital for a strong cough. Excessive fatigue as the result of critical illness A chest wall or abdominal incision causing pain A patient who has had a tracheostomy, even when the tracheostomy site is covered.

3. Decreased action of the cilia in the bronchial tree:• Action of the ciliated cells may be compromised because of: Physical interventions such as general anesthesia and intubation Pathologies such as COPD including chronic bronchitis Smoking also depresses the action of the cilia.

4. Increase in the amount or thickness of mucus:• Occurs in: Pathologies (e.g., cystic fibrosis, chronic bronchitis) and pulmonary infections (e.g.,

pneumonia) Intubation irriates the lumen of the airways and causes increased mucus

production Dehydration thickens mucus.

• Teaching an Effective Cough• Because an effective cough is an integral component of airway clearance, a patient must be

taught the importance of an effective cough, how to produce an efficient and controlled voluntary cough, and when to cough.

• The following sequence and procedures are used when teaching an effective• cough.1. Assess the patient’s voluntary or reflexive cough.2. Have the patient assume a relaxed, comfortable position for deep breathing and

coughing.3. Sitting or leaning forward usually is the best position for coughing. 4. The patient’s neck should be slightly flexed to make coughing more comfortable.5. Teach the patient controlled diaphragmatic breathing, emphasizing deep inspirations.6. Demonstrate a sharp, deep, double cough.7. Demonstrate the proper muscle action of coughing (contraction of the abdominals).

Have the patient place the hands on the abdomen and make three huffs with expiration to feel the contraction of the abdominals. Have the patient practice making a “K” sound to experience tightening the vocal cords, closing the glottis, and contracting the abdominals.

8. When the patient has put these actions together, instruct the patient to take a deep but relaxed inspiration, followed by a sharp double cough.

9. The second cough during a single expiration is usually more productive.10. Use an abdominal binder or glossopharyngeal breathing in selected patients with

inspiratory or abdominal muscle weakness to enhance the cough, if necessary.

• Precautions for Teaching an Effective Cough• Never allow a patient to gasp in air, because this increases the work (energy

expenditure) of breathing, causing the patient to fatigue more easily. It also increases turbulence and resistance in the airways, possibly leading to increased bronchospasm and further constriction of airways.

• A gasping action also may push mucus or a foreign object deep into air passages.

• Avoid uncontrolled coughing spasms (paroxysmal coughing).• Avoid forceful coughing if a patient has a history of a cerebrovascular accident

or an aneurysm. Have these patients huff several times to clear the airways, rather than cough.

• Be sure that the patient coughs while in a somewhat erect or side-lying posture.• Additional Techniques to Facilitate a Cough and Improve Airway

Clearance• To maximize airway clearance, several techniques can be used to stimulate a

stronger cough, make coughing more comfortable or improve the clearance of secretions.

• Manual-Assisted Cough• If a patient has abdominal weakness (e.g., as the result of a mid-thoracic or

cervical spinal cord injury), manual pressure on the abdominal area assists in developing greater intra-abdominal pressure for a more forceful cough. Manual pressure for cough assistance can be applied by the therapist or the patient.

• Therapist-Assisted Techniques• With the patient in a supine or semireclining position, the therapist places the

heel of one hand on the patient’s abdomen at the epigastric area just distal to the xiphoid process.

• The other hand is placed on top of the first, keeping the fingers open or interlocking them

• After the patient inhales as deeply as possible,the therapist manually assists the patient as he or she attempts to cough. The abdomen is compressed with an inward and upward force, which pushes the diaphragm upward to cause a more forceful and effective cough.

• This same maneuver can be performed with the patient in a chair • The therapist or family member can stand in back of the patient and apply

manual pressure during expiration.• P R E C A U T I O N : Avoid direct pressure on the xiphoid process during the

maneuver.• Self-Assisted Technique• While in a sitting position, the patient crosses the arms across the abdomen or

places the interlocked hands below the xiphoid process • After a deep inspiration, the patient pushes inward and upward on the

abdomen with the wrists or forearms and simultaneously leans forward while attempting to cough.