Seminar Delivered by :Seminar Delivered by : Dr. A . K . Tanaya (PT)Dr. A . K . Tanaya (PT) MPT StudentMPT Student Hi Tech Physiotherapy CollegeHi Tech Physiotherapy College BhubaneswarBhubaneswar

INTRODUCTIONINTRODUCTIONAIMAIMPRINCIPLESPRINCIPLESPRECAUTIONPRECAUTIONCLASSIFICATIONCLASSIFICATIONTECHNIQUETECHNIQUE

INTRODUCTIONINTRODUCTION

Exercises which are given to strengthen the Exercises which are given to strengthen the respiratory muscles(diaphragm ,accessory respiratory muscles(diaphragm ,accessory costal & apical muscles)to maintain or costal & apical muscles)to maintain or increase the range of inspiration & increase the range of inspiration & expiration is called breathing exercise.expiration is called breathing exercise.

AIMAIM Strengthen the muscles of respiration.Strengthen the muscles of respiration. Improve ventilation, oxygenation & gas exchange.Improve ventilation, oxygenation & gas exchange. Lessen the work of the breathing.Lessen the work of the breathing. Teach active ROM exercises of the shoulder & trunk that help Teach active ROM exercises of the shoulder & trunk that help

to expand the chest.to expand the chest. Facilitate the deep breathingFacilitate the deep breathing Improve pulmonary status & patient’s overall enduranceImprove pulmonary status & patient’s overall endurance Improve the ADLImprove the ADL Promote relaxationPromote relaxation Prevent pulmonary impairmentPrevent pulmonary impairment Improve patient’s overall functional capacityImprove patient’s overall functional capacity Deal with shortness of breath attackDeal with shortness of breath attack Improve strength & co-ordination of respiratory musclesImprove strength & co-ordination of respiratory muscles

The breathing exercises The breathing exercises are often associated with are often associated with the postural drainage , the postural drainage , respiratory therapy respiratory therapy devices & medications.devices & medications.

INDICATIONSINDICATIONS Pre & post operative cardiac surgery conditionsPre & post operative cardiac surgery conditions Acute respiratory distressAcute respiratory distress Chronic obstructive pulmonary diseases ,asthma & Chronic obstructive pulmonary diseases ,asthma &

bronchiectasisbronchiectasis PneumoniaPneumonia Ankylosing spondylitisAnkylosing spondylitis Scoliosis,kyphosis which affect the respiratory Scoliosis,kyphosis which affect the respiratory

functionfunction Nervous system deficits or trauma which cause Nervous system deficits or trauma which cause

weakness of respiratory muscles:- weakness of respiratory muscles:- High spinal cord injuryHigh spinal cord injury Acute , chronic or progressive myopathic or neuropathic diseasesAcute , chronic or progressive myopathic or neuropathic diseases

Stress managementStress management Relaxation Relaxation

PRINCIPLESPRINCIPLES The instruction to the patient regarding the The instruction to the patient regarding the

therapy should be given therapy should be given clearly & in simpler clearly & in simpler manner manner

The treatment area should be The treatment area should be quietquiet Explain the patient the importance of Explain the patient the importance of

breathing exercisebreathing exercise Patient should be Patient should be comfortable & relax comfortable & relax and and

wear loose clothing & avoid restrictive wear loose clothing & avoid restrictive clothingclothing

Position of patient is Position of patient is crook lying crook lying in bed with in bed with head and trunk head and trunk elevated to 45 degreeselevated to 45 degrees

PRINCIPLES …..contdPRINCIPLES …..contd Abdominal muscles are relaxed when head & Abdominal muscles are relaxed when head &

neck are well neck are well supported.supported. Hip & knee are flex and legs Hip & knee are flex and legs are supported with are supported with

a pillow a pillow As the patient is perfect in this position, As the patient is perfect in this position,

progression is taught in other position like progression is taught in other position like supine lying, sitting and standing positionsupine lying, sitting and standing position

The patient is taught relaxation techniquesThe patient is taught relaxation techniques The patient should practice on his/her own and The patient should practice on his/her own and

should be perfect with the correct techniquesshould be perfect with the correct techniques

PRECAUTIONSPRECAUTIONS• The expiration should be relax & passiveThe expiration should be relax & passive• We should never encourage the patient to expire We should never encourage the patient to expire

forcibly, as this leads to increase airway forcibly, as this leads to increase airway resistance and bronchospasmresistance and bronchospasm

• The patient should not continue prolong The patient should not continue prolong expiration (as this mixes with the next inspiration expiration (as this mixes with the next inspiration resulting in irregular and insufficient breathing resulting in irregular and insufficient breathing patterns)patterns)

• The patient should not use accessory muscles The patient should not use accessory muscles and upper chest to initiate inspirationand upper chest to initiate inspiration

• To avoid hyper- ventilation ,the patient should To avoid hyper- ventilation ,the patient should practice deep breathing for 3-4times(inspiration practice deep breathing for 3-4times(inspiration & expiration)& expiration)

CLASSIFICATIONSCLASSIFICATIONS Diaphragmatic breathingDiaphragmatic breathing Segmental breathingSegmental breathing

Apical breathingApical breathing Lateral costal breathingLateral costal breathing Posterior basal breathingPosterior basal breathing Lingular breathing Lingular breathing

Ventilatory muscles trainingVentilatory muscles training Diaphragmatic training using weightsDiaphragmatic training using weights Inspiratory resistance trainingInspiratory resistance training Incentive respiratory spirometryIncentive respiratory spirometry

Glosso - pharyngeal breathingGlosso - pharyngeal breathing Pursed lip breathingPursed lip breathing

AIMS:-AIMS:-Improve gas exchange Improve gas exchange

Improve oxygenationImprove oxygenation

Improve ventilationImprove ventilation

Improve ascent or descent of the diaphragmImprove ascent or descent of the diaphragm Mobilize lung secretion during postural drainageMobilize lung secretion during postural drainage

Decrease work of the breathingDecrease work of the breathing

PROCEDUREPROCEDURE• Patient positionPatient position::

• Half lying supported by the pillowHalf lying supported by the pillow• Therapist position:Therapist position:

• Therapist stand besides the patientTherapist stand besides the patient• Technique:-Technique:-

– Hand should place on rectus abdominis below the ant.costal Hand should place on rectus abdominis below the ant.costal marginmargin

– Initially therapist place hand on pt’s abdomen & ask the pt. Initially therapist place hand on pt’s abdomen & ask the pt. to inspire .so, abdomen bulges out & contractto inspire .so, abdomen bulges out & contract

– When pt. expire abdomen falls back to normal positionWhen pt. expire abdomen falls back to normal position

– Ask pt. to breath in through nose & breath out through Ask pt. to breath in through nose & breath out through mouth. practice for3-4 timesmouth. practice for3-4 times

– Initially therapist demonstrate the technique then train the pt Initially therapist demonstrate the technique then train the pt to practice by keeping hands on abdomen& feel contraction to practice by keeping hands on abdomen& feel contraction

Segmental breathingSegmental breathing• APICAL BREATHING:-APICAL BREATHING:-

– INDICATIONINDICATION:-:- LobectomyLobectomy– patient positionpatient position:-:-sitting,crook/half crook lyingsitting,crook/half crook lying– Therapist positionTherapist position:-:-stands in front of the pt.& stands in front of the pt.&

applies pressure below the clavicle with the finger applies pressure below the clavicle with the finger tipstips

• UNILATERAL APICAL BREATHING:-UNILATERAL APICAL BREATHING:-– DURING INSPIRATIONDURING INSPIRATION:-:-therapist applies the therapist applies the

stretch downward & inwards to chest & muscles stretch downward & inwards to chest & muscles move in direction of outward & upward.move in direction of outward & upward.

– This streches the external intercostals on the side This streches the external intercostals on the side of the pressure ,i.e right side or left sideof the pressure ,i.e right side or left side

DURING EXPIRATION:-DURING EXPIRATION:-• The therapist with palms The therapist with palms

gives firm downward gives firm downward pressure and the ribcage is pressure and the ribcage is moved downward and inward moved downward and inward on the side of the pressure on the side of the pressure

BILATERAL APICAL BILATERAL APICAL BREATHINGBREATHING

DURING INSPIRATION:-DURING INSPIRATION:-• Therapist applies the stretch down ward and Therapist applies the stretch down ward and

inward to chest and the muscles moves in the inward to chest and the muscles moves in the direction of outward and upwarddirection of outward and upward

• This help in stretching of inter-costal muscles on This help in stretching of inter-costal muscles on the side of pressure bilaterallythe side of pressure bilaterally

DURING EXPIRATION:-DURING EXPIRATION:-• Therapist with palms give firm downward Therapist with palms give firm downward

pressure and rib cage is moved downward and pressure and rib cage is moved downward and inward on the side of pressure bilaterallyinward on the side of pressure bilaterally

APICAL BREATHINGAPICAL BREATHING

LATERAL COSTAL BREATHINGLATERAL COSTAL BREATHING

This is also called as lateral basal expansionThis is also called as lateral basal expansionTYPES:-TYPES:-UNILATERAL BREATHINGUNILATERAL BREATHING:- :- Rt/lt sideRt/lt side Position of patient:- Crook lyingPosition of patient:- Crook lying Position of therapist:- Stand behind the patient and Position of therapist:- Stand behind the patient and hand is placed on the rt.side in case of rt.lateral hand is placed on the rt.side in case of rt.lateral costal breathing or lt.side in case of lt.lateral costal costal breathing or lt.side in case of lt.lateral costal breathing. breathing. TECHNIQUETECHNIQUE:- Chest move upward & outward during:- Chest move upward & outward during

inspiration &move downward & inward during inspiration &move downward & inward during expirationexpiration..

UNILATERAL COSTAL UNILATERAL COSTAL BREATHINGBREATHING

• DURING INSPIRATION:-DURING INSPIRATION:-– Therapist applies the stretch downward & inward to Therapist applies the stretch downward & inward to

chestchest– Muscles moves in the direction of outward & Muscles moves in the direction of outward &

upward.This stretches the external intercostals on the upward.This stretches the external intercostals on the side of pressureside of pressure..

• DURING EXPIRATION:-DURING EXPIRATION:-– Therapist with palm give firm downward pressure & Therapist with palm give firm downward pressure &

the ribcage is moved downward & inward on the the ribcage is moved downward & inward on the side of pressure side of pressure

BILATERAL COSTAL BREATHING• Therapist place both hand on the bilateral aspect of Therapist place both hand on the bilateral aspect of

chest wall and firm pressure is given for chest wall and firm pressure is given for Inspiration& expirationInspiration& expiration

DURING INSPIRATION:-• Therapist applies the stretch downward & inward Therapist applies the stretch downward & inward

to chest & muscles move outward & upward.This to chest & muscles move outward & upward.This help in stretching of external intercostals bilaterallyhelp in stretching of external intercostals bilaterally

DURING EXPIRATION:-• Therapist give firm downward pressure and ribcage is moved Therapist give firm downward pressure and ribcage is moved

downward & inward bilaterallydownward & inward bilaterally

LINGULAR BREATHING It is also called as right middle lobe expansion It is also called as right middle lobe expansion

Position of patientPosition of patient:- S:- Sitting positionitting position

Therapist positionTherapist position:- S:- Stand behind patient & hand tand behind patient & hand is place on right side of the chest below the axillais place on right side of the chest below the axilla

ProcedureProcedure::-(-(during inspirationduring inspiration):- Therapist ):- Therapist applies the stretch downward &inward to chest applies the stretch downward &inward to chest &muscles move in direction of outward & &muscles move in direction of outward & upward.This stretches the intercostals on side of upward.This stretches the intercostals on side of pressure.pressure.

During expirationDuring expiration:-:-Therapist give firm downward pressure Therapist give firm downward pressure & ribcage move downward & inward on side of pressure& ribcage move downward & inward on side of pressure

Ventilatory muscles trainingVentilatory muscles training

Indications:-Indications:- Acute pulmonary diseasesAcute pulmonary diseases Chronic pulmonary diseasesChronic pulmonary diseases WeaknessWeakness AtrophyAtrophy Insufficiency of muscles of Insufficiency of muscles of

inspiration inspiration

Types:-Types:-• Diaphragmatic training using weights:-Diaphragmatic training using weights:-• Position of patientPosition of patient:-supine lying:-supine lying• ProcedureProcedure:-put small wt of 3 to5 pounds :-put small wt of 3 to5 pounds

over epigastric region.over epigastric region.• ask pt breath-in against resistance.ask pt breath-in against resistance.• Increase the no of time of resistance Increase the no of time of resistance

breathing.breathing.• wt should increase gradually with time wt should increase gradually with time

increase up to 15 min.increase up to 15 min.• this helps in strengthen the diaphragm.this helps in strengthen the diaphragm.

Inspiratory resistance trainingInspiratory resistance training

• This technique done through breathing device called This technique done through breathing device called resistor.resistor.

• This resistor put in patient mouth & patient inhale This resistor put in patient mouth & patient inhale through the device ,that give resistance to inspiratory through the device ,that give resistance to inspiratory muscles.muscles.

• If diameter is more narrower,the resistance should more If diameter is more narrower,the resistance should more require.there should be gradual increase in time i.e 20 to require.there should be gradual increase in time i.e 20 to 30 min.30 min.

• Once strength & endurance is increase, then tube Once strength & endurance is increase, then tube diameter is decrease.diameter is decrease.

• Incentive respiratory spirometryIncentive respiratory spirometry:-:-also also called as sustained maximal inspiratory maneuevercalled as sustained maximal inspiratory maneuever. .

Glossopharyngeal breathingGlossopharyngeal breathing

• IndicationIndication:-:-• Severe weakness of inspiratory musclesSevere weakness of inspiratory muscles• Spinal cord injurySpinal cord injury• Post polio patient with inspiratory muscles weaknessPost polio patient with inspiratory muscles weakness

• Aim:-Aim:-• To increase patient inspiratory capacityTo increase patient inspiratory capacity• To prepare the patient for coughingTo prepare the patient for coughing• To advise the patient with difficult deep breathingTo advise the patient with difficult deep breathing• Procedure:-AProcedure:-Ask the pt.to take gulps of air.Mouth is sk the pt.to take gulps of air.Mouth is

close & tounge move the air to pharynx,glottis gets open close & tounge move the air to pharynx,glottis gets open & air goes to lung. & air goes to lung.

GPB involves a series of gulps using the lips, tongue, pharynx, and larynx to pull air into the lungs when the normal respiratory muscles are not functioning.GPB consists of cycles of 6 to10 gulps of air followed by exhalation. Exhalation occurs when the glottis opens and the inflated lungs deflate passively due to the elastic recoil of the lungs. GPB allow an individual to perform a functional cough to clear tracheal secretions, increase the volume of the speaking voice, and maintain chest wall mobility.

Pursed lip breathingPursed lip breathing

Indications:-Indications:- Chronic bronchitisChronic bronchitis AsthmaAsthma BronchiectasisBronchiectasis Cystic fibrosisCystic fibrosis bronchitisbronchitis

• Position of patientPosition of patient:-:-Sit Sit with relax positionwith relax position

• TechniqueTechnique:-:-Therapist places Therapist places the hands on abdominal muscles the hands on abdominal muscles & pt is ask to take deep inspiration & pt is ask to take deep inspiration & with the lips pursed patient is & with the lips pursed patient is ask to expire the airask to expire the air

BREATHINGEXERCISE

IN ANTENATAL

PERIOD

BREATHINGBREATHINGEXERCISE EXERCISE

IN ANTENATALIN ANTENATALPERIODPERIOD

Text book of physiotherapy for Text book of physiotherapy for cardiac and thoracic surgical cardiac and thoracic surgical

conditions –conditions – By By G.B.MADHURIG.B.MADHURIChest,heart & vascular disorders Chest,heart & vascular disorders

for physiotherapist-for physiotherapist- Edtd. By Edtd. By Patricia A.DowniePatricia A.Downie

REFERENCES:-REFERENCES:-