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~237~
International Journal of Ph
y
sical Education
,
S
p
orts and Health 2015
;
2
(
2
)
: 237-241
P-ISSN: 2394-1685
E-ISSN: 2394-1693
Impact Factor (ISRA): 4.69
IJPESH 2015; 2(2): 237-241
© 2015 IJPESH
www.kheljournal.com
Received: 05-09-2015
Accepted: 08-10-2015
Subin Solomen
Professor, Affiliated to COPMS,
EMCHRC, Perinthalmanna,
Kerala, India.
Pravin Aaron
Principal, Affiliated to
Padmashree Institute of
Physiotherapy, Bangalore,
India.
Correspondence
Subin Solomen
Professor, Affiliated to COPMS,
EMCHRC, Perinthalmanna,
Kerala, India.
Breathing techniques- A review
Subin Solomen, Pravin Aaron
Abstract
Physiotherapy should be offered to patients with a variety of medical respiratory conditions with the aim
of breathlessness management and symptom control, mobility and function improvement or maintenance,
and airway clearance and cough enhancement or support. Breathing exercises is used as strategy in Lung
expansion therapy, Bronchial hygiene therapy and PT techniques to reduce work of breathing. Breathing
exercises can be classified as inspiratory and expiratory as some exercise stresses more of inspiration
while some stresses expiration. Breathing exercises are used in Restrictive as well as obstructive
conditions. In restrictive types of disorders Deep Breathing, Diaphragmatic Breathing, Deep
Diaphragmatic Breathing, End – Inspiratory hold, Sustained Maximal Inspiration, Slow Maximal
Inspiration, Incentive Spirometer, Sniff, Segmental (Apical and Lateral Costal Activity) are commonly
used. Abdominal Breathing, Air Shift Breathing, Glossopharyngeal Breathing are commonly effective in
spinal cord injuries. Stacked Breathing, Air Shift Breathing are used in localized and generalised
atelectasis of upper lobe respectively. Chest mobility exercises and Belt exercises are used to prevent the
formation of disabling adhesions between two layers of pleura. Active cycle breathing technique and
Autogenic Drainage are commonly used for clearance of secretions. Breathing Control Technique,
Innocenti Technique, Pursed Lip Breathing are used during acute exacerbation and End – Expiratory
hold, Buteyko Breathing, Exhale With Activity, Stressed Respiratory Exercises, Panting, Pacing are
commonly used when the subjects are in stable phase. Inspiratory Muscle Training, Isocapnic Hyper
Ventilation, Inspiratory Resistive Training, Inspiratory Threshold Training are used to improve strength
and endurance of respiratory muscles. Breathing Cycle Technique is used in chronic hyperventilation
where there is breathlessness without an organic cause. This update has made as a result of the need to
clarify the effectiveness of different types of breathing exercise in respiratory conditions. This guideline
gives valuable information about different types of breathing exercise in management of respiratory
conditions to all respiratory physicians and physiotherapists working in respiratory care.
Keywords: Physiotherapy, Breathing exercise, obstructive disease, restrictive disease.
Introduction
Physiotherapy should be offered to patients with a variety of medical respiratory conditions,
with the aim of breathlessness management and symptom control, mobility and function
improvement or maintenance, and airway clearance and cough enhancement or support.
Strategies and techniques include: rehabilitation, exercise testing, and exercise prescription,
airway clearance, positioning and breathing techniques [1]. Reduced lung expansion,
accumulation of secretions and increased work of breathing are main problems seen with
respiratory disorders. Physiotherapists use Lung expansion therapy, Bronchial hygiene therapy
and PT techniques to reduce work of breathing to address the above problems [2]. Breathing
exercises is an important component in all of the above techniques.
Breathing exercise can be defined as the therapeutic intervention by which purpose full
alteration of a given Breathing pattern are categorized as breathing exercises [3]. Outcomes
have ranged from to increase lung volume, to clear secretions, to improve gas exchange, to
control breathlessness, to increase exercise capacity, to reduce blood pressure, to reduce
obesity, relaxation response for stress reduction and to control pain in natural child birth [3, 4, 5].
Breathing exercise can be classified as inspiratory and expiratory. Some of the breathing
exercises stresses inspiration thereby increasing lung volume where as others stresses on
expiration which assists in clearance of secretions.
In restrictive disorders of lungs, atelectasis, consolidation, pleural effusion and pneumothorax
there will be reduction of lung volume and capacities [6].
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International Journal of Physical Education, Sports and Health
Therefore the main aim is to improve expansion of lungs. The
mechanism of improvement of lung expansion can be due to
increase in transpulmonary pressure gradient, boosting
collateral ventilation and by physiology of interdependence.
Breathing exercises can be given if patient is conscious and
cooperative [2].
In restrictive types of disorders Deep Breathing,
Diaphragmatic Breathing, Deep Diaphragmatic Breathing, End
– Inspiratory hold, Sustained Maximal Inspiration, Slow
Maximal Inspiration, [7] Incentive Spirometer, [2] Sniff, [6]
Segmental (Apical and Lateral Costal Activity) are commonly
used [8]. Abdominal Breathing [9], Air Shift Breathing, [10]
Glossopharyngeal Breathing are commonly effective in spinal
cord injuries. Stacked Breathing [7], Air Shift Breathing are
used in localized and generalised atelectasis of upper lobe
respectively. Chest mobility exercises and Belt exercises are
used to prevent the formation of disabling adhesions between
two layers of pleura [8].
In Deep Breathing subjects were asked to breathe in deeply
and slowly through the nose and sigh out through the mouth.
Breathing through nose warms and humidifies air but doubles
resistance to air flow. Inspiration is slow to decrease velocity
and increase the strength of muscle contraction. Expiration is
through the mouth to keep the airway open patency of small
airway closure [6].
In Diaphragmatic breathing, the subjects were asked to get
comfortable position. They were instructed to rest the
dominant hand on your abdomen with elbows supported and
keeping their shoulder relaxed. Allow their hand to rise gently
while visualizing air filling the abdomen like a balloon [8].
Progress this exercises to side lying and relaxed standing. The
beneficial effects are improving pulmonary function and
ventilation. One of the detrimental effects is decreased efficacy
there by increased dyspnea. This may due to inadequate
learning; subjects may have to carry out a more consciousness
during diaphragmatic breathing and if optimal positioning is
not used there will be limited diaphragmatic excursion. The
other detrimental effect is paradoxical breathing. In COPD
there will be flattening of diaphragm and greater use of
accessory muscles so there will be greater pull on upper
thorax-inwards which results in paradoxical breathing. Good
candidate of COPD will be those who are having mild
obstruction with elevated respiratory rate, low tidal volume
and abnormal ABG. Poor candidate will be those who are
having moderate to severe COPD with marked hyperinflation.
Deep diaphragmatic breathing is a combination of deep
breathing with diaphragmatic breathing [11].
End – inspiratory technique can be administered along with
deep diaphragmatic breathing to further stress the inspiration.
By this method air can be entered into poorly ventilated
regions. It boosts collateral ventilation. It is not suitable for
breathless people [6].
Sniff is a simple and effective technique used to increase
diaphragmatic excursion further along with deep
diaphragmatic exercises. It augments collateral circulation.
Perform the normal diaphragmatic breathing exercise as
mentioned above. Then ask the subject to sniff in three times.
During exhalation, tell the subjects to let it out slow which
help to decrease RR and some relaxation. Progressively
decrease the no of sniffs as the day progresses [6].
Hypoventilation does occur in certain areas of the lungs
because of chest wall fibrosis, pain, and muscle guarding after
surgery, atelectasis and pneumonia. So in these circumstances
Segmental exercises can be given to increase localised
expansion of the lungs [8]. The techniques used with segmental
exercises may elicit localised drop in intra pleural pressure [7]
thereby increasing transpulmonary pressure gradient which
results in expansion. Manual cues such as vibration or pressure
sensation are provided over the regions of chest wall that is not
expanding well may also aid in expansion [7, 12, 13]. Three types
of segmental breathing that target the apical, lateral and
posterior segments of the lower lobes are apical expansion
exercises, lateral costal breathing and posterior basal
expansion exercises [8].
The following technique further stresses inspiration. First
squeeze chest during expiration then stretch at the very end of
expiration, allow inspiration to occur. Near the end of
inspiration apply a series of 3 or 4 gentle stretches rather
similar to repeated contractions [7].
Stacked breathing is the only breathing exercise where there is
more inspiratory efforts compared to a single expiratory effort.
In this technique subjects have to breathe in 3-4 times without
expiration, each time filling the lung a little bit more up to vital
capacity. This exercise is better fit for individuals with weak
respiratory muscles to achieve full inspiration prior to a cough.
A glottis closure between each attempt allows a buildup of
extra volume with in the lungs, thereby achieving a good
laryngeal control. Stacked breathing technique is also used
mainly for localised collapses [7].
In a slow maximal inspiration, subject asked to do slow
inspiration for as long as possible. This keeps the glottis open
and air can continue to move. This encourages recruitment of
all muscle fibers. A sustained maximal inspiration is a slow,
deep inhalation from FRC up to the total lung capacity,
followed by 5 to 10 sec breath hold. Both of these techniques
can increase lung expansion by altering transpulmonary
pressure gradient, boosting collateral ventilation and
improving the physiology of interdependence. Incentive
Spirometry which was developed by Barlett et al. uses the
principle of sustained maximal inspiration. It was designed to
mimic natural sighing or yawning by encouraging the subject
to take long slow deep breaths and hold. Types of incentive
spirometer are flow oriented and volume oriented spirometer.
Volume spirometer indicate volume achieved during sustained
maximal inspiration (eg coach spirometer, voldyne) and flow
oriented spirometer indicates degree of inspiratory flow (eg
Triflo, mediflo) [2]. Contraindications include unconscious
subjects, unable to co-operate. Hazards are hyperventilation,
hypoxemia, exaggerating bronchospasm.
Abdominal Breathing, Air Shift Breathing, Glossopharyngeal
Breathing are commonly effective in improving respiratory
function in spinal cord injuries. Glossopharyngeal breathing is
indicated in subjects with severe weakness of muscles of
inspiration like high spinal cord injury [14]. This technique is
often called frog breathing [15] and involves using the tongue to
move air into the lungs. Procedure is such that subject takes
several gulps of air. Then the mouth is closed, tongue pushes
the air back and traps it in the pharynx, air is then forced into
the lungs when glottis is opened [8] Each gulp of air delivers 60
to 200 mL of air to the inspiratory volume [16]. Six to nine
gulps are stacked together for its effectiveness. This technique
increases the depth of inspiration, vital capacity, Peak
expiratory flow rate and maximal voluntary ventilation [17].
Abdominal breathing exercise is the only breathing exercise
where expiration is done first followed by inspiration. This
exercise is indicated in subjects who are paralysed or
extremely weak diaphragms but with good abdominal and
accessory muscle strength. The procedure includes contraction
of abdominal muscles tightly followed by its relaxation.
Muscle contraction increases abdominal pressure pushes the
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International Journal of Physical Education, Sports and Health
diaphragm to unusually high position in thorax. When
abdominal muscles are relaxed the diaphragm passively falls
to produce expiration accessory muscles can assist with this
inspiratory effort to produce greater tidal volume. The
disadvantages are every time to breathe in a conscious effort is
necessary, subject must be in upright position to provide this
exercise and subjects require mechanical ventilation during
lying and sleep [9].
Any individual with paradoxical breathing or a poorly
expanding chest wall during inspiration should learn to
perform an airshift maneuver. When an individual has a
dominant diaphragmatic breathing pattern that results in
collapse of the anterior chest wall (as occurs in those with C4-
T4 motor complete injuries), the volume of air moving into
lungs does not act to expand the chest wall but instead moves
in a caudal direction [15] An air shift is a maneuver in which a
person inhales maximally, closes the glottis and relaxes the
diaphragm to the individual to move the air upward toward the
middle and upper lobes of the chest and creates expansion of
these regions. Practice with opening mouth. It can potentially
expand the chest from half to 2 inch. Position the patient in
supine lying. Ask the patient to take deep breath and hold that
breath. While holding the breath, therapist asks the patient to
suck in the abdomen so that air will move from lower part to
upper part of thorax. Instruct the patient to perform this
exercise daily. With Airshift technique, chest mobility can be
maintained for subjects who are with good chest wall range of
motion and intercostals muscle weakness. The uses are to
increase ROM of chest and a method of learning laryngeal
control. As both Airshift and stacked breathing techniques
used for achieving laryngeal control, they can be used for
better effectiveness of cough. Air shift Maneuver can be used
also for generalized collapses. The possible complications are
consequences associated with breath holding and
hyperventilation. To avoid this, individual should exhale
between attempts and should rest frequently in the training
sessions [9, 18].
Chest mobility exercises and Belt exercises [8, 19] are used to
prevent the formation of disabling adhesions between two
layers of pleura. Chest mobilization exercises can be defined
as any exercises that combine active movements of the trunk
or extremities with deep breathing. They are designed to
maintain or improve mobility of the chest wall, trunk, and
shoulder girdles when it affects ventilation or postural
alignment. These exercises are indicated mainly in Pleural
disorders, especially after ICD removal for increasing mobility
of one side of thorax and preventing adhesions between two
layers of pleura. Procedure is such that ask the patient to bend
away from affected side and expand that side during
inspiration. Then, have the patient push the fisted hand into the
lateral aspect of the chest, bend toward the tight side, and
breathe out. Belt exercises serve the purpose same as that of
chest mobility exercise where the difference is that
reinforcement over the chest is given with the help of a rolled
bed sheet. Belt exercises aid in increasing the mobility of lateral
basal (unilateral & bilateral) and posterior basal segments.
Impaired airway clearance can be interrupted by mucolytics,
nutrition, broncho dilators, anti-inflammatories, antibiotics and
airway clearance techniques. Airway clearance techniques or
bronchial hygiene therapy includes traditional methods like
coughing, huffing and manual drainage techniques such as
postural drainage, percussion, vibration & shaking where as
newer methods includes Mechanical devices like high
frequency oscillation, positive expiratory pressure mask,
flutter valve, intrapulmonary percussive ventilator & Breathing
strategies such as autogenic drainage(AD) and active cycle
breathing technique(ACBT). They foster independence
because once taught they can be used without assistance. They
are suited for the people with chronic lung problems. ACBT
consists of three phases breathing control, thoracic expansion
and forced expiratory technique (FET). FET consists of low
huffs and high huffs interspersed with breathing control. AD is
a Method of controlled breathing in which patient adjust the
rate location and depth of respiration. It can be of Belgian
approach and German approach. Belgian approach is divided
into three phases such as unsticky phase, collecting phase and
evacuating phase where as German approach has only one
phase [20].
In patients with obstructive disorders there will be reduction of
flow rate and increase in residual volume & total lung
capacities. They predominantly use accessory muscles so work
of breathing is increased. So goals of the management are to
change the breathing pattern, reduce work of breathing and use
more of energy conservation techniques. These types of
patients have a period of acute exacerbation followed by their
stable phase. Breathing Control Technique, Innocenti
Technique, and Pursed Lip Breathing is used during acute
exacerbation and End – Expiratory, Buteyko Breathing, Exhale
with Activity, Stressed Respiratory Exercises, Panting, Pacing
are commonly used when the subjects are in stable phase.
Breathing control is synonymous with diaphragmatic
breathing. But the only difference is that in diaphragmatic
breathing, it is done with maximal inspiration where as in
breathing control technique is performed at normal tidal
volume. The application of breathing control technique
includes its use along with FET and to control breathlessness.
Pursed Lip breathing exercise (PLB) stresses on expiration
therefore it can be used to control breathlessness and to reduce
work of breathing. It keeps airways open by creating back
pressure in the airways. The procedure is such that subject
loosely purse the lips and exhale (like blowing out a match
stick or candle). PLB decrease respiratory rate, increase tidal
volume, improves exercises tolerance. It can be active and
passive. PLB with forceful Expiration can increase turbulence
in airways and cause further restriction. Innocenti technique
aimed to prevent forceful expiration there by reduction of
excess energy consumption and improves expiratory flow.
Procedure is that at each breath instructs the subject to inhale
just before abdominal muscle recruitment. This allows smooth
transition from inspiration to expiration practice first with
physiotherapist voice then without. It helps to prevent airway
shutdown consumes less energy than pursed lip breathing
thereby improving PaO2 [6].
End – expiratory hold mimics as that of Buteyko breathing.
This technique is performed by slowing respiratory rate with
breath counting and at night, lying on left side and taping
mouth closed. The hold at the end of expiration elevates
PaCO2 which helps in broncho dilatation during stable phase.
This technique reverses the symptoms, lessens the need for
medication and prevents asthma attacks. Tension due to fear
and anxiety prevents full relaxation of muscles of inspiration,
therefore FRC is not attained. So Stressed Expiratory exercises
can be given to these types of subjects. It can give also to aid
clearance of secretions. Also this exercise allows identifying
presence of secretions from the sounds. The unwanted side
effect can be production of low lung volume. There are two
types of stressed expiratory exercises. The first type is high
volume high velocity where subject can do either relaxed
expiration to FRC from VC ( no real forcing of expiration) or
Panting where subjects inhale to VC , briefly exhale forcefully
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International Journal of Physical Education, Sports and Health
at high lung volume, inhale to VC and repeat several times.
The other type is Low volume (similar to Huff) High or low
velocity. In this technique subjects will Inhale to VC and
exhale without inhaling 3-4 times down to RV [7].
Pacing is a technique where breathing is coordinated with
activity. This can decrease WOB and relieve dyspnea during
activity. Subject and therapist simply test different inspiratory
to expiratory ratios with various activities like Cycling,
walking, stair climbing until they find the rate and pattern that
lower RR, relieves dyspnea and possibly improves SaO2.
Exhale with effort is employed only in most severely impaired
subjects or those with greatest complaints of dyspnea. The
procedure for this technique is to teach the subjects to break
any activity into one or more breaths (bending, lifting, getting
out of bed). Then Steps are, inhale during rest with
Diaphragmatic breaths, Exhale through pursed lips during
activity, Repeat sequence. Stopping of motion during
inspiration and continuing until activity is accomplished [3].
Inspiratory muscle training can be classified as low pressure
high flow loading or high pressure low flow loading. In low
pressure high flow loading also called as Normocapneic
hyperpneic training increase the rate of breathing without
altering PaCO2 value. In this technique subjects were asked to
breath at the highest rate they can manage for 15- 30 minutes.
A rebreathing circuit (polyethene bag, face mask) or addition
of CO2 to inspired air must be used to prevent hypocapnia.
The purpose is to increase endurance of respiratory muscles.
High pressure low flow loading can be of two types
Inspiratory resistive training or Inspiratory threshold training.
The Purpose of Inspiratory Resistive training is that to increase
strength and endurance of Respiratory muscles. In this method
the subject inhales through the tube of varying diameter. If
diameter is narrow, there will be more resistance in the tube.
First use the tube with greater diameter then gradually reduce
the diameter. Limitation of this method is that there will be
unreliable training loads if flow is controlled. In
Diaphragmatic training using weights mechanical resistance
will be given for diaphragm muscle for the subjects with
cervical and high thoracic lesions. Subject placed in supine
position. Weight pan is placed over the epigastric region.
Subjects with neurologically intact diaphragm can usually start
with 5 pounds. If a subject begins to use sternocleido mastoid,
weight should be decreased [3].
Breathing cycle technique is used in subjects with chronic
hyperventilation syndrome where there are no organic causes.
Low level of CO2 produces systemic effects such as
palpitation, tachycardia, breathlessness, dysphagia, dizziness
muscle pain; head ache etc. In this technique there will be
history of emotional disturbance. A sequence of instructions
will be given. In out in out in out, In out and in out and in, In
out two three in out two three, In and out two three in and out,
In and out two relax hold wait in and In one two out two three
four five and in one two out. The inclusion of instructions such
as “and” and numbers make the patient calm down from
breathlessness there by relieving from breathlessness [19].
Suggested sequence for administering breathing exercises
1) Assessment: Assess for any indication for breathing
exercises as mentioned before.
2) Preparation for breathing exercises-Patient should be
relaxed position. Prior to teaching breathing exercises,
perform bronchial drainage if required. The subjects can
be given broncho dilators through nebulisation and
humidification if required. Humidification to counteract
dry atmosphere and dehydration Analgesics may be
prescribed, if pain is inhibiting deep breathing.
3) Choice of breathing patterns. Normally subjects
predominantly use apical pattern. So stress lateral costal
and diaphragmatic breathing or a combination. Unilateral
breathing exercise can be given in case of lobectomy.
Manual contact is given to provide extraceptive input and
proprioceptive input. Also assist expiration by assisting
the downward and inward movement of chest wall. In
subjects with mild chronic disease or those after acute
exacerbation, who are using accessory muscles, their use
must be discouraged. In subjects with severe lung
impairment or those with acute exacerbation, therapist
should not attempt to alter the pattern.
4) Choice of starting position: If no dyspnoea present,
position should allow for freedom by movement of
diaphragm and rib cage and also allow the subject to
concentrate on breathing. The arms relaxed by sides to
prevent tension in Thoraco-humeral muscles. Lumbar
spine flattened and abdominal wall relaxed as in half
lying, sitting crook lying half lying. Choose position
which allows for greatest excursion of diaphragm. In
supine lying greater resistance of weight of abdominal
viscera which may be present if subject is horizontal or
tipped head down. Gravity tends to assist descend of
diaphragm in the upright position but it is only capable of
small excursion since it is already very low in position. In
side lying, isolation of lateral costal expansion is possible
for upper most lungs. Diaphragmatic breathing in side
lying will preferentially distribute inspired air to
dependent lung. If dyspnoea is present, ensure relaxation
of abdominals by hip flexed sitting assisted by gravity the
descend of diaphragm during inspiration, Increase activity
of neck extension than neck flexors compresses viscera
and pushes a low diaphragm up enhancing its potential for
improved excursion. Perfusion will be more in the upper
lobes in tipped position improves V/Q matching which is
helpful in pan lobular emphysema, which affects lower
lobe. Lying supine flat tipped down to maximum of 15 to
20 degree puts diaphragm at higher level to improved
excursion counteracted by air trapping which prevents
upward movement reduces advantage. Tip of more than
20 degrees produces more weight on the diaphragm which
further reduces by ascites and obesity [7].
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