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International Journal of Physical Education, Sports and Health 2015; 2(2): 237-241
P-ISSN: 2394-1685
E-ISSN: 2394-1693 Breathing techniques- A review
Impact Factor (ISRA): 4.69
IJPESH 2015; 2(2): 237-241
© 2015 IJPESH Subin Solomen, Pravin Aaron
www.kheljournal.com
Received: 05-09-2015
Accepted: 08-10-2015 Abstract
Physiotherapy should be offered to patients with a variety of medical respiratory conditions with the aim
Subin Solomen of breathlessness management and symptom control, mobility and function improvement or maintenance,
Professor, Affiliated to COPMS, and airway clearance and cough enhancement or support. Breathing exercises is used as strategy in Lung
EMCHRC, Perinthalmanna, expansion therapy, Bronchial hygiene therapy and PT techniques to reduce work of breathing. Breathing
Kerala, India. 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
Pravin Aaron conditions. In restrictive types of disorders Deep Breathing, Diaphragmatic Breathing, Deep
Principal, Affiliated to Diaphragmatic Breathing, End – Inspiratory hold, Sustained Maximal Inspiration, Slow Maximal
Padmashree Institute of Inspiration, Incentive Spirometer, Sniff, Segmental (Apical and Lateral Costal Activity) are commonly
Physiotherapy, Bangalore, used. Abdominal Breathing, Air Shift Breathing, Glossopharyngeal Breathing are commonly effective in
India.
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
[2]
and PT techniques to reduce work of breathing to address the above problems . 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
[3]
alteration of a given Breathing pattern are categorized as breathing exercises . 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
[3, 4, 5]
obesity, relaxation response for stress reduction and to control pain in natural child birth .
Correspondence Breathing exercise can be classified as inspiratory and expiratory. Some of the breathing
Subin Solomen exercises stresses inspiration thereby increasing lung volume where as others stresses on
Professor, Affiliated to COPMS, expiration which assists in clearance of secretions.
EMCHRC, Perinthalmanna, In restrictive disorders of lungs, atelectasis, consolidation, pleural effusion and pneumothorax
Kerala, India. [6]
there will be reduction of lung volume and capacities .
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International Journal of Physical Education, Sports and Health
[7]
Therefore the main aim is to improve expansion of lungs. The exercises may elicit localised drop in intra pleural pressure
mechanism of improvement of lung expansion can be due to thereby increasing transpulmonary pressure gradient which
increase in transpulmonary pressure gradient, boosting results in expansion. Manual cues such as vibration or pressure
collateral ventilation and by physiology of interdependence. sensation are provided over the regions of chest wall that is not
[7, 12, 13]
Breathing exercises can be given if patient is conscious and expanding well may also aid in expansion . Three types
[2]
cooperative . of segmental breathing that target the apical, lateral and
In restrictive types of disorders Deep Breathing, posterior segments of the lower lobes are apical expansion
Diaphragmatic Breathing, Deep Diaphragmatic Breathing, End exercises, lateral costal breathing and posterior basal
[8]
– Inspiratory hold, Sustained Maximal Inspiration, Slow expansion exercises .
[7] [2] [6]
Maximal Inspiration, Incentive Spirometer, Sniff, The following technique further stresses inspiration. First
Segmental (Apical and Lateral Costal Activity) are commonly squeeze chest during expiration then stretch at the very end of
[8] [9] [10]
used . Abdominal Breathing , Air Shift Breathing, expiration, allow inspiration to occur. Near the end of
Glossopharyngeal Breathing are commonly effective in spinal inspiration apply a series of 3 or 4 gentle stretches rather
[7] [7]
cord injuries. Stacked Breathing , Air Shift Breathing are similar to repeated contractions .
used in localized and generalised atelectasis of upper lobe Stacked breathing is the only breathing exercise where there is
respectively. Chest mobility exercises and Belt exercises are more inspiratory efforts compared to a single expiratory effort.
used to prevent the formation of disabling adhesions between In this technique subjects have to breathe in 3-4 times without
two layers of pleura [8]. expiration, each time filling the lung a little bit more up to vital
In Deep Breathing subjects were asked to breathe in deeply capacity. This exercise is better fit for individuals with weak
and slowly through the nose and sigh out through the mouth. respiratory muscles to achieve full inspiration prior to a cough.
Breathing through nose warms and humidifies air but doubles A glottis closure between each attempt allows a buildup of
resistance to air flow. Inspiration is slow to decrease velocity extra volume with in the lungs, thereby achieving a good
and increase the strength of muscle contraction. Expiration is laryngeal control. Stacked breathing technique is also used
[7]
through the mouth to keep the airway open patency of small mainly for localised collapses .
[6]
airway closure . In a slow maximal inspiration, subject asked to do slow
In Diaphragmatic breathing, the subjects were asked to get inspiration for as long as possible. This keeps the glottis open
comfortable position. They were instructed to rest the and air can continue to move. This encourages recruitment of
dominant hand on your abdomen with elbows supported and all muscle fibers. A sustained maximal inspiration is a slow,
keeping their shoulder relaxed. Allow their hand to rise gently deep inhalation from FRC up to the total lung capacity,
[8]
while visualizing air filling the abdomen like a balloon . followed by 5 to 10 sec breath hold. Both of these techniques
Progress this exercises to side lying and relaxed standing. The can increase lung expansion by altering transpulmonary
beneficial effects are improving pulmonary function and pressure gradient, boosting collateral ventilation and
ventilation. One of the detrimental effects is decreased efficacy improving the physiology of interdependence. Incentive
there by increased dyspnea. This may due to inadequate Spirometry which was developed by Barlett et al. uses the
learning; subjects may have to carry out a more consciousness principle of sustained maximal inspiration. It was designed to
during diaphragmatic breathing and if optimal positioning is mimic natural sighing or yawning by encouraging the subject
not used there will be limited diaphragmatic excursion. The to take long slow deep breaths and hold. Types of incentive
other detrimental effect is paradoxical breathing. In COPD spirometer are flow oriented and volume oriented spirometer.
there will be flattening of diaphragm and greater use of Volume spirometer indicate volume achieved during sustained
accessory muscles so there will be greater pull on upper maximal inspiration (eg coach spirometer, voldyne) and flow
thorax-inwards which results in paradoxical breathing. Good oriented spirometer indicates degree of inspiratory flow (eg
candidate of COPD will be those who are having mild Triflo, mediflo) [2]
. Contraindications include unconscious
obstruction with elevated respiratory rate, low tidal volume subjects, unable to co-operate. Hazards are hyperventilation,
and abnormal ABG. Poor candidate will be those who are hypoxemia, exaggerating bronchospasm.
having moderate to severe COPD with marked hyperinflation. Abdominal Breathing, Air Shift Breathing, Glossopharyngeal
Deep diaphragmatic breathing is a combination of deep Breathing are commonly effective in improving respiratory
[11]
breathing with diaphragmatic breathing . function in spinal cord injuries. Glossopharyngeal breathing is
End – inspiratory technique can be administered along with indicated in subjects with severe weakness of muscles of
[14]
deep diaphragmatic breathing to further stress the inspiration. inspiration like high spinal cord injury . This technique is
[15]
By this method air can be entered into poorly ventilated often called frog breathing and involves using the tongue to
regions. It boosts collateral ventilation. It is not suitable for move air into the lungs. Procedure is such that subject takes
[6]
breathless people . several gulps of air. Then the mouth is closed, tongue pushes
Sniff is a simple and effective technique used to increase the air back and traps it in the pharynx, air is then forced into
[8]
diaphragmatic excursion further along with deep the lungs when glottis is opened Each gulp of air delivers 60
[16]
diaphragmatic exercises. It augments collateral circulation. to 200 mL of air to the inspiratory volume . Six to nine
Perform the normal diaphragmatic breathing exercise as gulps are stacked together for its effectiveness. This technique
mentioned above. Then ask the subject to sniff in three times. increases the depth of inspiration, vital capacity, Peak
[17]
During exhalation, tell the subjects to let it out slow which expiratory flow rate and maximal voluntary ventilation .
help to decrease RR and some relaxation. Progressively Abdominal breathing exercise is the only breathing exercise
[6]
decrease the no of sniffs as the day progresses . where expiration is done first followed by inspiration. This
Hypoventilation does occur in certain areas of the lungs exercise is indicated in subjects who are paralysed or
because of chest wall fibrosis, pain, and muscle guarding after extremely weak diaphragms but with good abdominal and
surgery, atelectasis and pneumonia. So in these circumstances accessory muscle strength. The procedure includes contraction
Segmental exercises can be given to increase localised of abdominal muscles tightly followed by its relaxation.
[8]
expansion of the lungs .The techniques used with segmental 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 strategies such as autogenic drainage(AD) and active cycle
abdominal muscles are relaxed the diaphragm passively falls breathing technique(ACBT). They foster independence
to produce expiration accessory muscles can assist with this because once taught they can be used without assistance. They
inspiratory effort to produce greater tidal volume. The are suited for the people with chronic lung problems. ACBT
disadvantages are every time to breathe in a conscious effort is consists of three phases breathing control, thoracic expansion
necessary, subject must be in upright position to provide this and forced expiratory technique (FET). FET consists of low
exercise and subjects require mechanical ventilation during huffs and high huffs interspersed with breathing control. AD is
[9]
lying and sleep . a Method of controlled breathing in which patient adjust the
Any individual with paradoxical breathing or a poorly rate location and depth of respiration. It can be of Belgian
expanding chest wall during inspiration should learn to approach and German approach. Belgian approach is divided
perform an airshift maneuver. When an individual has a into three phases such as unsticky phase, collecting phase and
dominant diaphragmatic breathing pattern that results in evacuating phase where as German approach has only one
collapse of the anterior chest wall (as occurs in those with C4- [20].
phase
T4 motor complete injuries), the volume of air moving into In patients with obstructive disorders there will be reduction of
lungs does not act to expand the chest wall but instead moves flow rate and increase in residual volume & total lung
[15]
in a caudal direction An air shift is a maneuver in which a capacities. They predominantly use accessory muscles so work
person inhales maximally, closes the glottis and relaxes the of breathing is increased. So goals of the management are to
diaphragm to the individual to move the air upward toward the change the breathing pattern, reduce work of breathing and use
middle and upper lobes of the chest and creates expansion of more of energy conservation techniques. These types of
these regions. Practice with opening mouth. It can potentially patients have a period of acute exacerbation followed by their
expand the chest from half to 2 inch. Position the patient in stable phase. Breathing Control Technique, Innocenti
supine lying. Ask the patient to take deep breath and hold that Technique, and Pursed Lip Breathing is used during acute
breath. While holding the breath, therapist asks the patient to exacerbation and End – Expiratory, Buteyko Breathing, Exhale
suck in the abdomen so that air will move from lower part to with Activity, Stressed Respiratory Exercises, Panting, Pacing
upper part of thorax. Instruct the patient to perform this are commonly used when the subjects are in stable phase.
exercise daily. With Airshift technique, chest mobility can be Breathing control is synonymous with diaphragmatic
maintained for subjects who are with good chest wall range of breathing. But the only difference is that in diaphragmatic
motion and intercostals muscle weakness. The uses are to breathing, it is done with maximal inspiration where as in
increase ROM of chest and a method of learning laryngeal breathing control technique is performed at normal tidal
control. As both Airshift and stacked breathing techniques volume. The application of breathing control technique
used for achieving laryngeal control, they can be used for includes its use along with FET and to control breathlessness.
better effectiveness of cough. Air shift Maneuver can be used Pursed Lip breathing exercise (PLB) stresses on expiration
also for generalized collapses. The possible complications are therefore it can be used to control breathlessness and to reduce
consequences associated with breath holding and work of breathing. It keeps airways open by creating back
hyperventilation. To avoid this, individual should exhale pressure in the airways. The procedure is such that subject
between attempts and should rest frequently in the training loosely purse the lips and exhale (like blowing out a match
[9, 18] stick or candle). PLB decrease respiratory rate, increase tidal
sessions .
[8, 19] volume, improves exercises tolerance. It can be active and
Chest mobility exercises and Belt exercises are used to
prevent the formation of disabling adhesions between two passive. PLB with forceful Expiration can increase turbulence
layers of pleura. Chest mobilization exercises can be defined in airways and cause further restriction. Innocenti technique
as any exercises that combine active movements of the trunk aimed to prevent forceful expiration there by reduction of
or extremities with deep breathing. They are designed to excess energy consumption and improves expiratory flow.
maintain or improve mobility of the chest wall, trunk, and Procedure is that at each breath instructs the subject to inhale
shoulder girdles when it affects ventilation or postural just before abdominal muscle recruitment. This allows smooth
alignment. These exercises are indicated mainly in Pleural transition from inspiration to expiration practice first with
disorders, especially after ICD removal for increasing mobility physiotherapist voice then without. It helps to prevent airway
of one side of thorax and preventing adhesions between two shutdown consumes less energy than pursed lip breathing
[6]
layers of pleura. Procedure is such that ask the patient to bend thereby improving PaO2 .
away from affected side and expand that side during End – expiratory hold mimics as that of Buteyko breathing.
inspiration. Then, have the patient push the fisted hand into the This technique is performed by slowing respiratory rate with
lateral aspect of the chest, bend toward the tight side, and breath counting and at night, lying on left side and taping
breathe out. Belt exercises serve the purpose same as that of mouth closed. The hold at the end of expiration elevates
chest mobility exercise where the difference is that PaCO2 which helps in broncho dilatation during stable phase.
reinforcement over the chest is given with the help of a rolled This technique reverses the symptoms, lessens the need for
bed
sheet. Belt exercises aid in increasing the mobility of lateral medication and prevents asthma attacks. Tension due to fear
basal (unilateral & bilateral) and posterior basal segments. and anxiety prevents full relaxation of muscles of inspiration,
Impaired airway clearance can be interrupted by mucolytics, therefore FRC is not attained. So Stressed Expiratory exercises
nutrition, broncho dilators, anti-inflammatories, antibiotics and can be given to these types of subjects. It can give also to aid
airway clearance techniques. Airway clearance techniques or clearance of secretions. Also this exercise allows identifying
bronchial hygiene therapy includes traditional methods like presence of secretions from the sounds. The unwanted side
coughing, huffing and manual drainage techniques such as effect can be production of low lung volume. There are two
postural drainage, percussion, vibration & shaking where as types of stressed expiratory exercises. The first type is high
newer methods includes Mechanical devices like high volume high velocity where subject can do either relaxed
frequency oscillation, positive expiratory pressure mask, expiration to FRC from VC ( no real forcing of expiration) or
flutter valve, intrapulmonary percussive ventilator & Breathing Panting where subjects inhale to VC , briefly exhale forcefully
~ 239 ~
International Journal of Physical Education, Sports and Health
at high lung volume, inhale to VC and repeat several times. 3) Choice of breathing patterns. Normally subjects
The other type is Low volume (similar to Huff) High or low predominantly use apical pattern. So stress lateral costal
velocity. In this technique subjects will Inhale to VC and and diaphragmatic breathing or a combination. Unilateral
[7]
exhale without inhaling 3-4 times down to RV . breathing exercise can be given in case of lobectomy.
Pacing is a technique where breathing is coordinated with Manual contact is given to provide extraceptive input and
activity. This can decrease WOB and relieve dyspnea during proprioceptive input. Also assist expiration by assisting
activity. Subject and therapist simply test different inspiratory the downward and inward movement of chest wall. In
to expiratory ratios with various activities like Cycling, subjects with mild chronic disease or those after acute
walking, stair climbing until they find the rate and pattern that exacerbation, who are using accessory muscles, their use
lower RR, relieves dyspnea and possibly improves SaO2. must be discouraged. In subjects with severe lung
Exhale with effort is employed only in most severely impaired impairment or those with acute exacerbation, therapist
subjects or those with greatest complaints of dyspnea. The should not attempt to alter the pattern.
procedure for this technique is to teach the subjects to break 4) Choice of starting position: If no dyspnoea present,
any activity into one or more breaths (bending, lifting, getting position should allow for freedom by movement of
out of bed). Then Steps are, inhale during rest with diaphragm and rib cage and also allow the subject to
Diaphragmatic breaths, Exhale through pursed lips during concentrate on breathing. The arms relaxed by sides to
activity, Repeat sequence. Stopping of motion during prevent tension in Thoraco-humeral muscles. Lumbar
[3].
inspiration and continuing until activity is accomplished spine flattened and abdominal wall relaxed as in half
Inspiratory muscle training can be classified as low pressure lying, sitting crook lying half lying. Choose position
high flow loading or high pressure low flow loading. In low which allows for greatest excursion of diaphragm. In
pressure high flow loading also called as Normocapneic supine lying greater resistance of weight of abdominal
hyperpneic training increase the rate of breathing without viscera which may be present if subject is horizontal or
altering PaCO2 value. In this technique subjects were asked to tipped head down. Gravity tends to assist descend of
breath at the highest rate they can manage for 15- 30 minutes. diaphragm in the upright position but it is only capable of
A rebreathing circuit (polyethene bag, face mask) or addition small excursion since it is already very low in position. In
of CO2 to inspired air must be used to prevent hypocapnia. side lying, isolation of lateral costal expansion is possible
The purpose is to increase endurance of respiratory muscles. for upper most lungs. Diaphragmatic breathing in side
High pressure low flow loading can be of two types lying will preferentially distribute inspired air to
Inspiratory resistive training or Inspiratory threshold training. dependent lung. If dyspnoea is present, ensure relaxation
The Purpose of Inspiratory Resistive training is that to increase of abdominals by hip flexed sitting assisted by gravity the
strength and endurance of Respiratory muscles. In this method descend of diaphragm during inspiration, Increase activity
the subject inhales through the tube of varying diameter. If of neck extension than neck flexors compresses viscera
diameter is narrow, there will be more resistance in the tube. and pushes a low diaphragm up enhancing its potential for
First use the tube with greater diameter then gradually reduce improved excursion. Perfusion will be more in the upper
the diameter. Limitation of this method is that there will be lobes in tipped position improves V/Q matching which is
unreliable training loads if flow is controlled. In helpful in pan lobular emphysema, which affects lower
Diaphragmatic training using weights mechanical resistance lobe. Lying supine flat tipped down to maximum of 15 to
will be given for diaphragm muscle for the subjects with 20 degree puts diaphragm at higher level to improved
cervical and high thoracic lesions. Subject placed in supine excursion counteracted by air trapping which prevents
position. Weight pan is placed over the epigastric region. upward movement reduces advantage. Tip of more than
Subjects with neurologically intact diaphragm can usually start 20 degrees produces more weight on the diaphragm which
with 5 pounds. If a subject begins to use sternocleido mastoid, further reduces by ascites and obesity [7]
.
[3]
weight should be decreased .
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