BREATHING EXERCISES

BREATHING EXERCISES1Also called as ventilatory training.An aspect of management to improve pulmonary status and to increase a patients 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 patients overall function in daily living activities.Depending on a patients 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.

2Goals of Breathing Exercises andVentilatory Muscle Training

Improve or redistribute ventilation. Increase the effectiveness of the cough mechanism and promote airway clearance. Prevent postoperative pulmonary complications. Improve the strength, endurance, and coordination of the muscles of ventilation. Maintain or improve chest and thoracic spine mobility. Correct inefficient or abnormal breathing patterns and decrease the work of breathing. Promote relaxation and relieve stress. Teach the patient how to deal with episodes of dyspnea. Improve a patients overall functional capacity for daily living, occupational, and recreational activities.Aid in bronchial hygiene---Prevent accumulation of pulmonary secretions, mobilization of these secretions, and improve the cough mechanism. 3Indications of breathing exercisesCystic fibrosisBronchiectasisAtelectasisLung abscessNeuromuscular diseasesPneumonias in dependent lung regions.Acute or chronic lung diseaseCOPD For patients with a high spinal cord lesion/ Deficits in CNS: spinal cord injury, myopathies etc. Prophylactic care of preoperative patient with history of pulmonary problems After surgeries (thoracic or abdominal surgery)Airway obstruction due to retained secretions.For patients who must remain in bed for an extended period of time.As relaxation procedure.4Guidelines 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-Fowlers 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.5Observe and assess the patients spontaneous breathing pattern while at rest and later with activity.Determine whether ventilatory training is indicated.Establish a baseline for assessing changes, progress, andoutcomes 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 patients 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.

6PRECAUTIONS:When teaching breathing exercises, be aware of the following precautions: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.Do not allow a patient to take a highly prolonged expiration. This causes the patient to gasp with the next inspiration. The patients breathing pattern then becomes irregular and inefficient.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.Allow the patient to perform deep breathing for only three or four inspirations and expirations at a time to avoid hyperventilation.7CONTRAINDICATIONS:Increased ICPUnstable head or neck injuryActive hemorrhage with hemodynamic instability or hemoptysisRecent spinal injuryEmpymaBronchoplueral fistulaFlail chestUncontrolled hypertensionAnticoagulationRib or vertebral fractures or osteoporosisAcute asthma or tuberculosisPatients who have recently experienced aheartattack. Patients with skin grafts or spinal fusions will have undue stress placed on areas of repair.

8Bony 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 pneumothoraxChest tubes. 9TYPES OF BREATHING EXERCISES:Diaphragmatic breathing Pursed lip breathing Segmental breathing(costal expansion exercise) a)Apical breathing b)lateral costal expansion c)Posterior basal expansion Sustained maximal inspiration (deep breathing)

10DIAPHRAGMATIC BREATHING

The semireclining (as shown) and semi-Fowlers 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.11GOALS OF DIAPHRAGMATIC BREATHING:To improve the efficiency of ventilation and oxygenationDecrease the work of breathingIncrease the excursion (descent or ascent) of the diaphragmImprove gas exchange and oxygenation.Diaphragmatic breathing exercises also are used during postural drainage to mobilize lung secretions.Reduces work of breathingReduces the incidence of post operative pulmonary complicationsImprove ventilationEliminates accessory muscle activity Decrease respiratory rate Increase tidal ventilation Improve distribution of ventilation12PROCEDURE/ TECHNIQUE:Prepare the patient in a relaxed and comfortable position in which gravity assists the diaphragm, such as a semi- Fowlers position.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).Diaphragmatic breathing enhance diaphragmatic descent during inspiration and diaphragmatic ascent during expiration Physiotherapist assist diaphragmatic ascent by directing the patient to allow the abdomen to retract gradually during exhalation or by contracting abdominal muscles actively Diaphragmatic descent is assisted by directing the patient to protract the abdomen gradually during inhalation.

13Place your hand(s) on the rectus abdominis just below anterior costal margin. Ask the patient to breathe in slowly and deeply through the nose. 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.Have the patient practice this three or four times and then rest. Do not allow the patient to hyperventilate.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.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 patients hand should rise slightly during inspiration and fall during expiration.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).14RE 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.

15Resisted 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 BREATHING16PURSED LIP BREATHINGPursed-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 ventilationReleases trapped air in the lungsKeeps the airways open longer and decreases the work of breathingProlongs