Breathing retraining (exercise)

Many patient suffering from respiratory diseases need to be taught a more relaxed and
economical pattern of breathing also to improve the efficiency and less work of
breathing .

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Indications of breathing exercises

Acute or chronic lung disease
Chronic obstructive lung disease
Pneumonia
Atelectasis
Acute respiratory distress
2-pain in abdominal and thoracic area because of surgery or trauma
3-air way obstruction due to bronchospasm or secretions
4-deficits in central nervous system lead to muscle weakness
5-sever orthopedic abnormality that affect respiration(scoliosis,kyphosis)
Goals of breathing exs
Improve ventilation and respiration
Increase the effectiveness of cough mechanism
Improve strength , endurance and coordination of respiratory muscles
Maintain and improve chest and thoracic spine mobility
Correct any abnormal breathing patterns
Promote relaxation
Precautions when doing breathing exs
Never allow the patient to force expiration, expiration should be relaxed and
passive forced expiration increases the turbulation of air in the air way which may
lead to bronchospasm
Dont allow the patient to take a prolonged expiration this will lead the patient to
gasp with the next inspiration.leading to irregular breathing pattern
Dont allow the patient to initiate inspiration with accessory ms advise him to keep
upper chest quiet
Allow the patient to practice deep breathing for only three or four cycles at a time
to avoid hyperventilation
..
Physiological base of breathing exercise:
Normal respiratory cycle consisted of inspiration, expiration, and pause 1:2 ratio.
-----INSPIRATION: Inspiration is the active part of the breathing process, which is
initiated by the respiratory control centre in medulla oblongata (Brain stem).
Activation of medulla causes a contraction of the diaphragm and intercostal muscles
leading to an expansion of thoracic cavity and a decrease in the pleural space pressure
-----EXPIRATION: Expiration is a passive event due to elastic recoil of the lungs
-----COUPLING OF THE LUNGS AND THE CHEST WALL: The lungs are not
directly attached to the chest wall but they change their volume and shape according
to the changes in shape and volume of the thoracic cavity. Pleura covering the

surfaces of the lungs (visceral) or the thoracic cavity (parietal) together with a thin
(20 m) layer of liquid between them create a liquid coupling
Air enters the lungs through the mouth or nose and travels down to windpipe (trachea)
into increasingly smaller airways. The structure of the airway tubes is similar to a tree
trunk dividing into smaller and smaller branches. The smallest tube, which is about
the thickness of a strand of hair, ends in bunches of tiny air sacs (alveoli). Each air sac
is covered with very fine blood vessels (capillaries). When breathing in air, the air
moves through the airways down to the air sacs. The oxygen passes from the air sacs
into the blood stream and is carried to the rest of the body
Deep Breathing Exercises
Nose exercise
Aims:
To strength the diaphragm and the intercostal muscles.
To increase expansion of the lungs.
Loosening of thick secretions.
Teach the patient the right way of breathing.
Graduations of Nose Exercises
1. Massage beside the nose (nose muscles) (for stimulation).
2. Feel the air at the tip of the nose.
3. Smelling of the surroundings.
4. Narrowing of one opening.
5. Shaking above the nose.
6. Sniffle (long breathing).
7. Snuffle (short breathing).
8. Massage beside the nose. (for relaxation).
2-Pursed lips breathing:
Aims:
1-Reduces the respiratory rate.
2-Increases tidal volume.
3-It relives dyspnea, increase exercise tolerance.
4-Pursed lips breathing prevent collapse of the small air ways as it reflect a positive
pressure in the small air ways at the end of expiration which will prevent air trapping

Breathe in (inhale) slowly through nose for two counts, keep mouth closed
"purse" lips (o-shape mouth).
Breathe out (exhale) slowly and gently through your nose(Breathe out twice
longer as you breathe in)
3-Diaphragmatic breathing exercise
Aims:
1- To control breathing during attacks of dyspnea and during exertion.
2- To improve ventilation in the bases of the lungs and to loosen secretions
3- Strength Diaphragm Excursion
4- Prevent Post operative complications
5- Increases rib cage motion
Application
- Set the patient in a comfortable position.
- Place your hand in the patients abdomen.
- Instruct the patient to breathe in into my hand. Feel your abdomen gently rise and
push my hand upwards.
- Begin with guiding the movement with your hands, and then increase the resistance
gradually.
- During expiration, resistance should not reduce suddenly; rather the weight of the
hand should follow the abdomen back to the resting position.
- When patient had mastered the breathing pattern in supine, progress to sitting,
standing, walking and finally stairs

- Place patient's hands over his abdomen at level of xiphoid process and let him feel
his abdomen move in and out

Resisted diaphragmatic breathing:

Patient expire under slight pressure gently not forcibly of therapist hand on patient's
abdomen (xiphoid process level)
Place weight (sand bags) at xiphoid process, the weight allowed from 40-60% of maxi
mal inspiratory capacity.
Increase weight gradually as patient improved

II. Localized Breathing Exercise

Aims :
Localized breathing exercises help to ventilate isolated lobes of the lung which are
useful for improving movement of the thoracic cage and for assisting in removal of
secretions.
Pressure is applied to appropriate areas of the chest wall utilizing proprioceptive
stimuli so that efficient expansion of these areas may be obtained.
The patient should be in half-lying position with the knees slightly flexed over a
pillow
Place palm of hand over the area need to be trained and his fingers relaxed over the
area.
Instruct patient with inspiration to expand ribs against his hand and hold maximum
inspiration for 3 seconds
At end of expiration physical therapist apply firm pressure against chest
Application

Apical expansion:
Hands position: above clavicle, tips of fingers below clavicle.Patient instructed to

breathe in and expand chest upward and Patient should not elevate his shoulder girdle
Indicated if there is underlying disease in upper lobe (cystic fibrosis, emphysema,
thoracic surgery, lobectomy, and pneumothorax.
Sternal expansion:
Hands position: over the sternum.
Costal expansion:
Hands position: in mid-axillary line over the 7th & 8th ribs.

Posterior basal (lower costal expansion):

Hands position: over posterior aspect of lower ribs

III.

Belt Exercise
Length : 2 meters.
Width : 30 cm.
Advantages:
- After operation as it make equal pressure in all points and takes a large area so its
pressure become not painful which is more suitable for operative cases and fatly subjects.
- Easy to be used by the patient himself.
Disadvantages:
- Trick movements are difficult to be noted.
- Cannot be used for small and irregular areas

IV:

Exercises connected with respiration

This can give: mobilizing, strengthening and/or stretching exercise connected with
respiration (expiration and/or inspiration).
Upper limbs and lower limbs:
- Abduction, Extension with inspiration.
- Adduction, Flexion with expiration.
Trunk:
- Bending forward (flexion) with expiration.
- Bending backward (extension) with inspiration.
- Turning trunk with expiration

Controlled Cough Technique

1. Sit comfortably with your feet resting firmly on the floor, and lean
forward slightly.
2. Take three to four deep diaphragmatic breaths before coughing.
3. Take a deep breath, hold your breath for three seconds, tighten
your abdominal muscles and cough twice. The first cough will loosen
your sputum. The second cough will move the sputum high in your
throat.
4. Spit it into a piece of tissue and check the color. If it is a yellow,
green or red in colour, talk to your doctor. Throw the tissue away.
5. Take a break and repeat once or twice if you do not cough up any
sputum.
Coping with being Short of Breath
1. Find a relaxation position that is most comfortable for you. Do not
worry about how fast you are breathing.
2. Breathe in through your mouth and out through your mouth.
3. Begin to lengthen the time you breathe out.
4. Try to breathe in through your mouth and out through pursed
lips.

5. Breathe in through your nose and out through pursed lips.

6. Start diaphragmatic breathing and continue to breathe out
through pursed lips. 7. Continue until you feel more relaxe