Breathing exercises and ventilatory training are fundamental interventions for preventing acute and chronic pulmonary disease, with goals of improving ventilation, airway clearance, and preventing postoperative complications. The document outlines various breathing techniques including diaphragmatic breathing, pursed lip breathing, and segmental breathing and provides guidelines for teaching patients and precautions for different conditions.

1. JAMIA MILLIA ISLAMIA
CENTER FOR PHYSIOTHERAPY AND REHABILITATION SCIENCES
BREATHING EXERCISES
SUBJECT – PHYSIOTHERAPY IN CARDIOPULMONARY CONDITIONS (BPT 402)
SUBIMTTED TO – DR. JAMAL MOIZ
SUBMITTED BY - MOHD ZAHID
BPT 4TH YEAR
DATE OF SUBMISSION – 4 JAN 2021

2. DEFINATION
• Breathing exercises and ventilatory training are the fundamental interventions for the prevention for acute and chronic pulmonary disease
patients with high spinal cord lesion and who underwent thoracic and abdominal surgery and bedridden patients.
• Studies indicate that breathing exercise and ventilatory training have affect and alter a patients rate and depth of ventilation ,so these
technique is used to improve the pulmonary status and increase patients overall endurance
Goals of breathing exercises
• Improve ventilation
• Increase the effectiveness of cough and promote
• airway clearance
• To prevent post operative pulmonary complications
• To improve the strength endurance coordinatio of the muscles of ventilation

3. • Maintain and improve chest and thoracic spine mobility
• Promote relaxation and relive stress
• To teach the patient how to deal with episodes of dyspnea
GUIDELINE FOR TEACHING BREATHING EXERCISES
• Choose a quiet area-to get a proper interaction with minimal distraction
• Explain the patient about the aim and how it work for his impairment
• Have the pat: in relaxed position and loosen the clothes, make him in semi-fowlers position with head and trunk elevated approx: 45˚
(total support to the head and trunk and flexing the hip and knees with pillow support) the abdominal muscle become relaxed.
• Other positions, such as supine, sitting, or standing may be used as the patient progresses during treatment.
• Observe and access the patients spontaneous breathing pattern while at rest and during activity
• Determine whether Rx is indicated or not
• If necessary teach the patient relaxation techniques, relax the muscles of upper thorax neck and shoulder to minimize the use of
accessory muscle work.
• Special attention on sternocleidomastoids, upper trapezius and levator scapulae.
• Demonstrate the breathing pattern to the patient
• Have the patient practice the correct technique in verity of positions at rest and with activity.

4. PRECAUTIONS
• Never allow the patient to force expiration-it may increase the turbulence in the air way which leads to bronchospasm and
airway resistance.
• Avoid prolonged expiration-it cause the patient to gasp with the next inspiration and the breathingn pattern become
irregular and inefficient.
• Do not allow the patient to initiate inspiration with accessory muscles and upper chest ,advise him that upper chest should
be quiet during breathing
• Allow the patient to perform deep breathing only for 3-4 times (inspiration and expirations) to avoid Hyperventilation.
INDICATIONS
• Cystic fibrosis
• Bronchiectasis
• Atelectasis
• Lung abscess
• Pneumonias

5. • Acute lung disease
• COPD-emphysema, chronic bronchitis
CONTRAINDICATIOS
• Severe pain and discomfort
• Acute medical or surgical emergency
• Patients with reduced conscious level
• Increased ICP
• Unstable head or neck injury
• Active hemorrhage with hemodynamic instability or
• Hemoptysis
• Flail chest
• Uncontrolled hypertension
• Anticoagulation
• Rib or vertebral fractures or osteoporosis
• Acute asthma or tuberculosis

6. • Patients who have recently experienced a heart attack.
• Patients with skin grafts or spinal fusions will have undue stress placed on areas of repair.
• Bony 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.
• Recent (within one hour) meal or tube feed
• Untreated pneumothorax
TYPES OF BREATHING EXERCISES
• Diaphragmatic breathing.
• Glosso-phryngeal breathing.
• Pursed lip breathing.
• Segmental breathing(costal expansion exercise).
a) Apical breathing
b) Lateral costal expansion
c) Posterior basal expansion

7. DIAPHRAGMATIC BREATHING
• Diaphragmatic breathing ex: are use to mobilize lung secretion in PD.
• Diaphragm controls breathing at an involuntary level ,a patient with COPD can be taught breathing control by optimal use
of diaphragm and relaxation of accessory muscles
PROCEDURE
• The patient in relaxed and comfortable position in which the gravity assist the diaphragm such as semifowlers position.
• Do relaxation techniques (shoulder roll or shrugs coupled with relaxation) if patient uses accessory muscle activation
• Place your hands over the rectus abdominis just below the anterior costal margin ask the patient to breath slowly and
deeply via nose by keeping the shoulder relaxed and upper chest quiet allowing the abdominal to rise now ask him to
slowly let all the air out using controlled expiration through mouth.
• Have him to practice this for 2-4 times if he finds any difficulty in using diaphragm have the patient inhale several times in
succession through the nose by using sniffing action this facilitates the diaphragm
• For self monitor have the patients hand over the ant costal margin and feel the movt: (hand rise and fall) by placing one
hand over abdomen he can also feel the contraction of abdominal muscles which occurs with controlled expiration or
coughing.
• After he understands and able to do the controlled breathing using a diaphragmatic pattern keep the shoulder relaxed and
practice in verity of positions (supine sitting standing) and during activity (walking and climbing stair).

8. RESISTED DIAPHRAGMATIC BREATHING
• Have the patient in a head up position
• Place a small weight (1.30- 2.20 kg or 3-5 lb) over the epigastric region of his abdomen.
• Tell the patient to breath in deeply while trying to keep the upper chest quiet
• Gradually increase the time that the patient breaths against the resistance of weight
• Weight can be increased when he can sustain diaphragmatic breathing pattern with out the use of any accessory muscles of
inspiration for 15minuts.
GLOSSOPHARYNGEAL BREATHING
• It is used primarily for ventilatory dependent patients due to absent or incomplete innervation of diaphragm because of high
cervical cord injury or neuromuscular disorders.
• It can also be used as an emergency procedure for malfunctioning of ventilator.
• PROCEDURE
• Patient take several gulp of air (6 to 10), then by closing the mouth the tongue pushes the air back and trap it in the pharynx
the air is then forced to lungs when the glottis is opened.
• This increases the depth of inspiration & patient’s inspiratory & vital capacity

9. PURSED LIP BREATHING
• Pursed-lip breathing is a strategy that involves lightly pursing the lips together during controlled
exhalation.
• Taught to patients with COPD to deal with episodes of dyspnea.
• It helps to Improves ventilation and Releases trapped air in the lungs.
• Keeps the airways open longer and Prolonged slows the breathing rate.
• It moves old air out of the lungs and allow new air to enter the lungs.
PROCEDURE
• Patient in a comfortable position and relaxed, explain the patent about the expiration phase (it should be relaxed and
passive), abdominal muscles contraction must be avoided
• Ask the patient to breathe in slowly and deeply through the nose and then breathe out gently through lightly pursed lips
(blowing on and bending the flame of a candle )
• It can be applied as a 3-5 minutes “rescue exercise” or an Emergency Procedure to counteract acute exacerbations or
dyspnea (shortage of air or breathlessness) in COPD and asthma.

10. SEGMENTAL BREATHING
• It is performed on a segment of lung, or a section of chest wall that needs increased ventilation or
Movement
• Hypoventilation occur in certain areas of the lungs because of chest wall fibrosis, pain after surgery, atelectasis , trauma to
chest wall, pneumonia and post mastectomy scar
• Therefore, it will be important to emphasize expansion of such areas of the lungs and chest wall
Techniques
• Lateral costal expansion
• Posterior basal expansion
• Right middle lobe or lingula expansion
• Apical expansion
 Lateral costal expansion
• may be done unilaterally or bilaterally.
• The patient may be sitting or in a hook lying position.
• Place your hands along the lateral aspect of the lower ribs.
• Ask the patient to breathe out, and feel the rib cage move downward and inward.

11. • As the patient breathes out, place firm downward pressure into the ribs with the palms of your hands.
• Just prior to inspiration, apply a quick downward and inward stretch to the chest. This places a quick stretch on the external
intercostals to facilitate their contraction. These muscles move the ribs outward and upward during inspiration
• Apply light manual resistance to the lower ribs to increase sensory awareness as the patient breathes in deeply and the
chest expands.
• When the patient breathes out, assist by gently squeezing the rib cage in a downward and inward direction
• Taught patient to perform the maneuver independently, ask him to apply resistance with his hand or with a towel.
 Posterior basal expansion
• This form of segmental breathing is important for the post surgical patients who is in bed in a semireclining position for an
extended period of time.
• Secretion often accumulate over the posterior segments of lower lobes.
 Procedure
• Have the patient sit and lean forward on a pillow, slightly bending the hips.
• Place the PT hand over the posterior aspect of the lower rib and do the same procedure in lateral costal expansion.
 Right middle lobe or lingula expansion
• While the patient in sitting place your hand at either the right or left side of the patient’s chest just below the axilla, and
follow the same procedure in lateral costal expansion

12. DIAPHRAGMATIC
BREATHNING
Self assisted technique

13. LATERAL COSTAL
EXPANSION
BILATERAL COSTAL EXPANSION SITTING

14. BELT EXERCISES TO REINFORCE LATERAL
COSTAL BREATHING
a) By applying resistance during
inspiration
b) By assisting with pressure along the rib
cage during expiration
GLOSSOPHARYANGEAL BREATHING

15. SUMMARY
• Breathing exercises and ventilatory training are the fundamental interventions for the prevention for acute and chronic
pulmonary disease patients and ventilatory training are the fundamental interventions for the prevention for acute and chronic
pulmonary disease patients
• Various goals of breathing exercises are improve ventilation, airway clearances, prevent post operative complication etc
• Several guidelines for breathing exercises mention above
• Indications like cystic fibrosis, atelectasis, lung abscess etc and contraindications like Acute medical or surgical emergency,
Patients with reduced conscious level, increased ICP ,unstable head or neck injury, flail chest etc mention above
• Types of breathing exercises – diaphragmatic breathing, glooso phyngeal breathing , pursed lip breathing, segmental breathing
mention in detail above

16. REFERENCES
• Downie P.A. Cash Textbook of Chest, Heart And Vascular Disorders For Physiotherapy ( 4th edition)
• Dean . E and Frownfilter , D. Cardiopulmonary physical therapy (3rd edition)