This document discusses various breathing exercises used in airway clearance therapy. It describes techniques like diaphragmatic breathing, pursed lip breathing, and segmental breathing. Diaphragmatic breathing aims to strengthen the diaphragm muscle and improve gas exchange. Pursed lip breathing is designed to make breaths more effective for those with lung conditions like COPD by slowing respiration. Segmental breathing consciously directs breathing to specific chest segments to promote lung expansion. Precautions and procedures are provided for safely performing these exercises.

1. under supervision
Dr. Suad Ghaben
By: Mahmoud B. F. Wahba
No: 20171189
Wednesday, Decampere 9, 2020

2. There are several that fall into type of
therapy used to Airway Clearance Therapy,
remove secretions and breathing exercise to
improve gas exchange.
includes
 manual secretion removal technique
(postural drainage, percussion, shaking)
 Airway clearance technique (cough or huff)
 Independent secretion removal technique
(active cycle of breathing, autogenic
drainage )
 breathing exercises/breathing training.
 pre and post-surgical care.
 Activities for increase functional ability
but this guide is specifically focused on
breathing exercises.

3. BREATHING EXERCISE
are exercises that work on to improve pulmonary status & to improve endurance and function in ADLs
& prevention for acute and chronic pulmonary disease mainly for chronic lung diseases.
Efficacy breathing exercises(1)
 To re-training of patients to use primary respiratory muscles efficiently.
 Strengthen the diaphragm, allowing it to assist with lung expansion and improve air reaching
the base of the lung
 Take the burden off accessory muscles in the neck, back and chest that are used. and
Strengthening when become weak with patient in ICU.
 Clear the airway of excess sputum (If the patient suffers from a effusion in both lungs,
breathing exercises can only be used after fluid drainage, but if it is in unilateral lung,
Postural drainage can be used with breathing exercises(2)
 Improve lung function
 Removal of spasms that occur with a severe cough
 Reduce the risk of developing respiratory infections or atelectasis (alveoli collapse) & Speed
up the healing process.

4.  Control of the respiratory system in the medulla oblongata is involuntary but can be
overridden by voluntary action such as breathing exercises or reflexes such as speech,
laughter, emotion, pain, sudden cold and some pathological states (2).
 studies indicate that breathing exercise and ventilatory training have affect and alter a
patient’s rate and depth of ventilation, so this technique is used to improve the pulmonary
status and increase patient’s overall endurance. (3)
 If sputum builds up in the lungs, it may become infected and increase the risk of pneumonia
& impedes the ability of the lungs to expansion (My Health Alberta 2019; Penn Medicine
2016), so breathing and coughing exercises are necessary to aid breathing and remove
excess secretion in the recovery phase.
 A study by the University of Melbourne found that preoperative education and teaching
of respiratory exercises halves the rate of post-surgery complications for major
abdominal surgery patients (Boden & Denehy 2018).(4)
Research study

5. Type of breathing exercise:
 There are many breathing exercises used in the rehabilitation of many health problems,
such as
 respiratory diseases (obstructive or restrictive lung disease)
 spinal injuries (effect on diaphragm muscle)
 post-trauma or surgery, or in ICU
 pregnant women.
 Before starting breathing exercises for lungs, you need to decide what purpose you intend to
do. Most of the time, people choose one pool or another to get these results.(5)
 to improve the efficiency of ventilation
 decrease the work of breathing
 increase the excursion of the diaphragm
 improve gas exchange and oxygenation.
 facilitate relaxation
 maintain or improve mobility of chest wall
 prevent pulmonary compromise

6.  is also called ( Deep, belly breathing or abdominal breathing).
 that helps strengthen your diaphragm muscle.
 Indication
 Post-operative pain or surgical procedure such as
thoracic or abdominal surgeries.
 Pulmonary disease (primary or secondary)
 obstructive lung diseases. (not lungs expansion)
 COPD (improves their breathing during activities they find strenuous in
ADLs.)(6)
 Asthma (A 2013 review of three randomized controlled trials investigated the
effects of diaphragmatic breathing on quality of life ( QOL) among people with
asthma. It found moderate evidence of short- and long-term improvements in
QOL following diaphragmatic breathing exercises.) (7)
 Cystic fibrosis
 Lung abscess
Diaphragmatic breathing exercise:

7.  Restriction of breathing due to musculoskeletal abnormality
 Central nervous system deficit
 ICU
 Stress and anxiety (A 2017 study notes that diaphragmatic breathing reduces
levels of the stress hormone cortisol in the body. Because of this, it may help
alleviate symptoms of stress and anxiety.) (8)

8.  Contraindication
 increase PaCO2
 marked hyperinflation of the lungs with diaphragmatic movement
 Diaphragmatic breathing is not always beneficial as a standalone treatment. People should not
rely on diaphragmatic breathing alone to treat conditions such as asthma or chronic obstructive
pulmonary disease, as a 2018 study indicates that in the literature there are reports of some
harmful effects of diaphragmatic breathing in COPD patients when used as a standalone therapy.
(10)

9. 1) Explain procedure to patient. (should focus on the breathing
technique & teach the patient relaxation techniques, relax the muscles
of upper thorax neck and shoulder to minimize the use of accessory muscle work)
1) Position the patient long-sitting position, upright position or Semi-Fowler's position.
2) Place the therapist's hand gently over the subcostal angle and abdominal to feel to expansion
3) during exhalation, apply gentle pressure on the subcostal angle
4) Increase to firm pressure at the end of exhalation.
5) Release pressure allowing a full inhalation.
6) Allow the patient to perform deep breathing only for 3-4 times, to avoid Hyperventilation.
PROCEDURE

10. 8) When checking the quality of the diaphragm, we put resistance during
inhalation
9) Observe the patients spontaneous breathing pattern and rhythm while at rest
and during activity to determine whether Patient is indicated or not
10) Doing diaphragm breathing exercise within activities of daily life during upright
sitting, standing, walking, and stair climbing precaution
 clinical signs of respiratory muscle fatigue(inspiratory muscle)
 tachypnea or dyspnea with cyanosis
 patient with paradoxical breathing patterns vertical rib cage movement with excessive accessory
muscles activity. Abdominal hollowing without distension)
 In cases of severe hyperinflation or poor diaphragmatic movement during inhalation, placing the
patient in a semi-Fowler's position may increase symptoms, increase the work of breathing, and
dyspnea in some persons.(9)

11. SELF-CARE PROCEDURE
1) Sit in a comfortable position on flat surface.
2) Relax your shoulders and focus on the diaphragm muscle.
3) Put a hand on your chest and a hand on your stomach.
4) Breathe in through your nose for about two seconds. Breathe,
until you feel your stomach is expanding.
1) Purse your lips (as if you’re about to drink through
2) a straw), press gently on your stomach, and exhale slowly for about two seconds.
3) Repeat these steps several times for best results (to 5-10times)

12. Pursed lip breathing
is a breathing technique designed to make your breaths more effective by making them slower and
more control over your breathing, which is particularly important for people with lung conditions
such as COPD.
 In a 2018 study, effectiveness of pursed lip exercises for COPD patients demonstrated the an
important part of rehabilitation programs for these patients.(11)

13.  Efficacy(12)
 increase tidal volume and reduce the work of breathing.
 reduce dyspnea by slowing the respiratory rate.
 improve gas exchange (both oxygen and carbon dioxide).
 decrease mechanical disadvantage of an impaired ventilatory pump.
 increasing exercise tolerance.
 Decrease the respiratory rate and minute ventilation.
 Improve gas mixing at rest for patients with COPD .
 facilitate relaxation by taking deep breaths.

14.  indications
 Primarily used for patients with obstructive disease with experience dyspnea at rest or
with minimal activity/exercise
 tachypnea (abnormally rapid breathing.)
 who use an ineffective breathing pattern during activity/exercise
 Precautions:
 The use of forceful exhalation during lip breathing should be avoided so as not to increase
the pressure of inter-thorasic as this can cause further restrictions on the small
bronchioles
 Contraindications
 Bronchiectasis
 Diabetic (hypoglycemia)
 Clinical depression (Breathing with longer exhalations stimulates the parasympathetic
nervous system, as this can worsen it because you put the body in a state of relaxation
with increased lack of motivation.)
 Age
 Severe Personality Disorders
 Psychoactive Substances
(13)

15. 1) Have the patient breathe slowly and deeply through the nose.
2) Then gently exhale through gently pointed lips as if blowing out a candle.
Intra-bronchial pressure increases.(Like O-shape)
3) Press gently on the patient's abdomen during the exhalation period
4) The contraction of the abdominal muscles can be used wisely to increase the volume of exhalation.
5) Practice this technique 4-5 times a day at first so you can get the correct breathing pattern.
 reminders
 Do not force the air out.
 Always breathe out for longer than you breathe in.
 Breathe slowly, easily, and relaxed ... in and out ... until you are in complete control.
Procedure:

16.  may be defined as localized respiration consciously directed to one segment of the chest
while the other segments remain relaxed.(13)
 Four types of segmental breathing exercise are: (13)
 Lateral costal expansion
 Posterior basal expansion
 Right middle or lingulae expansion
 Apical expansion
Segmental Breathing

17.  Utilization of segmental breathing exercises accomplishes many objectives
 the most important of which is to promote the expansion or expansion of an
anatomical segment, lobe or lung
 improved aeration and expansibility, thus reducing the possibility of collapsed lung
 stimulation of the cough reflex mechanism, thus preventing excessive accumulation
of secretions in the bronchial tree & pleural fluid and secretions.
 maintain or restore functional residual capacity,
 maintain or improve mobility of chest wall and prevent pulmonary compromise.

18.  alter regional distribution of gas,
 prevention of panic response in the patient through development of a Chief
sense of confidence derived from a feeling of controlled breathing.
 development of normal motion.
 decrease paradoxical breathing (deflation of a lung or portion of a lung during
the phase of inspiration and the inflation of the lung during the phase of
expiration)
 Contraindication :
prevent to use in hypoventilation until the medical condition permits it

19.  Indications
 patients who have Pleurisy, pneumonia, incision, or post trauma pain that cause a decreased
movement in a portion of the thorax (splinting)
 at risk for developing atelectasis (lung collapse).
 post thoracotomy, post mastectomy scar or post chest radiation-fibrosis.
 Inappropriate in cases of intractable hypoventilation until the medical situation is resolved
(palliative therapy to reduce bronchogenic tumor size or a chest tube to reduce pneumothorax).
 In relationship to COVID-19, segmental breathing can be utilized to target specific lung
segments that have been affected by alveolar collapse or damage.
 pulmonary hygiene purposes for all diagnoses that experience consolidation including COPD,
Pneumonia, and CHF.

20.  Procedure
 Explain procedure to the patient.
 Position the patient to facilitate inhalation to a certain segment, such as
postural drainage positions. upright sitting.
 Apply gentle pressure to the thorax over the area of hypoventilation during
exhalation.
 increase to firm pressure just prior to inspiration.
 Asks the patient to breathe in against the resistance of the therapist's hands.
 release resistance allowing a toll inhalation

22.  The basis of incentive spirometry involves having the patient take a sustained maximal
inspiration (SMI).
 Benefit
 to increase tidal volume (inhaled,)
 sustain or improve alveolar inflation
 maintain or restore functional residual capacity.
 In a 2019 study, the effect of Sustained maximal inspiration was found to be similar to
that of incentive spirometers (15)
 Incentive spirometry may be more effective than Intermittent positive pressure
breathing (IPPB) because it maximizes the amount of air inhaled while maintaining
relatively low airway pressures.
sustained maximal inspiration

23.  Indications(17)
 Pre-operative screening of patients at risk of postoperative complications.
 Lack of pain control as post- operative pain, especially thoracic and abdominal
surgery or post-trauma pain or acute lobar collapse
 to prevent or treat atelectasis.
 Restrictive lung disease associated with a dysfunctional diaphragm or accessory
respiratory musculature
 alternative for clinical use in cases where incentive spirometers equipment
acquisition is not possible (16)

24.  Contraindications (17 )
 patients with COPD or Asthma
 Very young patients or pediatrics with developmental delay
 Hyperventilation
 Fatigue & Hypoxemia secondary to interruption of oxygen
therapy
 Patients unable to take deep breathe effectively due to pain,
diaphragmatic dysfunction, or opiate analgesia.
 Patients who are heavily sedated or comatose

25.  explain the procedure to patient
 (Advise patient to take approximately ten incentive spirometry breaths per waking
hour (use clinical reasoning to prescribe using Frequency, Intensity, Time and Type
principles).
 Inspire slowly through nose or pursed lips to maximal inspiration.
 Hold maximal inspiration for three seconds.
 Passively exhale the volume.
 Incentive spirometers (devices used to measure and encourage deep spiration) can assist
the patient in achieving maximal inspiration during
 Deep breathing offers a similar effect. However, using an incentive device as feedback
may create greater inhaled volumes, greater control of flow and more motivation to
participate in therapy
 Procedure.

26.  GPB is also known as frog breathing or air gulping
 The major purpose is Assist coughing.
 is a means of increasing a patient’s inspiratory capacity when there is severe weakness of
the muscles of inspiration.
 Originally developed to help polio patients with severe muscle weakness, this type of
breathing pattern is used today, and taught to patients with high spinal cord injuries
who can easily develop respiratory problems.
 The use of GPB has been shown to be sufficient to maintain arterial blood gases within
normal range(18)
 GPB may prove useful in improving cough effectiveness in patients with tetraplegia or
neuromuscular disorders, impaired tracheobronchial clearance
Glossopharyngeal Breathing

27.  indication(19)
 The most common use of GPB is
 in patients who are able to breathe spontaneously but whose power to cough and clear secretions is
inadequate
 Patients with high-level quadriplegia.
 patients with poliomyelitis
 patient who is unable to voluntarily alter tidal breathing.
 Use of GPB continuously, during the day, but during sleep he returns to mechanical ventilation in the
patients with a reduced vital capacity owing to respiratory muscle paralysis

28.  Contraindication(19)
 patients with a tracheostomy when the cuff is inflated.
 patients with airflow obstruction or pulmonary disease, due to the risk of air trapping.
 GPB should not be attempted in patients with neuromuscular disorders affecting swallowing
and in patients with a progressive disorder, intermittent positive pressure breathing (IPPB)
may be more appropriate than GPB(20)
 Precautions:
 This sequence should be practiced slowly at first and then gradually speeded up until the movement flows.
 A leak of air may occur through the nose and, until it is prevented by the soft palate, a Close the nose may be
required.

29.  mouth opened to draw in air
 The mouth and pharynx are filled with air by depressing the cricoid cartilage and tongue
 While maintaining this position the jaw are closed, trapping the air
 air pushed back with tongue into trachea
 vocal folds closed to prevent passive air leaks.
 Entire maneuver is then repeated
 Precautions:
 This sequence should be practiced slowly at first and then gradually speeded up until the movement
flows.
 A leak of air may occur through the nose and, until it is prevented by the soft palate, a Close the nose
may be required.
procedure

31.  In the case of weak abdominal muscles, the force of intra-abdomen pressure is weak. It
cannot provide an effective cough to expel secretions in the lung or the air accumulated
inside it.
 It can benefit from some methods to strengthen the abdomen muscles, by
 Abdominal strengthening exercises such as core and global muscle (in case the patient is
able to do exercises)
 The use of the abdomen corset in the event of inability to perform exercises
 can facilitate relaxation
 decrease breathlessness
 increase inspiratory muscle strength
Abdominal strengthen

32. They are exercises that are used especially for athletes and who
suffer from short breathing
It is one of the exercises used in ADLs, and it is multiple
exercises such as:
 Rib Breathing
 shoulder shrugging
 Elbow Touch
 Windmill
 Seated Kicks
Coordination breathing exercises :

33. Reference
1. https://www.ausmed.com/cpd/articles/breathing-exercises
2. Physiotherapy in Respiratory Care: An Evidence-based Approach to RespiratoryBMJ.
2018;360:j5916. Published 2018 Jan 24. doi:10.1136/bmj.j5916
3. https://www.slideshare.net/rahulapcvtp/breathing-exercise-rahul-ap-mpt
4. Boden I, Skinner EH, Browning L, et al. Preoperative physiotherapy for the prevention of
respiratory complications after upper abdominal surgery: pragmatic, double blinded,
multicentre randomised controlled trial [published correction appears in BMJ. 2019 Apr
25;365:l1862].
5. https://www.ausmed.com/cpd/articles/breathing-exercises
6. https://www.medicalnewstoday.com/articles/diaphragmatic-breathing#conditions-it-can-help-with
7. Prem V, Sahoo RC, Adhikari P. Effect of diaphragmatic breathing exercise on quality of life
in subjects with asthma: A systematic review. Physiother Theory Pract. 2013;29(4):271-277.
8. Ma X, Yue ZQ, Gong ZQ, et al. The Effect of Diaphragmatic Breathing on Attention,
Negative Affect and Stress in Healthy Adults. Front Psychol. 2017;8:874. Published 2017
Jun 6. doi:10.3389/fpsyg.2017.00874

34. Reference
9. Vitacca M, Clini E, Bianchi L, Ambrosino N. Acute effects of deep diaphragmatic
breathing in COPD patients with chronic respiratory insufficiency. Eur Respir J.
1998;11(2):408-415. doi:10.1183/09031936.98.11020408
10. Mendes LP, Moraes KS, Hoffman M, et al. Effects of Diaphragmatic Breathing With
and Without Pursed-Lips Breathing in Subjects With COPD. Respir Care. 2019;64(2):136-
144. doi:10.4187/respcare.06319
11. Sakhaei S, Sadagheyani HE, Zinalpoor S, Markani AK, Motaarefi H. The Impact of
Pursed-lips Breathing Maneuver on Cardiac, Respiratory, and Oxygenation Parameters in
COPD Patients. Open Access Maced J Med Sci. 2018;6(10):1851-1856. Published 2018 Oct
20. doi:10.3889/oamjms.2018.407
12. https://www.healthline.com/health/pursed-lip-breathing
13. https://www.breathinglabs.com/clinical-use/postoperative-care/
14.Wilma-Nell Harmony, B.S., Segmental Breathing, PhysicalTherapy,Volume 36, Issue 2, 1 February
1956, Pages 106–107, https://doi.org/10.1093/ptj/36.2.106

35. Reference
15. Mendes LPS, Teixeira LS, da Cruz LJ, Vieira DSR, Parreira VF. Sustained maximal inspiration has
similar effects compared to incentive spirometers. Respir Physiol Neurobiol. 2019;261:67-74.
doi:10.1016/j.resp.2019.01.006
16. (https://erj.ersjournals.com/content/52/suppl_62/PA1705) Maximal sustained inspiration promotes similar
changes on breathing pattern and chest wall motion compared to Incentive spirometry. Liliane Mendes, Luana
Teixeira, Layza Cruz, Danielle Vieira, Veronica Parreira. European Respiratory Journal Sep 2018, 52 (suppl
62) PA1705; DOI: 10.1183/13993003.congress-2018.PA1705
17. https://www.physio-pedia.com/Incentive_Spirometry
18. (M. Jones & F. Moffatt. Cardiopulmonary physiotherapy. Bios Scientific Publisher Ltd. 2002)
19. https://www.physio-pedia.com/Glossopharyngeal_Breathing
20. Jennifer A. Prayor & Barbara A. Webber. Physiotherapy for Respiratory and cardiac problems. 2nd edition.
Churchill Livingstone. 1998
https://smartvest.com/top-2-breathing-techniques-for-copd/
https://www.aarogya.com/specialties/physiotherapy/segmental-breathing.html
YouTube links
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36. Thank you
11/11/2020