The document discusses breathing exercises and ventilatory training for pulmonary conditions like COPD, chronic bronchitis, emphysema, and asthma. Breathing exercises aim to improve ventilation, increase cough effectiveness, prevent postoperative complications, improve muscle strength and endurance, maintain chest mobility, and teach patients to manage dyspnea. Specific techniques covered include diaphragmatic breathing, pursed lip breathing, and segmental breathing exercises targeting different areas of the lungs. Precautions are outlined to avoid forced exhalation or prolonged expiration which could worsen symptoms.

1. Rahul.AP , MPT
MANAGEMENT OF PULMONARY
CONDITIONS

2. BREATHING EXERCISE
 Breathing ex: and ventilatory training are the
fundamental interventions for the prevention for acute
and chronic pulmonary disease mainly for COPD
(chronic bronchitis, emphysema and asthma), 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.

3. GOALS OF BREATHING
EXERCISE
 Improve ventilation
 Increase the effectiveness of cough and promote
airway clearance
 To prevent post operative pulmonary complications
 To improve the strength endurance coordination of the
muscles of ventilation
 Maintain and improve chest and thoracic spine mobility
 Promote relaxation and relive stress
 To teach the patient how to deal with episodes of
dyspnea
 Assisting in removal of secretions.

4.  Correct abnormal breathing patterns and decrease
the work of breathing.
 Aid in bronchial hygiene---Prevent accumulation of
pulmonary secretions, mobilization of these
secretions, and improve the cough mechanism.

5. 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 works 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.

6. SEMI-FOWLERS POSITION

7.  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

8. PRECUATIONS
 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 breathing 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

9. INDICATIONS
 Cystic fibrosis
 Bronchiectasis
 Atelectasis
 Lung abscess
 Pneumonias
 Acute lung disease
 COPD –emphysema, chronic bronchitis
 For patients with a high spinal cord lesion/ spinal cord
injury, myopathies etc.
 After surgeries (thoracic or abdominal surgery)
 For patients who must remain in bed for an extended
period of time.(obstruction due to retained secretions)
 As relaxation procedure.

10. CONTRAINDICATIONS
 Severe pain and discomfort
 Acute medical or surgical emergency
 Patients with reduced conscious level

11. TYPES OF BREATHING
EXERCISES
 Diaphragmatic breathing
 Glossophryngeal breathing
 Pursed lip breathing
 Segmental breathing(costal expansion exercise)
a) Apical breathing
b) Lateral costal expansion
c) Posterior basal expansion

12. BREATHING EXERCISE
TECHNIQUES
DIAPHRAGMATIC BREATHING
 Diaphragm is the primary muscle for breathing
(inspiration) diaphragm controls breathing at an
involuntary level ,a patient with primary pulmonary
disease like COPD can be taught breathing control by
optimal use of diaphragm and relaxation of accessory
muscles
 Diaphragmatic breathing ex: are also use to mobilize
lung secretion in PD

13. PROCEDURE
 Prepare the patient in relaxed and comfortable position
in which the gravity assist the diaphragm such as semi-
fowlers position
 If you notice any accessory muscle activation stop him
and do relaxation techniques (shoulder roll or shrugs
coupled with relaxation)
 Place your hands over the rectus abdominis just below
the ant: 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.

14.  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)

17. RE EDUCATION OF
DIAPHRAGM:
 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.

18. Resisted diaphragmatic breathing
 PT use small weight, such as sandbag to strengthen and
improve the endurance of the diaphragm
 Have the patient in a head up position
 Place a small weight (3-5 lb) over the epigastric region of
his abdomen (1.30- 2.20 kg)
 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

19. Glossophryngeal breathing
 It is a means of increasing a patients inspiratory
capacity when there is a severe weakness of the
muscle of inspiration
 It is taught to patients who have difficulty in deep
breathing.
 This type of breathing pattern was originally
developed to assist post polio patients with
severe muscle weakness

20. PROCEDURE
 Patient take several gulp of air 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

21. 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 Prolong exhalation
slow the breathing rate
 It moves old air out of the lungs and allow new air to
enter the lungs

22. PROCEDURE
 Patient in a comfortable position and relaxed, explain the
patent about the expiration phase (it should be relaxed and
passive)
 abdominal muscle contraction must be avoided (therapist
hand over the patients abdominal to check for contraction)
 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 )
 By providing slight resistance an increased positive
pressure will generate with in the airway which helps to
keep open small bronchioles that otherwise collapse

23.  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.

24. 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

25. ADVANTAGES OF SEGMENTAL
BREATHING
 Prevent accumulation of pleural fluid and secreations
 Decreases paradoxical breathing
 Decrease panic
 Improve chest mobility

26. Lateral costal expansion
 This is sometimes called lateral basal expansion and
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.
 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.

27.  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.
 The patient may then taught to perform the maneuver
independently, ask him to apply resistance with his
hand or with a towel

28. LATERAL COSTAL EXPANSION
SUPINE

29. LATERAL COSTAL EXPANSION
SITTING

30. Lateral Costal
Upper costal Lower Costal

31. BELT EXERCISES TO REINFORCE LATERAL COSTAL
BREATHING
(A) by applying resistance during inspiration
(B) by assisting with pressure along the rib cage during expiration.

32. Posterior basal expansion
 This form of segmental breathing is important for the post
surgical patients who is in bed in a semi-reclining 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

33. 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

34. FORCED EXPIRATORY
TECHINIQUES
 The FET employs a forced expiration or huff following a
medium size breath to mid lung volume then tighten the
abdominal muscle firmly while huffing (expiring
forcefully with an open glottis) with out contracting the
throat muscles
 There should be a period of 15-30 sec relaxation with
gentle diaphragmatic breathing that follow 1 or 2 huffs
 Once secretions is felt on the upper most airway a huff
or double cough can remove it

35. Thank you…