This document provides information on various breathing exercises and their goals, indications, contraindications, and techniques. The main goals of breathing exercises are to improve ventilation, cough effectiveness, strength and endurance of respiratory muscles, chest mobility, and breathing patterns. Exercises include diaphragmatic breathing, pursed lip breathing, and localized expansion techniques. The document describes how to perform each exercise and provides guidance on proper technique and positioning.

1. BREATHING
EXERCISES
1
Dr. Minhaj Tahir
MPT(CARDIO-THORACIC)
Assistant professor
RAMA UNIVERSITY, KANPUR

2. 2
INTRODUCTION
• It is also known as “Ventilatory Training”.
• Breathing exercises are fundamental interventions for
the prevention or comprehensive management related to
acute or chronic pulmonary disorders.
• An aspect of management to improve pulmonary status
and to increase a Patient’s overall endurance and
function during daily living activities.

3. 3
• Simply, breathing exercise were designed to retrain the
muscles of respiration, improve ventilation, lessen the
work of breathing(WOB), and improve gaseous exchange
and patient’s overall function in daily living activities.
• Depending on a patient’s underlying pathology and
impairments, exercises are done to improve ventilation
often are combined with medication, airway clearance,
the use of respiratory therapy devices, and a graded
exercise (aerobic conditioning) program.
Cont.

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“GOALS OF BREATHING
EXERCISES”
• Improve or redistribute ventilation.
• Increase the effectiveness of the cough mechanism &
promote airway clearance.
• Prevent postoperative pulmonary complications.
• Improve the strength, endurance & coordination of the
muscles of ventilation.
• Maintain or improve chest & thoracic spine mobility.

5. • 6. Correct inefficient or abnormal breathing patterns &
decrease the work of breathing.
• 7. Promote relaxation & relieve stress.
• 8. Teach the patient how to deal with episodes of dyspnea.
• 9. Improve a patient’s overall functional capacity for daily
living, occupational, & recreational activities.
• 10. Aid in bronchial hygiene—Prevent accumulation of
pulmo. secretions, mobilisation of these secretions, & improve
the cough mechanism.
Cont.

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INDICATIONS
• Cystic Fibrosis
• Bronchiectasis
• Atelectasis
• Lung abscess
• Neuromuscular diseases
• Pneumonia in dependent lung regions
• Acute or chronic lung diseases
• COPD

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• For patients with high spinal cord lesion/ Deficits in CNS:
SCI & Myopathies etc.
• Prophylactic care of preoperative patient with history of
pulmonary disorders.
• Postoperative (thoracic & abdominal surgeries)
• Airway obstructions due to retained secretions.
• For long duration bedridden patients.
• As relaxed procedure.
Cont.

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CONTRAINDICATIONS
• Increased ICP
• Unstable head or neck injury
• Active haemorrhage with haemodynamic instability or haemoptysis
• Recent spinal injury
• Empyema
• Bronchoplueral fistula
• Flail chest

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• Uncontrolled HTN
• Anticoagulants
• Rib or vertebral fractures or osteoporosis
• Untreated pneumothorax
• Bony metastases, brittle bones, bronchial haemorrhage &
emphysema
• Recent(within 1hour) meal or RT feed.
Cont.

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GUIDELINES FOR
BREATHING EXERCISES
• Choose a quiet area for instruction .
• Explain to the patient the aims & rationale of breathing exercises.
• The patient’s position is important in order to achieve relaxation,
concentration & freedom of thoracic & abdominal movement.The position
most commonly used are:
A. Semi-Fowler’s or Half lying position
B. Side lying or high side lying with the upper arm supported on a pillow
C. Supine
D. Sitting in a comfortable upright chair
E. Standing

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12. • Observe & assess the patient’s breathing pattern.
• Determine whether ventilatory training is indicated.
• Establish a baseline for assessing changes, progress &
outcomes of intervention.
• If necessary, teach the patient relaxation techniques.
• Pay particular attention to relaxation of the SCM, upper
trapezius, & levator scapulae muscles.
POINTS TO PONDER
12

13. 13
• Depending on the patient’s underlying pathology & impairments,
determine whether to emphasise 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 & with activity.
POINTS TO PONDER…CONT.

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PRECAUTIONS
• Never allow the patient to force expiration it may increase the
turbulence in the airway which leads to bronchospasm and airway
resistance.
• Avoid prolonged expiration as 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 be quiet
during breathing.
• Allow the patient to perform deep breathing only for 3-4
times(inspiration & expiration) to avoid hyperventilation.

15. TYPES OF BREATHING
EXERCISES
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• Diaphragmatic Breathing
• Pursed Lip Breathing
• Glossopharyngeal Breathing
• Localised Expansion Exercises

16. DIAPHRAGMATIC BREATHING
• Diaphragm is the primary
muscle of breathing
(inspiration) diaphragm
control breathing at an
involuntary level, a patient
with primary pulmonary
disease like COPD can be
taught breathing control
by optimal use of
diaphragm & relaxation of
accessory muscles.
• It is also used to mobilise
lung secretion in PD.
16

17. 17
• Prepare the patient in relaxed & comfortable position in which
the gravity assist the diaphragm such as Semi-Fowler’s position.
• Notice any accessory muscle activation,Stop,& Teach relaxation
techniques.
• Place your hands over the rectus abdominis just below the ant.
costal margin ask the patient to breath slowly & deeply via nose
by keeping the shoulders relaxed & upper chest quiet allowing
the abdominal to use now ask him to slowly let all the air out
using controlled expiration through mouth.
CONT.

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• It should be practiced 2-4 times, if patient 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
& feel the movement ( hand rise & fall) by placing one hand over
abdomen patient can also feel the contraction of abdominal
muscles which occurs with controlled expiration or coughing.
• As patient understands; practice it in various positions ( supine,
sitting & standing) & during activity ( walking & climbing stairs).
CONT.

19. RE-EDUCATION OF DIAPHRAGM
•Place the index & 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 & patient is
instructed to take breath in.
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20. RESISTED DIAPHRAGMATIC
BREATHING
• Patient use a small weight such as sandbag to strengthen and to improve the
endurance of the diaphragm.
• Have the patient in a head up position.
• Place a small Weight (3.5lb) over the epigastric region of his abdomen (1.30-2.20kg).
• 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 without the
use of any accessory muscles of inspiration for 15 minutes
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GLOSSOPHARYNGEAL
BREATHING
• It is a means of increasing 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.
PROCEDURE:
• Patient take several gulp of air by closing the mouth ,the tongue
pushes the air back and trap it in the pharynx then air is then
forced to lungs when the glottis is opened.

22. CONT.
22

23. 23
PURSED LIP BREATHING
• It is a strategy that involves lightly pursing the lips together
during controlled exhalation.
• Taught to patients with COPD to deal with episodes of
dyspnoea.
• It helps to improve 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 & allow new air to enter the
lungs.

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PROCEDURE FOR PLB
• Patient in a comfortable position and relaxed, explain the patient about the
expiration phase (it should be relaxed and passive)
• Abdominal muscle contraction must be avoided
• Ask the patient to breath in slowly and deeply through the nose and then
breath out gently through lightly pursed lips (Blowing onand 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.
• It can be applied as a 3-5 minutes “rescue exercise” or an Emergency
Procedure to counteract acute exacerbations or dyspnea (SOB) in COPD &
asthma.

25. PLB
25

26. LOCALISED EXPANSION
EXERCISES
• These are useful for assisting in the removal of
secretions and improving movement of the thoracic cage.
• Individual lobes of the lungs are ventilated by these
exercises.
• Pressure is applied to appropriate areas of the chest
wall; utilising proprioceptive stimuli, more efficient
expansion of these areas may be obtained.

27. LOCALISED EXPANSION
EXERCISES
VARIOUS TYPES:
• Lateral Basal Expansion
• Apical Expansion
• Posterior Basal Expansion
• Upper Lateral Expansion
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LATERAL COSTAL EXPANSION
• It is also known as “lateral basal expansion”.
• It is performed both unilaterally or bilaterally.
• The patient may be sitting or in semi-Fowler’s position.
• Place your hands along the lateral aspect of the lower ribs.
• Ask the patient in breath 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.

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• 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 breeds 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 manoeuver
independently, ask him to apply resistance with his hand or with a
towel or belt.
CONT.

30. LATERAL
COSTAL
EXPANSION
IN SUPINE POSITION
30

31. LATERAL
COSTAL
EXPANSION
IN SITTING POSITION
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32. BELT EXERCISES TO
REINFORCE
LATERAL COSTAL
BREATHING
IN SITTING POSITION
By applying resistance
during inspiration
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33. APICAL EXPANSION
• This is useful when there is restricted upper chest
movement, or incomplete expansion of lung tissue,
particularly where there is an apical pneumothorax e.g.
following lobectomy.
• Pressure is applied below the clavicle using the tips of
the fingers.
• The patient breathes in, expanding the chest forwards
and upwards against the pressure of the fingers.
• The shoulders should be relaxed, and the expansion held
momentarily before expiration.

34. APICAL EXPANSION
34

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POSTERIOR BASAL EXPANSION
• The patient should sit leaning forward from the hips with a
straight back.
• Have the patient sit and lean forward on a pillow, slightly
bending the hips. Place your hands over the posterior
aspect of the lower ribs, and follow the same procedure
just described for lateral coastal expansion.

36. CONT.
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37. 37
• For the left side: the belt is placed round the back of the
chest at the level of the xiphisternum.The piece of belt coming
round from the left side is held forward with the right hand in
order to give pressure to the posterior part of the ribs.
• The other end of the belt is crossed over the thighs and is
fixed under the left thigh.
• The patient breathes out, and pull the belt firmly forwards,
and he then breathes in and expands the ribs backwards
against the resistance of the belt.
SELF TECHNIQUE

38. • At full inspiration and the
pressure is released and
expansion is maintained for
a moment before expiration.
• The procedure is reversed
for the right side.
CONT.

39. UPPER LATERAL EXPANSION
• The technique used is similar to that for lateral basal
expansion.
• The pressure is applied just below the axilla (not more than
2inch or 5 cm).

40. RELAXATION
POSITIONS FOR THE
BREATHLESS
PATIENTS
40

41. 41
• Whenever a patient’s normal breathing pattern is interrupted
shortness of breath can occur. It is helpful to teach a patient how
to monitor his or her level of SOB and to prevent episodes of
dyspnoea by CONTROLLED BREATHING TECHNIQUES, PACING
ACTIVITIES and becoming aware of what activity or situation
precipitates a SOB attack.
• Pacing is the performance of functional activities such as walking,
stair-climbing or work related task within the limits of patients
ventilatory capacity. Although some patients may understand
intuitively the limits to which functional activities can be pushed,
others must be taught to recognise the early signs of dyspnea.
POINTS TO PONDER

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• HIGH SIDE-LYING : Five or six pillows are used to raise the
patient shoulders while lying on his side. 1pillow should be placed between
the waist and axilla to keep the spine straight and prevent slipping down
the bed.
• The top pillow must be above the shoulders so that only the head and
neck are supported. The underneath forearm can be placed under the head
pillow, or resting on the bed underneath the pillow in the waist .
• It is more comfortable if the knees are bent and the top leg placed in
front of the one beneath. The position is helpful for patients in acute
respiratory distress or those who suffer from acute breathlessness during
the night.
CONT.

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• Forward lean sitting: The patient sits at the table
leaning forward from the hips with the head and upper
chest supported on several pillows. The back must be
kept a straight, so that diaphragmatic movement is not
inhibited. Children can sit or kneel with the head and
upper chest resting against pillows.
• Relaxed Sitting: This is an unobtrusive position that
can be taken up easily. The back should be kept a
straight, with the forearm is resting on the thighs and the
wrists relaxed.
CONT.

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• Forwardly lean standing: The patient should lean
forward with the forearm resting on an object of suitable
height, such as the windowsill or banisters.
• Relaxed standing: The patient can lean back against
the wall with the feet please slightly apart and
approximately 30 cm away from it. The shoulders and
arms should be relaxed.
CONT.

45. VARIOUS
RELAXATION
POSITIONS
45