Breathing exercises, also called ventilatory training, are fundamental interventions for patients with pulmonary diseases. They can improve ventilation, increase cough effectiveness, prevent postoperative complications, and more. There are various types of breathing exercises, including diaphragmatic breathing, pursed lip breathing, and segmental breathing. Diaphragmatic breathing focuses on belly breathing to improve strength. Pursed lip breathing prolongs exhalation to slow breathing rate. Segmental breathing targets specific areas of the lungs that need more ventilation. Proper technique and positioning are important to teach patients how to correctly perform different breathing exercises.

1. BREATHING EXERCISES
PRESENTED BY:
KELSANG DOLKAR

2. ANATOMY AND PHYSIOLOGY

5. BREATHING EXERCISES
Breathing exercises also called ventilatory training are the
fundamental interventions for acute and chronic pulmonary disease
patients,also for it’s prevention and can be performed by those who
underwent thoracic surgery and bedridden patients.
Studies indicate that breathing exercise and ventilatory training have
great effect and alteration in a patient’s rate and depth of
ventilation,so this is the reason why,these techniques are used to
improve the pulmonary status and increase patient’s overall
endurance.

6. GOALS OF BREATHING EXERCISE
Improve ventilaton
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 mobilty
Promote relaxation and relieve stress
To teach the patient how to deal with episodes of dyspnea
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

7. GUIDELINES FORTEACHING
BREATHING EXERCISES
1. Choose a quiet area-to get a proper interaction with minimal distraction
2. Explain the patient about the Aim and how it works for his impairment
3. Have the patient in relaxed position and loosen the cloths,position them in semi-fowlers with
head and trunk elevated approx:45c (total support to the head and trunk and flexing the hip
and knees with pillow support)
4. Other positions, such as supine,sitting or standing,may be used as the patient progresses
during treatment
5. Observe and access the patients spontaneous breathing while at rest during activity
6. Determine whether prescription is indicated or not
7. If necessary teach the patient relaxation techniques,relax the muscles of upper thorax neck
and shoulder to minimize the use of accessory muscle work
8. Demonstrate the breathing pattern to the patient
9. Have the patient practice the correct technique

8. PRECAUTIONS

9. INDICATIONS
Cystic fibrosis
Bronchiectasis
Atelectasis
Lung abscess
Pneumonia
For patient with a high spinal cord
injury/lesion
COPD
Chronic bronchitis
Emphysema
For patient who must remain in bed for
extended period of time
As relaxation procedure

10. CONTRAINDICATIONS
Severe pain and discomfort
Acute medical or surgical emergencies
Patients with reduced conscious level
Increased ICP(intra cranial pressure)
Unstable head or neck injury
Active haemorrhage with
haemodynamic instability or
hemoptysis
Flail chest,Rib or vertebral fractures
Uncontrolled hypertension
Anticoagulation
Patients who recently experienced
heart attack
Patients with skin grafts or spinal
fusions will have undue stress placed on
areas of repair
Brittle bone
Verify that patient has not eaten for at
least one hour (same with tube feed)
Untreated pneumothorax

11. TYPES OF BREATHING EXERCISE
1. DIAPHRAGMATIC BREATHING
2. GLOSSOPHARYNGEAL BREATHING
3. PURSED LIP BREATHING
4. SEGMENTAL BREATHING (COSTAL EXPANSION EXERCISE)
A.APICAL BREATHING
B.LATERAL COSTAL EXPANSION
C. POSTERIOR BASAL EXPANSION

12. 1.DIAPHRAGMATIC BREATHING
DIAPHRAGMATIC BREATHING OR DEEP BREATHING is breathing
that is done by contracting the diaphragm,a muscle located
horizontally between the thoracic cavity and abdominal cavity.
Air enters the lungs,the chest does not rise and the belly
expands during this type of breathing
Mainly performed for COPD patient, others v.i.z ;improvement of
pulmonary function,cardio respiratory function,respiratory muscle
strength

13. PROCEDURE
1) Prepare the patient in relaxed and comfortable position in
which the gravity assist the diaphragm such as semi
fowlers position.
2) If you notice any accessory muscle activation stop him
and instruct to do relaxation techniques (shoulder roll or
shrugs coupled with relaxation)
3) 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 abdomen to rise, now ask
him to slowly let all the air out using controlled expiration
through mouth.

14. CONT..

 4) 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
 5) For self monitor have the patients hand over the anterior costal
margin and feel the movement: (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
 6) After he understands and able to do the controlled breathing using
a diaphragmatic pattern keep the shoulder relaxed and practice in
different positions (supine,sitting and standing) and during activity
(walking and climbing stair).

15. RESISTED DIAPHRAGMATIC BREATHING
1) Patient use small weight, such as sandbag to strengthen and
improve the endurance of the diaphragm
2) Have the patient in a head up position
3) Place a small weight (1.30 - 2.20 kg) over the epigastric region of
his abdomen.
4) Tell the patient to breath in deeply while trying to keep the upper
chest quiet
5) Gradually increase the time that the patient breaths against the
resistance of weight
6) Weight can be increased when he can sustain diaphragmatic
breathing pattern with out the use of any accessory muscles of
inspiration for 15minuts.

16. 2. GLOSSOPHARYNGEAL 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.
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.
Glossopharyngeal breathing with inspiratory action of neck
muscles can reduce ventilatory dependence or can be used as
an emergency procedure for malfunctioning of ventilator.

17. PROCEDURE
Patient take several gulp of air (6 to 10 gulps),
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.

18. 3. 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 exhalation slows the breathing
rate.
 It moves old air out of the lungs and allow new air to enter the lungs.

19. PROCEDURE
1. Place the Patient in a comfortable position and relaxed, explain the
patent about the expiration phase (it should be relaxed and passive).
2. Abdominal muscle contraction must be avoided (therapist hand over
the patients abdomen to check for contraction).
3. 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 ).
4. By providing slight resistance, an increased positive pressure will
generate within the airway which helps to keep open small
bronchioles that otherwise collapse.
5. It can be applied as a 3-5 minutes “rescue exercise” or an Emergency
Procedure to counteract acute problem or dyspnea (shortage of air
or breathlessness)also in COPD and asthma.

20. 4.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

21. ADVANTAGES OF SEGMENTAL BREATHING
Prevent accumulation of pleural fluid and secretions
Decreases paradoxical breathing
Decrease panic episode
Improve chest mobility

22. TECHNIQUES
A.Lateral costal expansion
B.Posterior basal expansion
C.Right middle lobe or lingula expansion
D.Apical expansion

23. A. 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 you 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.
Apply light manual resistance to the lower ribs to increase sensory awareness as the
patient breathes in deeply and the chest expands.

24. CONT..
When the patient breathes out, assist by gently squeezing the rib cage in a
downward and inward direction.
The patient may then can be taught to perform the procedure independently,
ask him to apply resistance with his hand or with a towel acting as like a belt.

25. B. 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 Patient hand over the posterior aspect of the lower rib and
do the same procedure as in lateral

26. C. RIGHT MIDDLE LOBE OR LINGULA EXPANSION

While the patient is 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.

27. D. APICAL EXPANSION
Patient is in sitting position,applies
pressure (usually unilaterally) below the
clavicle with their finger tips,these pattern
is appropriate in an apical pneumothorax
after a lobectomy