This presentation summarizes all breathing exercises used to rehabilitate a cardiopulmonary patient both inside and outside of a healthcare setup. It provides with the proper technique of the various exercises and conditions in which they are indicated.

1. BREATHING
EXERCISES
APOORVA BALODHI
BPT (4th Year)

2. Breathing exercises and ventilatory training are the
fundamental interventions for the prevention of acute
and chronic pulmonary diseases in patients with high
spinal cord lesion and who underwent thoracic, and
abdominal surgery and bed ridden patient’s.
These alter a patient’s rate and depth of ventilation
thus improving pulmonary status and increase
patient’s overall endurance.

3. INDICATIONS
• Cystic fibrosis
• Bronchiectasis
• Atelectasis
• COPD-emphysema, chronic bronchitis
• Lung abscess
• Pneumonia
• Patients with high spinal cord lesion/SCI, myopathies
• After surgeries (thoracic/abdominal)
• Bed-ridden patients
• As a relaxation procedure

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

5. TYPES OF BREATHING
Three types are commonly used:
• Diaphragmatic breathing
• Glossopharyngeal breathing
• Pursed lip breathing
• Segmental breathing(costal expansion exercise)
a) Apical breathing
b) Lateral costal expansion
c) Posterior basal expansion

6. 1. 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
exercises are also used to mobilize lung secretions in
pulmonary diseases.

7. PROCEDURE
• Prepare the patient in relaxed and comfortable position
in which the gravity assists 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 anterior costal margin and ask the patient to breathe
slowly and deeply via nose by keeping the shoulder
relaxed and upper chest quiet. Allow the abdomen to
rise. Now ask him to slowly let all the air out using
controlled expiration through mouth.

8. • 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 patient’s 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).
• After he understands and is able to do the controlled
breathing using a diaphragmatic pattern, keep the
shoulder relaxed and practice in a variety of positions
(supine sitting standing) and during activity (walking and
climbing stair).

9. 2. GLOSOPHARYNGEAL BREATHING
• It is a means of increasing a patient’s inspiratory
capacity when there is a severe weakness of the
muscles 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.

10. PROCEDURE
• Patient takes several gulps of air by closing the mouth.
The tongue pushes the air back and traps it in the
pharynx. The air is then forced to lungs when the glottis
is opened.

11. 3. PURSED LIP BREATHING
• Pursed-lip breathing is a strategy that involves lightly
pursing the lips together during controlled exhalation.
• It is taught to patients with COPD to deal with episodes
of dyspnoea.
• It helps to improve ventilation and releases trapped air in
the lungs.
• It keeps the airways open longer and prolongs
exhalation by slowing the breathing rate.
• It moves old air out of the lungs and allows new air to
enter the lungs.

12. PROCEDURE
• Patient is 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
(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 (like 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 small bronchioles open that otherwise collapse.

13. • It can be applied as a 3-5 minutes “rescue exercise” or
an Emergency Procedure to counteract acute
exacerbations or dyspnoea (shortage of air or
breathlessness) in COPD and asthma.

14. 4. SEGMENTAL BREATHING
• Performed on a segment of lung or a section of chest
wall that needs increased ventilation or movement.
• It’s questionable whether a patient can be taught to
expand localized areas of the lung while keeping other
areas quiet.
• Hypoventilation does occur in certain areas of the lungs
because of pain and muscle guarding after surgery.
• Therefore, it is important to emphasize expansion of
problems areas of the lungs and chest wall under certain
conditions.

15. Apical expansion
• Patient in sitting position.
• Apply pressure (usually unilaterally) below the clavicle
with the fingertips.
• This pattern is appropriate in an apical pneumothorax
after a lobectomy.

16. 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 to
fix the patient’s attention to the areas at which movement
the is to occur.
• 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.

17. • Apply light manual resistance to the lower ribs to
increase sensory awareness as the patient breathes in
deeply, and the chest expands and ribs flare. Then, as
the patient breathes out, assist by gently squeezing the
rib cage in a downward and inward direction.
• Tell the patient to expand the lower ribs against your
hand as he or she breathes in.
• Apply gentle manual resistance to the lower rib area to
increase sensory awareness as the patient breathes in
and the chest expands and ribs flare.
• Then, again, as the patient breathes out, assist by gently
squeezing the rib cage in a downward and inward
direction.
• The patient may then be taught to perform the
manoeuvre independently. He or She may place the
hand(s) over the ribs or apply resistance using a belt.

18. Posterior basal expansion
• Deep breathing emphasizing posterior basal expansion
is important for the postsurgical patient who is confined
to bed in a semireclining position for an extended period
of time because secretions often accumulate in the
posterior segments of the lower lobes.
• 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.
• Follow the same procedure as described above.
• This form of segmental breathing is important for the
post surgical patient who is confined to bed in a semi
upright position for an extended period of time.
Secretions often accumulate in the posterior segments of
the lower lobes.