The document discusses diaphragm facilitation techniques aimed at improving breathing patterns in patients with respiratory issues, particularly post-surgery or due to neurological dysfunction. It outlines various methods for enhancing diaphragmatic breathing and managing accessory muscle use, emphasizing the importance of patient positioning and relaxation techniques. Strategies such as sniffing, lateral costal breathing, and upper chest inhibition are detailed to aid in effective ventilation and rehabilitation.

1. Diaphragm Facilitation Techniques
Dr. Hina Vaish (PT)
BPT, MPT (Cardiopulmonary), MIAP
Assistant Professor, MMIPR,
Maharishi Markhandeshwar ( Deemed to be
University), Mullana, Ambala

2. Breathing at rest is generally
perceived as effortless under
normal conditions.

3. But!
In patients often after surgery, respiratory
disease, or dysfunction secondary to
neurological insult or injury, the vital capacity
may be significantly decreased and the oxygen
consumption may be greatly increased resulting
from the use of accessory muscles or the extra
effort needed to breath or cough.

4. Ventilatory strategies
depends on the patient's individual
problem

5. The goal with patients with primary lung disease
is to teach them to relax the neck and chest
accessory muscles and use more diaphragmatic
breathing to reduce the work of breathing.
However, patients with secondary pulmonary
dysfunction patients, may have accessory
muscles intact, but they are not able to use
them to faciliate deep breathing or coughing. In
these cases the goal is to teach them to use the
accessory muscles to balance the upper and
lower chest.

7. Diaphragm
• Main muscle of inspiration
Dome shaped
Two hemi-diaphragms
Accounts for 75% of volume change (quiet
breathing)

8. DIAPHRAGMATIC BREATHING
• For relaxation & coordinated breathing
pattern
• Greater tidal volume is achieved with
diaphragmatic breathing and improve overall
ventilation

9. Diaphragmatic Facilitation Techniques
• Relaxing techniques
• Re-patterning
• Sniffing
• Diaphragmatic scoop
• Lateral Costal facilitation Technique
• Upper Chest Inhibition Technique
• Normal Timing techniques

10. The first step in facilitating any
breathing pattern is to position the
patient for respiratory success.

11. Relaxation of upper chest and
shoulders
• Maximal contractions leads to maximal
relaxation
• This technique can be applied to upper chest
and shoulders
• Verbal commands can be very important with
this procedure.

12. Cont…

13. Cont…
• The therapist places his or her hands on the
patient's shoulder girdle. The patient is asked
to shrug his or her shoulders up into the
therapist's hands and hold it.
• The emphasis is on the relaxation phase.

14. Re-patterning Techniques
• When the patient needs more support to gain
control of breath and is experiencing shortness of
breath.
• Ask the patient to exhale “ try to blow out easily
with lips pursed. Donot force it, just let it come
out.
• Once patient feels some control of breath then
ask to hold breath at top of inspiration just for 1-2
seconds.
• Avoid valsalva maneuver

15. Sniffing
• Sniffing is primarily diaphragmatic breathing
• Place the patient in gravity eliminated position
• Relatively posterior pelvis
• Use pillow under head
• Arms down below 90 degree of flexion

16. Cont…
• Place the patients hand on their stomach for
increased proprioceptive feedback
One long sniff
Sniff Twice, then exhale
Sniff 3 times , then slowly exhale

17. Diaphragmatic Scoop Technique
• Place patient in gravity eliminated postion
• Feel the patients breathing pattern by placing
your hand at the umblicus
• After normal rate at the end of patients
exhalation, give a slow stretch and scoop
hand up and under anterior thorax.
• Oral command is given while scoop stretch
“breathe into my hand”

18. Cont…
• Try not to have patients take too many deep
breaths; they may begin to feel light-headed
because they may hyperventilate and blow off
too much Carbon dioxide.

19. Lateral Costal Breathing
• Lower chest lateral costal expansion facilitate
diaphragmatic and intercostal breathing
• Mid chest lateral costal expansion will recruit
primarily intercostal activity

20. Bilateral lower lobe expansion
Bilateral mid-chest
expansion exercise.

21. Upper Chest Inhibition
• Position the patient appropriately.
• For a couple of respiratory cycles without
applying any pressure to feel the upper chest's
movement

22. Cont…
• On the patient's next inspiratory effort apply
pressure or resistance to the expansion of the
upper chest. This gentle pressure will cause
postural inhibition to the anterior and
superior movement of the upper chest.
• After each expiratory cycle, add more pressure
until the patient subconsciously increases the
lower chest breathing out of necessity.

23. • This technique should never cause an increase
in anxiety or it will only encourage more upper
chest breathing rather than less.
Cont…..

24. Normal Timing
• A normal timing technique adapted from the
physical therapy approach of PNF can help the
patient work on this sequence.
• Position the patient in supine or supported
sitting with neutral pelvis position.
• At the end of an expiratory cycle using the
hand placement of the diaphragm scoop, asks
the patient to breathe in "here." With the
other hand, the therapist moves up

25. Cont…
• The chest wall to the lower sternum and
touches the patient with the instructions
again to "now breathe here.“
• Finally, the therapist uses the first hand to
move up to the upper sternum (usually
around the level of the sternal angle) and asks
the patient to "now breathe here.“
• The manual cues provide tactile cuing

26. Facilitating effective ventilation goes far
beyond just the diaphragmatic exercise,
physiotherapists can be incorporate
techniques and strategies to get their
patients to assist them in reaching their
greatest rehabilitation potential.

27. THANK YOU