This document describes techniques for localized breathing exercises to improve lung ventilation and clear secretions. It discusses basal, apical, and posterior basal expansion specifically. Basal expansion uses the "bucket-handle" movement of the ribs caused by diaphragm contraction. It is best taught unilaterally to allow shoulder relaxation. The techniques involve the therapist applying pressure to areas of the chest during inhalation to encourage expansion. Goals include expanding lung tissue, increasing ventilation in chronic conditions, and removing secretions. Care must be taken to avoid fatigue and breathlessness.

1. LOCALISED BASAL
EXPANSION
DR. T SUNIL KUMAR
DEPT. OF PHYSIOTHERAPY

2. INTRODUCTION
• LOCALISED BREATHING EXERCISES ARE USEFUL
FOR ASSISTING IN THE REMOVAL OF SECRETIONS
AND IMPROVING MOVEMENT OF THE THORACIC
CAGE.
• IT IS UNLIKELY THAT INDIVIDUAL LOBES OF THE
LUNG ARE VENTILATED BY THESE EXERCISES.
• THEY SHOULD NOT BE PERFORMED DURING
ATTACKS OF BREATHLESSNESS.
• IT HAS BEEN STATED THAT LOCALISED BASAL
EXPANSION UTILISES THE ‘BUCKET-HANDLE’
MOVEMENT OF THE RIBS.

3. • ALTHOUGH THERE IS A CERTAIN AMOUNT OF
CONTROVERSY ABOUT THIS, IT SEEMS TO BE
AGREED THAT THE MOVEMENT IS CAUSED BY THE
CONTRACTION OF THE OUTER FIBRES OF THE
DIAPHRAGM WHEN THE CENTRAL TENDON IS
FIXED.
• WHEN TREATING MOST CONDITIONS IT IS
PREFERABLE TO TEACH UNILATERAL BASAL
EXPANSION, OTHERWISE THE PATIENT IS UNABLE
TO RELAX THE SHOULDER GIRDLE ADEQUATELY
AND THIS TENDS TO EXAGGERATE THE MOVEMENT
OF THE UPPER CHEST.

4. POSITION OF THE PATIENT
• THE PATIENT SHOULD BE IN A HALF-LYING POSITION
WITH THE KNEES FLEXED OVER A PILLOW, OR SITTING
IN AN UPRIGHT CHAIR.
TECHNIQUE
• THE PHYSIOTHERAPIST PLACES THE PALM OF THE
HAND IN THE MID-AXILLARY LINE OVER THE 7TH AND
8TH RIBS; FINGERS SHOULD BE RELAXED AND WELL
ROUND THE POSTERIOR ASPECT OF THE THORAX.
• THE PATIENT IS INSTRUCTED TO RELAX AND BREATHE
OUT, ALLOWING THE LOWER RIBS TO SINK DOWN AND
IN: THIS MOVEMENT MUST NOT BE FORCED.

6. • AT THE END OF EXPIRATION THE
PHYSIOTHERAPIST SHOULD APPLY FIRM PRESSURE
AGAINST THE CHEST AND INSTRUCT THE PATIENT
WITH THE NEXT INSPIRATION TO EXPAND THE
LOWER RIBS AGAINST THERAPIST’S HANDS.
• PRESSURE SHOULD BE RELEASED AT THE END OF
INSPIRATION AND THE WEIGHT OF THE HANDS
FOLLOW THE CHEST BACK TO REST.
• PRESSURE IS RE-APPLIED WHEN THE PATIENT IS
READY TO BREATHE IN AGAIN.

7. • IF THE AIM OF THE TREATMENT IS TO EXPAND LUNG
TISSUE, THE EMPHASIS SHOULD BE ON HOLDING THE
MAXIMUM INSPIRATION FOR 3 SECONDS (WARD, 1966)
AND THEN ‘SNIFF IN A LITTLE MORE AIR.
• WHERE THERE IS A REGION OF LUNG WHICH HAS
PARTIALLY OBSTRUCTED AIRWAYS OR DECREASED
COMPLIANCE, THE ALVEOLI WILL FILL AT A SLOWER
RATE THAN THE UNAFFECTED AREAS (I.E. INCREASED
TIME CONSTANT).
• PATIENTS WITH AIRWAYS DISEASE OR SCATTERED
AREAS OF ATELECTASIS HAVE LOCAL VARIATIONS OF
TIME CONSTANTS.

8. • THESE AREAS NEED MORE TIME TO EXPAND THAN
UNAFFECTED AREAS, THEREFORE SLOW DEEP
BREATHING WITH A HOLD ON INSPIRATION ALLOWS
THEM MORE CHANCE OF GAINING VENTILATION.
• HOLDING THE BREATH ALSO ALLOWS TIME FOR THE
AIR TO DIFFUSE THROUGH THE PORES OF KOHN.
• THERE IS COLLATERAL AIR DRIFT AT ALVEOLAR LEVEL
AND HENCE A ‘SNIFF WILL PROVIDE A LITTLE MORE
EXPANSION.
• ONCE THE PATIENT HAS LEARNED THE CORRECT
TECHNIQUE, HE IS TAUGHT TO GIVE PRESSURE
HIMSELF.

9. • SOME PATIENTS WHO HAVE LIMITED WRIST
EXTENSION WILL FIND IT EASIER TO APPLY
PRESSURE WITH THE BACK OF THE FINGERS OR
THE PALM OF THE OPPOSITE HAND.
• WHEN USING ANY OF THESE
METHODS THE PATIENT SHOULD
NOT ELEVATE HIS SHOULDER
GIRDLE, OR ACHIEVE COSTAL
EXPANSION BY SIDE FLEXION OF
THE SPINE.
• THE USE OF A WIDE BELT MADE OF
WEBBING OR SOME OTHER STRONG,
NON-EXTENSIBLE MATERIAL MAY BE
HELPFUL.

10. • WHEN HELPING TO REMOVE SECRETIONS FROM
THE LUNGS, OR WHEN TRYING TO STIMULATE
INCREASED VENTILATION IN A CHRONIC
CONDITION OR AFTER ABDOMINAL OR THORACIC
SURGERY, IT IS OFTEN HELPFUL TO CONCENTRATE
ON ONE PHASE OF BREATHING AT A TIME, AS FULL
RANGE COSTAL EXERCISES MAY BE TIRING.
• FULL INSPIRATION CAN BE ENCOURAGED
VERBALLY AND MANUAL RESISTANCE GIVEN TO
ENCOURAGE EXPANSION.
• FULL INSPIRATION IS HELD FOR ABOUT 3
SECONDS, THE EXPIRATORY PHASE IS NATURALLY
PASSIVE IN THIS EXERCISE.

11. • EXPIRATORY COSTAL EXERCISES MAY BE
PRACTISED TO ENCOURAGE MAXIMUM COSTAL
MOVEMENT AND TO STIMULATE COUGHING.
• THE PATIENT GENTLY BREATHES OUT FULLY,
ACTIVELY CONTRACTING THE EXPIRATORY
MUSCLES.
• THE PHYSIOTHERAPIST MAY ASSIST WITH
INCREASED GENTLE PRESSURE AT FULL
EXPIRATION.
• THE INSPIRATION WILL NOT BE EMPHASISED IN
THIS EXERCISE.

12. • AS FULL EXPIRATION NARROWS THE AIRWAYS,
THIS EXERCISE SHOULD BE AVOIDED IF
BRONCHOSPASM IS PRESENT.
• CARE MUST BE TAKEN TO GIVE ENOUGH RESTS
BETWEEN THE EFFORTS OF THE BREATHING
EXERCISES.
• EACH DEEP BREATH SHOULD BE DONE SLOWLY
AND PACED FOR THE INDIVIDUAL, TO PREVENT
BREATHLESSNESS OR DIZZINESS.

13. APICAL EXPANSION
• IT IS NECESSARY TO TEACH APICAL EXPANSION
EXERCISES IF THERE IS UNDERLYING DISEASE IN
THE UPPER LOBE.
• WHEN THERE IS INVOLVEMENT OF THE UPPER
LOBES, AS IN CYSTIC FIBROSIS OR EMPHYSEMA,
THE PATIENT IS ALREADY OVER-INFLATING THE
UPPER CHEST AND NEEDS TO CONCENTRATE ON
RELAXED DIAPHRAGMATIC BREATHING AND
LOCALISED BASAL EXPANSION.

14. • IN CERTAIN CASES AFTER THORACIC SURGERY,
FOR EXAMPLE RESIDUAL APICAL PNEUMOTHORAX
FOLLOWING LOBECTOMY, OR WHEN THERE IS
RESTRICTED MOVEMENT AND DEFORMITY OF THE
CHEST WALL CAUSED BY EXTENSIVE PLEURAL
THICKENING, APICAL EXPANSION EXERCISES ARE
USEFUL.
• THEY SHOULD BE TAUGHT UNILATERALLY.

15. TECHNIQUE
• PRESSURE IS APPLIED BELOW THE CLAVICLE
USING THE TIPS OF THE FINGERS.
• THE PATIENT IS INSTRUCTED TO BREATHE IN AND
EXPAND THE CHEST UPWARDS AGAINST THE
PRESSURE OF THE FINGERS.
• FULL INSPIRATION MAY BE HELD FOR A MOMENT
BUT THE SHOULDERS MUST REMAIN RELAXED.
• THE PATIENT SHOULD BE IN A WELL SUPPORTED
HALF-LYING OR SITTING POSITION AND CAN BE
TAUGHT TO GIVE PRESSURE HIMSELF WITH THE
OPPOSITE HAND.

17. POSTERIOR BASAL EXPANSION
• THIS EXERCISE IS USEFUL IF MOVEMENT IS
RESTRICTED IN THIS AREA.
• PRESSURE IS GIVEN UNILATERALLY OVER THE
POSTERIOR ASPECT OF THE LOWER RIBS AND THE
PATIENT CAN BE TAUGHT TO APPLY THIS
PRESSURE HIMSELF.

19. THANK YOU