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Breathing exercises.physiotherapy.improve breathing.pdf

The document discusses various breathing exercises and techniques. It describes the anatomy involved in breathing like the nose, trachea, diaphragm and lungs. It explains different types of breathing exercises like diaphragmatic breathing, pursed lip breathing and glossopharyngeal breathing. The goals, principles, guidelines for teaching and indications/contraindications of breathing exercises are provided. Resisted diaphragmatic breathing is also summarized.

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BREATHING EXERCISES
  The process that moves air in and out of the lungs called breathing or pulmonary ventilation. Breathing is only one of the processes that deliver oxygen to where it is needed in the body and remove carbon dioxide.
      ORGANS THAT INVOLVED IN BREATHING Nose Trachea Bronchi Bronchioles Lungs Muscles along with diaphragm
NOSE      The beginning of the respiratory tract. Function :- Warm Moisten Filter fine particles
TRACHEA    Tube like structure. Function :- Responsible for transporting air for respiration from the larynx to the bronchi.
DIAPHRAGM   Is a sheet of internal skeletal muscle. It separates the thoracic cavity containing heart & lungs , from the abdominal cavity
LUNGS   The lungs are a pair of spongy, air-filled organs located on either side of the chest (thorax). The lungs are the main functional organ of the respiratory trac.
BREATHING PROCESS        Breathing starts at the nose. You inhale air into your nose, and it travels down the back of your throat and into your windpipe or trachea. Trachea then divides into air passages called bronchial tubes. Bronchial tubes pass through the lungs, they divided into smaller air passages called bronchioles or bronchial tree. The bronchioles end in tiny balloon-like air sacs called alveoli. The body has over 300 million alveoli. The alveoli are surrounded by a mesh of tiny blood vessels called capillaries. Here, oxygen from the inhaled air passes through the alveoli walls and into the blood and carbon dioxide passes out of the blood into the air in the alveoli.
         MUSCLES OF INSPIRATION Diaphragm (primary m/s of inhale) Scalene (elevates 1st two ribs) Sternocleidomastoid (elevates sternum) Serratus anterior( supporting m/s) External intercostal( moves upward and outward) MUSCLES OF EXPIRATION External oblique Rectoabdominal Internal oblique Transverse abdominal
BREATHING EXERCISES DEFINATION
  Breathing ex and ventilatory training are the fundamental interventions for the prevention for acute and chronic pulmonary disease patients with high spinal cord lesion and who underwent thoracic and abdominal surgery and bedridden patients. Studies indicate that breathing exercise and ventilatory training have affect and alter a patients rate and depth of ventilation ,so these technique is used to improve the pulmonary status and increase patients overall endurance.
GOALS OF BREATHING EXERCISE        Improve ventilation Increase the effectiveness of cough and promote airway clearance To prevent post operative pulmonary complications To i mprove the strength endurance coordination of the muscles of ventilation Maintain and improve chest and thoracic spine mobility Promote relaxation and relive stress To teach the patient how to deal with episodes of dyspnea
   Assisting in removal of secretions. 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.
Principles        Area of exercises. Explanation & Instructions to the patient. Patients position. Evaluate the patient. Demonstration of exercise. Patient practice. Exercise room.
GUIDELINE FOR TEACHING BREATHING EXERCISES     Choose a quiet area-to get a proper interaction with minimal distraction Explain the patient about the aim and how it works for his impairment Have the pat: in relaxed position and loosen the clothes, make him in semi-fowlers position with head and trunk elevated approx: 45˚ (total support to the head and trunk and f l exing the hip and knees with pillow support) the abdominal muscle become relaxed. Other positions, such as supine, sitting, or standing, may be used as the patient progresses during treatment.
      Observe and access the patients spontaneous breathing pattern while at rest and during activity Determine whether Rx is indicated or not If necessary teach the patient relaxation techniques, relax the muscles of upper thorax neck and shoulder to minimize the use of accessory muscle work. Special attention on sternocleidomastoids, upper trapezius and levator scapulae. Demonstrate the breathing pattern to the patient Have the patient practice the correct technique in verity of positions at rest and with activity.
PRECUATIONS     Never allow the patient to force expiration-it may increase the turbulence in the air way which leads to bronchospasm and airway resistance. Avoid prolonged expiration-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 should be quiet during breathing Allow the patient to perform deep breathing only for 3-4 times (inspiration and expirations) to avoid Hyperventilation.
INDICATIONS        Cystic fibrosis Bronchiectasis Atelectasis Lung abscess Pneumonias Acute lung disease For patients with a high spinal cord lesion/ spinal cord injury, myopathies etc.     COPD –emphysema, chronic bronchitis After surgeries (thoracic or abdominal surgery) For patients who must remain in bed for an extended period of time.(obstruction due to retained secretions) As relaxation procedure.
CONTRAINDICATIONS          Severe pain and discomfort Acute medical or surgical emergency Patients with reduced conscious level Increased ICP Unstable head or neck injury Active hemorrhage with hemodynamic instability or hemoptysis Flail chest Uncontrolled hypertension Anticoagulation
        Rib or vertebral fractures or osteoporosis Acute asthma or tuberculosis Patients who have recently experienced a heart attack. Patients with skin grafts or spinal fusions will have undue stress placed on areas of repair. Bony metastases, brittle bones, bronchial hemorrhage, and emphysema are contraindications for undue stress to the thoracic area. Verify that patient has not eaten for at least one hour. Recent (within one hour) meal or tube feed Untreated pneumothorax
TYPES OF BREATHING EXERCISES     Diaphragmatic breathing Glossophryngeal breathing Pursed lip breathing Segmental breathing(costal expansion exercise) a) Apical breathing b) Lateral costal expansion c) Posterior basal expansion
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 ex: are also use to mobilize lung secretion in PD.
PROCEDURE    Prepare the patient in relaxed and comfortable position in which the gravity assist the diaphragm such as semifowlers 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 ant: costal margin ask the patient to breath slowly and deeply via nose by keeping the shoulder relaxed and upper chest quiet allowing the abdominal to rise now ask him to slowly let all the air out using controlled expiration through mouth.
   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 snif f i ng action this facilitates the diaphragm For self monitor have the patients hand over the ant costal margin and feel the movt: (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 able to do the controlled breathing using a diaphragmatic pattern keep the shoulder relaxed and practice in verity of positions (supine sitting standing) and during activity (walking and climbing stair).
Resisted diaphragmatic breathing       PT use small weight, such as sandbag to strengthen and improve the endurance of the diaphragm Have the patient in a head up position Place a small weight (1.30- 2.20 kg or 3-5 lb) over the epigastric region of his abdomen. 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 We i ght c an be i nc re ase d w he n he c an sust ai n diaphragmatic breathing pattern with out the use of any accessory muscles of inspiration for 15minuts.
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 dif f iculty 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.
PROCEDURE   Patient take several gulp of air (6 to 10), 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.
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.
PROCEDURE      Patient in a comfortable position and relaxed, explain the patent 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 (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 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 (shortage of air or breathlessness) in COPD and asthma.
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
ADVANTAGES OF SEGMENTAL BREATHING     Prevent accumulation of pleural fluid and secretions Decreases paradoxical breathing Decrease panic episode Improve chest mobility
Techniques     Lateral costal expansion Posterior basal expansion Right middle lobe or lingula expansion Apical expansion
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. Ask the patient to breathe out, and feel the rib cage move downward and inward. As the patient breathes out, place f i rm 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. 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 maneuver independently, ask him to apply resistance with his hand or with a towel.
BELT EXERCISES TO REINFORCE LATERAL COSTAL BREATHING (A) by applying resistance during inspiration (B) by assisting with pressure along the rib cage during expiration.
    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 PT hand over the posterior aspect of the lower rib and do the same procedure in lateral costal expansion.
 Right middle lobe or lingula expansion While the patient in 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.
 Apical expansion
• • Dr. Kavita Meena Department of physiotherapy THANK YOU THANK YOU THANK YOU THANK YOU