BREATHING EXERCISEZ

MUSCLES OF RESPIRATION
• 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)
• EXPIRATION
– External oblique
– Rectoabdominal
– Internal oblique
– Transverse abdominal
 BREATHING EXERCISES
• 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 improve 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
 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 pt: 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 flexing 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 sniffing 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
• Weight can be increased when he can sustain 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 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.
 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
• move the ribs outward and upward during
inspiration
 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 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
• 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