Breathing exercises
Mazyad Alotaibi
Respiration
Respiration can be divided into:
External respiration: ventilation and exchange of gasses
in the lungs.
 Internal respiration: ventilation and exchange of gasses
in the tissues.
Exchange occurs as result:
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- Ventilation: mechanical
- Diffusion: random movement
Breathing
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Breathing (pulmonary ventilation). consists of
two cyclic phases:
Inhalation, also called inspiration - draws gases
into the lungs.
Exhalation, also called expiration - forces gases
out of the lungs.
Respiratory System Functions
1.
2.
3.
4.
5.
supplies the body with oxygen and disposes of
carbon dioxide
filters inspired air
produces sound
contains receptors for smell
helps regulate blood PH
Structures of the Respiratory
System
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Consists of an upper respiratory tract (nose to larynx) and a
lower respiratory tract ( trachea onwards) .
Conducting portion transports air.
- includes the nose, nasal cavity, pharynx, larynx, trachea,
and progressively smaller airways, from the primary bronchi
to the terminal bronchioles
Respiratory portion carries out gas exchange.
- composed of small airways called respiratory bronchioles
and alveolar ducts as well as air sacs called alveoli
Upper Respiratory Tract
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Composed of the nose and nasal cavity,
paranasal sinuses, pharynx (throat), larynx.
All part of the conducting portion of the
respiratory system.
Upper Respiratory Tract
Lower Respiratory Tract
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Conducting airways (trachea, bronchi, up to
terminal bronchioles).
Respiratory portion of the respiratory
system (respiratory bronchioles, alveolar
ducts, and alveoli).
Conducting zone of lower
respiratory tract
Muscles of Inspiration
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The primary muscle of inspiration is
- Diaphragm which : works during quiet
breathing forces abdominal contents down &
forward
Accessory muscles which work during strenuous
physical activities are: External intercostals,
pectoralis minor, scaleni & sternocleidomastoid :
they lift ribs up and outwards
Muscles of Inspiration
Muscles of Expiration
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Expiration during quiet breathing is passive due to
elastic recoil of chest cavity
Decrease in lung size force air out of lungs
During exercise and voluntary hyperventilation,
– rectus abdominus, transverse abdominus:
diaphragm up
– internal intercostals: pull ribs downwards
push
Primary and Accessory
Ventilatory Muscles
Inspiration
• Primary muscles: diaphragm, scalenes, parasternals
•Accessory muscles: sternocleidomastoids, upper trapezius, pectoralis
major and minor, subclavius, and possibly the external intercostals
 Expiration
• Primary muscles: none active during tidal (resting) expiration
•Accessory muscles: abdominals including the rectus abdominis,
transversus abdominis, and internal and external obliques;
pectoralis major; and possibly the
internal intercostals
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Goals of Breathing Exercises
• Improve or redistribute ventilation.
• Increase the effectiveness of the cough mechanism and promote
airway clearance.
• Prevent postoperative pulmonary complications.
• Improve the strength, endurance, and coordination of the muscles of
ventilation.
• Maintain or improve chest and thoracic spine mobility.
• Correct inefficient or abnormal breathing patterns and decrease the
work of breathing.
• Promote relaxation and relieve stress.
• Teach the patient how to deal with episodes of dyspnea.
• Improve a patient’s overall functional capacity for daily living,
occupational, and recreational activities
Examination
Evaluation of the patient with pulmonary dysfunction and
determination of a diagnosis, prognosis, and intervention plan are
based on the findings derived from a comprehensive examination,
including a history, systems review, and specific tests
Components of the Examination
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General Appearance of the Patient
Analysis of Chest Shape and Dimensions
Symmetry of the chest and trunk. Observe anteriorly, posteriorly, and laterally; the
thoracic cage should be symmetrical.
Mobility of the trunk. Check active movements in all directions and identify any
restricted spinal motions, particularly in the thoracic spine.
Shape and dimensions of the chest. The anteroposterior (AP) and lateral dimensions are
usually 1:2.
Posture or Preferred Positioning
Breathing Pattern
Assess the rate, regularity, and location of ventilation at rest and with activity. A normal
respiratory rate for a healthy adult is 12 to 20 breaths per minute.
Chest Mobility
Symmetry of chest movement. Analysis of the symmetry
of the moving chest during breathing gives the therapist information about the mobility of
the thorax and indicates indirectly what areas of the lungs may or may not be
responding.
Abnormal Breathing Patterns
• Dyspnea. Distressed, labored breathing as the result of shortness of
breath.
 Tachypnea. Rapid, shallow breathing; decreased tidal volume but
increased rate; associated with restrictive or obstructive lung
disease and use of accessory muscles of inspiration.
 Bradypnea. Slow rate with shallow or normal depth and regular
rhythm; may be associated with drug overdose.
 Hyperventilation. Deep, rapid respiration; increased tidal volume
and increased rate of respiration; regular rhythm.
 Orthopnea. Difficulty breathing in the supine position.
 Apnea. Cessation of breathing in the expiratory phase.
 Apneusis. Cessation of breathing in the inspiratory phase.
Principles of breathing exercises
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If possible, choose a quiet area for instruction in which therapist
can interact with the patient with minimal distractions.
Explain to the patient the aims and rationale of breathing
exercises
Have the patient assume a comfortable, relaxed position
Observe and assess the patient’s spontaneous breathing pattern
while at rest and later with activity.
Demonstrate the desired breathing pattern to the patient.
Have the patient practice the correct breathing pattern in a variety
of positions at rest and with activity.
Precautions: When teaching breathing exercises, be aware of the following
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Never allow a patient to force expiration. Expiration should be
relaxed or lightly controlled.
Do not allow a patient to take a highly prolonged expiration.
Do not allow the patient to initiate inspiration with the accessory
muscles and the upper chest.
Allow the patient to perform deep breathing for only three or four
inspirations and expirations at a time to avoid hyperventilation.
Breathing patterns and procedures
Diaphragmatic breathing
The patient places his or her own hands on the abdomen to
feel the movement of proper diaphragmatic breathing. By placing
the hands on the abdomen, the patient can also feel the contraction
of the abdominals, which occurs with controlled expiration or
coughing
Segmental Breathing
- Are designed to expand localized areas of the lung
Two examples of segmental breathing that target the lateral and
posterior segments of the lower lobes are described. However,
segmental breathing techniques also may need to be directed to the
middle and upper lobes if there is accumulation of secretions or
insufficient lung expansion in these areas.
Lateral Costal Expansion: can be carried out unilaterally or
bilaterally Deep breathing while focusing on movement of the
lower portion of the rib cage may facilitate diaphragmatic
excursion. This technique is particularly important for the patient
with a stiff lower rib cage, as is often seen with chronic bronchitis,
emphysema, or asthma.
Bilateral lateral costal expansion—supine.
Bilateral lateral costal expansion sitting
The patient applies his or her own manual pressure
during lateral costal expansion.
Belt exercises reinforce lateral costal breathing (A) by applying
resistance during inspiration and (B) by assisting with pressure along
the rib cage during expiration
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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
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Procedure
Have the patient sit and lean forward on a pillow, slightly bending
the hips . The therapist hands is placed over the posterior aspect of
the lower ribs, and follow the same procedure just described for
lateral costal expansion.
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Posterior basal expansion: the therapist hands is
placed over the posterior aspect of the lower
ribs.
Right middle lobe expansion: in which the
therapist hands at either the right or the left side
of the patient’s chest, just below the axilla.
Apical expansion: in which pressure is applied
below the clavicle with the fingertips
Pursed Lip Breathing: Pursed-lip
breathing is a strategy that involves
lightly pursing the lips together during controlled exhalation. This
breathing pattern often is adopted spontaneously by patients with
COPD to deal with episodes of dyspnea. Patients with COPD using
pursed-lip breathing report a decrease in their perceived level of
exertion during activity.
Procedure
Have the patient assume a comfortable position and relax as
much as possible. Have the patient breathe in slowly and deeply
through the nose and then breathe out gently through lightly
pursed lips as if blowing on and bending the flame of a candle
but not blowing it out. Explain to the patient that expiration must
be relaxed and that contraction of the abdominals must be
avoided. Place your hand over the patient’s abdominal muscles to
detect any contraction of the abdominals.
EXERCISES TO MOBILIZE THE CHEST
Chest mobilization exercises are any exercises that combine active
movements of the trunk or extremities with deep breathing. They
are designed to maintain or improve mobility of the chest wall,
trunk, and shoulder girdles when it affects ventilation or postural
alignment. For example, a patient with hypomobility of the trunk
muscles on one side of the body does not expand that part of the
chest fully during inspiration. Exercises that combine stretching of
these muscles with deep breathing improve ventilation on that side
of the chest.
Chest mobilization during inspiration and expiration.
To mobilize the lateral rib cage have the patient (A) bend away
from the tight side during inspiration and (B) bend toward the tight
side during expiration
.
(A) A stretch is applied to the pectoralis muscles during inspiration,
and (B) the patient brings the elbows together to facilitate expiration.
(A) Chest expansion is increased with bilateral movement
of the arms overhead during inspiration. (B) Expiration is then
reinforced
by reaching the arms toward the floor.