, Julie Burkin1, Catherine Moffat1 and Anna Spathis1
(1)
Department of Palliative Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
Abstract
Breathing techniques are most commonly used in combination with positioning and the fan to the face or other facial cooling. This chapter will focus on three different breathing techniques that can help reduce the feeling of breathlessness:
Breathing Control
Pursed-lips Breathing
Recovery Breathing
Technique selection, modification to suit the patient and combining techniques will be discussed, as well as the role of breathing pattern re-education in breathlessness management.
My doctor said you would teach me how to breathe correctly. What a ridiculous idea, I have been breathing all my life!
– A patient’s view on breathing techniques.
Introduction
Breathing techniques are most commonly used in combination with positioning and the fan to the face or other facial cooling. This chapter will focus on three different breathing techniques that can help reduce the feeling of breathlessness:
Breathing Control
Pursed-lips Breathing
Recovery Breathing
Technique selection, modification to suit the patient and combining techniques will be discussed, as well as the role of breathing pattern re-education in breathlessness management.
Breathing Control vs Diaphragmatic Breathing
The terms Breathing Control and Diaphragmatic Breathing are often used interchangeably however the British Thoracic Society and Association of Chartered Physiotherapists in Respiratory Care (BTS/ACPRC) (2009) guidelines (p. i49) offer the following two different definitions:
Breathing Control
“Normal tidal breathing encouraging relaxation of the upper chest and shoulders.”
Diaphragmatic Breathing
“Breathing using abdominal movement, reducing the degree of chest wall movement as much as possible.”
The key difference between Breathing Control and Diaphragmatic Breathing is the volume of air taken in on each breath. Breathing Control advocates “normal tidal breathing” i.e. bringing breathing back to normal tidal volume. Diaphragmatic breathing has been described to be a long, slow, deep inspiration, similar to breathing techniques used in Yoga, Tai Chi and other complementary therapies with the aim to deliberately increase tidal volume and slow respiratory rate. However the differentiation of Diaphragmatic Breathing from Breathing Control is not universally recognised and these terms are sometimes used interchangeably.
In severe Chronic Obstructive Pulmonary Disease (COPD) deliberately increasing tidal volume may increase lung hyperinflation causing asynchronous rib cage movement, uneven distribution of air within the lungs and therefore increase the work of breathing and dyspnoea (Vitacca et al. 1998; Gosselink et al. 1995).
This led the BTS/ACPRC (2009) guidelines to recommend that Diaphragmatic Breathing is not advocated for patients with hyperinflation and should not be taught routinely to patients with severe COPD.
Breathing Control: Efficient Breathing
“Sitting, with my hand on my tummy and breathing from there. It helps a lot when I am breathless and its very relaxing”- A patient with COPD.
“She said don’t push your breath out, just let it go, let it relax. I notice I recover very quickly now by doing this when breathless” – A patient with lung cancer.
A trial of Breathing Control has been recommended for the management of breathlessness in COPD (BTS/ACPRC 2009). National Institute for Clinical Excellence (NICE) Lung Cancer Guidelines (NICE 2011) suggests Breathing Control should be considered as part of a system of non-pharmacological measures to manage breathlessness.
Breathing Control encourages patients to bring their breathing back to an efficient breathing pattern with the aim to relax the breathing accessory muscles and bring the focus breathing back to the efficient and relatively fatigue resistant diaphragm.
Apart from promoting efficient use of respiratory muscles Breathing Control may also help in the management of breathlessness by reducing the speed of airflow; promoting laminar flow, efficiency of air movement and even distribution of air within the lungs. Breathing Control may deter unnecessary hyperventilation and its associated symptoms by promoting the return of breathing to an appropriate tidal volume and respiratory rate. Dynamic hyperinflation may also be deterred as exhalation is relaxed and lengthened and respiratory rate and tidal volume are controlled. Some patients report Breathing Control to be a relaxing and calming focus when breathless.
When assessing how efficiently a patient is breathing it can help to compare their breathing pattern to the ‘ideal’ efficient breathing described in Table 5.1.
Table 5.1
Efficient breathing
Appropriate minute volume | Appropriate respiratory rate |
Appropriate tidal volume | |
Efficient muscle use | Reduce breathing accessory muscle use |
Focus breathing on using the efficient diaphragm | |
Expiration is passive at rest and is created by the passive recoil of the lung and thoracic cage. Aim for expiration to be as passive as pathology allows. | |
Efficient breathing pattern | Expiration is longer than inspiration, with a normal ratio of 1:1.5–2. ‘Normal’ expiration will be even longer in those with obstructive airways disease. |
End expiratory pause | |
Nose vs mouth | Nose breathing at rest |
Patients with a chronic pathology may breathe in a certain way either due to pathological changes, ‘bad habits’ or reversible causes. Teaching a patient Breathing Control will help them ‘undo’ bad habits and achieve as efficient breathing as possible in the presence of pathological changes. Reversible causes such as poor posture and tight musculature should also be addressed.
Introducing Breathing Control
For patients to have confidence in a breathing technique they need to understand how it works. Some patients may be very sceptical, while others may feel ‘learning how to breathe right’ is just what they need. It is therefore important to begin with patient education involving a simple anatomy lesson and explanation regarding how Breathing Control works before teaching the technique its self. Diagrams showing the movement of the diaphragm during breathing and the location of the breathing accessory muscles are a valuable educational tool.
The Diaphragm
The diaphragm does about 95 % of the work of normal, tidal breathing with minimal contribution of the accessory muscles. The diaphragm has a high ratio of fatigue resistant muscles fibres and is the most fatigue resistant of all skeletal muscles. Essentially the diaphragm is designed to contract with every breath throughout our life, just like our heart beating, and does not tire easily.
When learning Breathing Control at rest patients often want to please and strive for large movements of the tummy, creating large inspiratory volumes, when in fact the aim of Breathing Control is to try to return to ‘normal’ tidal volume breathing. It is therefore worth explaining to patients that the diaphragm only moves down about 1 cm when breathing at rest, the movement at the tummy is therefore very subtle. During exercise the diaphragm may move down up to 10 cm, in normal, healthy lungs (West 2008).
Breathing Accessory Muscles
Breathing accessory muscles are muscles that assist with breathing when the work of breathing increases (Fig. 5.1). Any muscle that attaches to the ribs or sternum has the potential to be a breathing accessory muscle, if the angle of pull is correct. It is normal to use the breathing accessory muscles when breathless, whether you are a marathon runner or a person with a chronic pathology who becomes breathless just walking across the room. The primary role of the inspiratory accessory muscles (Fig. 5.1a, b) is to move the upper limbs and stabilise the shoulder girdle, not to contract on every breath. For this reason they can become fatigued if used to aid breathing for longer than necessary. It is therefore important to try to bring the breathing focus back to the efficient diaphragm as quickly as possible to help recovery from breathlessness.
The abdominal muscles are the expiratory accessory muscles (Fig. 5.1c) that contract to help push the diaphragm up and expel the air from the lungs when the work of breathing is increased due to pathology or exertion. Expiratory accessory muscles maybe used particularly by those with those with obstructive lung disease who struggle to release air from their lungs. These muscles also fatigue easily and should be encouraged to relax when no longer required to aid breathing.
Figure 5.1
Breathing accessory muscles © CBIS, 2013. (a) Anterior accessory muscles of inhalation. (b) Posterior accessory muscles of inhalation. (c) Accessory muscles of exhalation
The Breathing Action of the Diaphragm
Everyone has a preferred learning style. Aids to learning include:
Verbal description
Diagrams
Demonstration
Experiencing for themselves
When teaching a breathing technique it is important to include a variety of teaching styles to try to suit the patient’s needs. Try not to overload the patient with too much detail, although some patients maybe fascinated and want more information.
The movement of the diaphragm cannot be felt directly. In order for the patient to link the movement they feel at the tummy with the action of the diaphragm it is important they understand the movement of the diaphragm during normal breathing. The movement of the diaphragm maybe shown through diagrams (Fig. 5.2), demonstration and patient experience.
Figure 5.2
Diaphragm movement during normal breathing © CBIS, 2013
Demonstrating the Movement of the Diaphragm
1.
Clinician holds a domed A4 piece of paper at their own tummy, flattening it as they breathe in and doming it as they breathe out.
2.
Clinician puts their hand on their own tummy and exaggerates the breathing movement at the tummy, with the tummy expanding as they breathe in and falling as they breathe out.
3.
Patient places their own hand between umbilicus and lower ribs and feels the movement for themselves, under the clinician’s guidance.
If the patient is struggling to feel this movement they may find it useful for you to put your hand on their tummy (with or without their hand) and describe the movement as you feel it.
It may also help to describe the abdomen as a box with the diaphragm as the ceiling, the tummy muscles as the walls and the pelvic floor as the floor. As the ceiling (diaphragm) comes down as you breathe in, the walls (tummy muscles) bulge outwards. It is therefore important to keep the walls (tummy muscles) soft and relaxed when learning Breathing Control otherwise it will be difficult to feel the breathing movement. This is why positioning and general relaxation are important first steps in learning Breathing Control. This is to promote relaxation of the abdominal muscles, which are also the expiratory accessory muscles and therefore may be hyperactive from overuse and also to help relax the inspiratory accessory muscles around the neck, shoulders and upper chest so the breathing focus can come more naturally from the tummy, without the upper chest dominating.
Explaining Breathing Control to Patients and Carers
“When someone is very breathless they tend to breathe from the top of their chest. This is a normal thing to do when breathless whether you are an athlete at the end of a race or someone who has a medical condition that makes them feel breathless. When you breathe from the top of your chest you are using the breathing accessory muscles. These are muscles around your upper chest and shoulders that usually move your arms. When you are very breathless these muscles can pull on your ribs and help with breathing.
Unfortunately these upper chest muscles are not designed to help with breathing long term. They get tired easily and may become tight and sore from overuse. It is therefore important to breathing your breathing back to your tummy as soon as you are able. This focuses the breathing back to the strong, efficient diaphragm that is designed for breathing and does not tire easily. It takes less effort to breathe from your diaphragm and so your breathlessness should ease.
Try to breathe from you tummy, with your shoulders relaxed, when you are up and active. This may help you reduce the breathlessness you feel when on the move”.
When to Use Breathing Control
Breathing Control is most commonly used to help recover from breathlessness, no matter what the pathological cause. It is important to also consider its use during activity and exercise to try to keep breathing as efficient as possible and avoid hyperventilation. Breathing ‘from the tummy’ does not often come easily and therefore Breathing Control requires regular practice at rest in order to become familiar with the technique so it can be used effectively when breathless. Regular practice of Breathing Control at rest promotes general relaxation and may also help avoid development, or aid correction, of habitual inefficient breathing patterns.
Teaching Breathing Control
“Now they have taught me to breathe from my stomach…. instead of up here…….. They are a great help, especially learning to breathe from here and breathing in and out” – Gentleman with Pulmonary Fibrosis
The term Breathing Control implies effort and forceful control over breathing when in fact the opposite is true.
When learning Breathing Control the more effort a patient puts into ‘getting it right’ often the worse the breathing pattern becomes. The term ‘relaxed tummy breathing’ better reflects the aim of the technique and is more easily understood by patients. The focus should therefore be on relaxation of the body, particularly the neck, shoulders and upper chest ensuring the breathing accessory muscles relax and ‘let go’. The patient should ‘notice’ the movement of the abdomen, rather than make it happen.
Breathing Control may sound simple but can be quite complicated to achieve especially in a breathless, anxious patient who may have experienced breathlessness over a number of years. ‘Bad habits’ and misconceptions about breathing can form. It is the clinician’s skill to see what maybe improved about a patient’s breathing pattern i.e. what is habit, poor posture, tight, over active muscles, anxiety or misunderstanding and thus can be changed with practice; and what is pathology driven and cannot be changed. Often a stepwise process to achieving efficient breathing can help to unravel why a patient breathes the way that they do (Table 5.2).
Table 5.2
The steps of teaching Breathing Control
Step | Description | Aim |
---|---|---|
1 | Position & Posture | Adjust position and posture to encourage correct breathing muscle use and to promote comfort and relaxation. |
Relax body and mind | Relax the body, especially breathing accessory muscles of inspiration (neck, shoulders and upper chest) and exhalation (abdominal muscles). Reduce accessory muscle use as much as able. Nose breathe, if able and comfortable. | |
2 | Feel the breath | ‘Tune into’ how breathing feels without trying to change anything. |
Notice the tummy rise as you breathe in | Noticing and recognise the action of the diaphragm on the tummy as you breathe. | |
Notice the tummy fall as you breathe out | ||
3 | Float the air in, relax the breath out | Achieve normal tidal volume. Take in just the air you need. Make exhalation as passive as possible. Expiration may lengthen and respiratory rate may slow. Expiration should be longer than inspiration. |
Quiet, gentle breaths | Slow inspiratory flow, promote smooth, laminar flow within the airways to reduce turbulence and resistance. Respiratory rate may slow and tidal volume may reduce. | |
4 | Notice the natural pause after the breath out | Notice the pause but do not try to change it. Be comfortable with it. |
Rest in this pause, wait for the next breath to come, do not rush into the next breath | Allow the expiratory pause to lengthen, if comfortable to do so, to further slow respiratory rate and promote relaxation. |
These steps are to help guide the teaching of Breathing Control and retrain breathing patterns. Some patients may mange to move through all these steps in one session, however most patients will require a number of sessions to work through each step. Go at the patient’s own pace and try not to push them onwards as this will increase tension and frustration. Some patients, especially those with more severe disease, may not achieve all steps and may never get beyond step 2.
Step 1
The initial step focuses on relaxation of the breathing accessory muscles as well as relaxation of the mind and body. The breathing accessory muscles maybe particularly tense from daily use. Remember these not only include the inspiratory accessory muscles around the neck, shoulders and upper chest but also the expiratory accessory muscles around the abdomen. Any tight clothing or belts should be loosened. General relaxation techniques may be of benefit to patients who struggle at this step. The patient should nose breathe, if able and comfortable.
Step 2
This step is about noticing the abdominal movement with each breath but not try to change it. The patient is not forcing this movement through effort, they are just relaxing their breathing accessory muscles, which includes their abdominal muscles, and feeling the tummy rise and fall as they breathe.
Step 3
Once the patient is comfortable with feeling the abdominal movement you may like to then focus on how the diaphragm is used. Inspiration is active but only take in the air that is needed, no more. Ensure the patient understands we are not looking for a big movement at the tummy, it should be very subtle, just float the air in. Remind the patient that the diaphragm only moves down 1 cm during relaxed breathing at rest.
The out breath should be as passive as possible, don’t waste extra energy, just relax and let go. Remind the patient that it is the elastic recoil of the lung and chest wall that creates expiration, no effort required, it will happen by its self. In severe obstructive lung disease (COPD/emphysema) expiratory accessory muscles of the abdomen may be required on expiration but the aim is to reduce to their activity to a comfortable minimum.
The expiration phase is important to allow breathing muscles to return to their resting length and for the inhaled tidal volume to be fully exhaled otherwise breath stacking and dynamic hyperinflation will result. Remember expiration time may also be longer than the 1:1.5–2 ratio in obstructive airways disease.
It is sometimes not helpful to deliberately lengthen exhalation in those with restrictive lung disease, such as pulmonary fibrosis or those with lung cancer, as this may cause discomfort and coughing due to airway collapse or compression at lower lung volumes.
Step 4
When a person’s breathing is very relaxed there may be a short pause after expiration. Some patients may be able to notice this pause and then relax into it, allowing it to lengthen. Patients with more severe disease may not be able to achieve this. Some may find it uncomfortable, causing them to tense and upset their breathing pattern, so do not force it. Allow it to happen if it is comfortable.
Breathing Control vs Breathing Pattern Re-education
Some may argue that this in depth way of teaching Breathing Control goes beyond the definition of Breathing Control and moves into the realms of breathing pattern re-education, especially steps 3–5. However relaxing and lengthening the out breath and finding and resting in the expiratory pause help to slow respiratory rate and may reduce hyperventilation and hyperinflation, therefore helping to ease breathlessness.
Breathing Control and breathing pattern re-education both have the aim of achieving efficient breathing and therefore there will be some blurring of the boundaries. The BTS/ACPRC (2009) states that Breathing Control is “Normal tidal breathing encouraging relaxation of the upper chest and shoulders” The word ‘normal’ could also imply a normal breathing pattern as well as normal volume and therefore it appears appropriate to consider the pattern of breathing when teaching Breathing Control.
Some breathless patients with chronic heart or lung pathologies may have developed breathing pattern disorders not driven by their pathology but by ‘bad habits’ due to long term stress, anxiety or hyper-vigilance of breathing.
Hyper-vigilance of breathing may cause patients to attribute unpleasant symptoms to pathology when in fact they may be due to hyperventilation, poor breathing pattern or inefficient breathing muscle use.
Improving breathing efficiency may help patients recognise what symptoms are pathology based and what can be changed through improved breathing.
Patients are encouraged to practice Breathing Control at rest when not breathless so that they are familiar with it in times of need. In breathing pattern retaining usually 1–2, 10 min sessions a day is recommended with regular breathing ‘checks’ during the day initiated by a frequent task such as boiling the kettle, opening a cupboard etc. Sometimes patients put a visual reminder i.e. sticker dot in places they frequent throughout the day. It is important patients do not become obsessive about their breathing and once ‘checked’ it should be forgotten (Bradley 2011).
This regular practice in its self is an opportunity to improve a patient’s breathing pattern and efficiency of their breathing in general day to day life. It is therefore an opportunity not to be missed. Improving breathing pattern efficiency is a valuable part of the breathlessness management package. Some patients may not require much breathing pattern re-education while for others it may be a significant part of their management.
If the patient appears to show an abnormal breathing pattern or hyperventilation on exercise testing that cannot be attributed to pathology and that is not improved by teaching Breathing Control using the stages above then a review by Respiratory Physiotherapist with an interest in breathing pattern disorders (sometimes known as disordered breathing or chronic hyperventilation syndrome) is indicated.
Signs that may indicate a breathing pattern disorder in those with chronic heart or lung pathology
Frequent sighs, yawns, sniffs, throat clearing coughs
Habitual mouth breather, blocked nose
Tense shoulders, upper chest breather
Unnecessary accessory muscle use
Large or variable tidal volumes, particularly at rest
Fast or variable respiratory rate, particularly at rest
Noisy breathing
Hyperventilation just prior to activity, when speaking or during activity (shown on exercise testing)
Variable quality of voice
Disproportionate breathlessness compared with pathological impairment
Symptoms of hyperventilation such as bilateral pins and needles in fingers or around mouth or light-headedness when breathless
Patients Who Find Breathing Control Difficult
Some patients struggle to relax their upper chest and feel the breathing movement at their abdomen. Often the harder they try to do the breathing technique correctly the more the breathing accessory muscles and upper chest movement come into play. Relaxation and ‘trying less’ is the key to success. Below are some ideas that may help patients who are struggling to master the technique.
Position and Posture
The affect of posture on breathing pattern and muscles use should not be underestimated. The most common postures to learn Breathing Control in is supported sitting in a chair or long sitting, with legs out straight in front, often with a pillow under the knees to improve comfort. If a patient is struggling with relaxation of the shoulders, upper chest and abdominal muscles it is worth trying a change of posture.
Consider a more supported position for an anxious patient or someone who finds it difficult to relax. Fully supported, with pillows under the arms and behind the head in long sitting or side lying with a pillow between the knees can be useful in such cases. Side lying is also a good position for a patient with a thoracic kyphosis or a large abdomen as it allows the abdominal contents to move forward out of the way of the diaphragm. The more supported and comfortable the position the easier it will be for the patient to relax their postural muscles of the abdominal wall, chest and shoulder muscles. The more their abdominal muscles relax the easier it will be for them to ‘feel’ the breathing movement of the diaphragm. Remember the head is heavy and therefore should be comfortably supported to encourage relaxation of the neck and shoulder muscles.