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 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 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.

Everyone has a preferred learning style. Aids to learning include:

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.

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.

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.

“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

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).

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.

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.