, Julie Burkin1, Catherine Moffat1 and Anna Spathis1
(1)
Department of Palliative Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
Abstract
Positioning improves the efficiency and effectiveness of both primary and accessory muscles of breathing and therefore helps to ease breathlessness. Patients who are breathless take up a wide variety of positions and choice of position is often influenced by pathology. This chapter will review the variety of positions that help to ease breathlessness at rest and after exertion. Theories and mechanical basis regarding why such positions help reduce breathlessness will be explored. The use of walking aids, to enable positions of ease to be used during mobilising, will also be discussed.
Getting my breath back with this kind of position, leaning on my elbows, that was a very useful suggestion
– A gentleman with pulmonary fibrosis.
Introduction
Positions to ease breathlessness are often used in conjunction with breathing techniques and facial cooling using a fan, wet flannel or cold spray. The forward lean position and passively fixing the shoulder girdle is recommended in the British Thoracic Society and Association of Chartered Physiotherapists in Respiratory Care (BTS/ACPRC) (2009) guidelines to help ease breathlessness in those with COPD, although the evidence base is not strong as positioning has not been a topic of research interest in recent times.
Figure 4.1
Abdominal muscles, the accessory muscles of expiration © CBIS, 2013
Figure 4.2
Forward lean with back against wall © CBIS, 2013
Figure 4.3
Anterior breathing accessory muscles © CBIS, 2013
Figure 4.4
Posterior inspiratory breathing accessory muscles © CBIS, 2013
Figure 4.5
Upper limb bracing with elevation © CBIS, 2013
Figure 4.6
‘Hands on hips’, upper limb bracing © CBIS, 2013
Figure 4.7
Combined forward lean with upper limb bracing © CBIS, 2013
Figure 4.8
Use of walking aids to ease exertional breathlessness © CBIS, 2013
Figure 4.9
Supported forward lean in sitting © CBIS, 2013
Figure 4.10
High side lying © CBIS, 2013
Positions of ease are often taken up instinctively by patients when breathless. It may reassure patients to know that similar positions are used by athletes to ease breathlessness after finishing a race. Patients usually select the most appropriate position for them, therefore, as part of their assessment, clinicians should ask patients if they have found certain positions help ease their breathing.
Providing Advice on Positioning
Suggest a patient tries a position of ease, if they are do not already use one
Explain how and why certain positions may ease breathlessness, therefore improving the patient and carers confidence in managing breathlessness.
If a patient instinctively uses a position of ease offer modifications that may improve the position’s effectiveness.
Suggest alternative positions for different situations.
Where appropriate, suggest and explain the use of walking aids to improve the effectiveness of breathing muscles and therefore ease breathlessness when mobilising.
Suggest positions for breathlessness at rest.
Forward Lean
The diaphragm is the primary muscle of inspiration. It is believed that a forward lean position helps to dome the diaphragm, lengthening its muscle fibres, improving the length-tension relationship and therefore improving its force generating and ventilatory capacity (O’Neill and McCarthy 1983; Sharp et al. 1980; Barach 1974). The accessory muscles of exhalation, which include the abdominals (Fig. 4.1), may also be placed in an improved position for contraction by some degree of forward lean.
Doming the diaphragm with forward lean is thought to be of particular benefit to those with obstructive lung disease such as COPD or emphysema who have hyperinflated lungs and therefore their diaphragm is in a shortened position. However patients with very severe hyperinflation with extremely flattened diaphragms may prefer a less flexed position to avoid ‘fixing’ the diaphragm between the abdominal contents and hyperinflated lung. Such patients may prefer to focus on positions that fix the upper limbs to improve inspiratory accessory muscle efficiency.
In milder episodes of breathlessness forward lean alone, as in Fig. 4.2, may be enough to ease breathing through doming of the diaphragm and perhaps improved abdominal muscle contraction.
Leaning vs Bending from the Waist
It’s weird … I can go for a walk … several hundred yards … breathless up to a point and yet … I like bend … and then I start the breathlessness. It’s very unpleasant … suffocation.
– Gentleman with lung cancer.
It is worth noting that the forward lean position is just a lean from the waist and not a full bend. Patients often find bending fully, for example when picking up an item from the floor or putting on their socks and shoes, actually increases their feeling of breathlessness, no matter what the pathology. This is especially true for patients who have very hyperinflated lungs or those with large or tight abdomens. Bending fully may cause the abdominal contents to push up against and obstruct the downward movement of the diaphragm during inspiration. A rational explanation as to why breathlessness is increased when bending down may help to reduce patient anxiety. This explanation may also open up conversation regarding the use of long handled aids to assist with activities of daily living and avoid bending.
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