How can breathing techniques help COPD patients manage their symptoms. What are the benefits of pursed-lip breathing for COPD. How does diaphragmatic breathing strengthen the respiratory system in COPD patients. Why is proper breathing technique crucial for managing COPD symptoms. How can COPD patients incorporate these breathing exercises into their daily routine.

Understanding COPD and the Importance of Proper Breathing Techniques

Chronic Obstructive Pulmonary Disease (COPD) is a progressive lung condition that significantly impacts breathing. For those living with COPD, shortness of breath is a common and often distressing symptom. However, there’s hope in the form of specialized breathing techniques that can help manage symptoms and improve quality of life.

Why are proper breathing techniques so crucial for COPD patients? These techniques help retrain the respiratory system, making breathing more efficient and reducing the anxiety associated with breathlessness. Two particularly beneficial methods are pursed-lip breathing and diaphragmatic breathing.

The Science Behind Pursed-Lip Breathing for COPD

Pursed-lip breathing is a simple yet effective technique that involves inhaling through the nose and exhaling through pursed lips. This method offers several benefits for COPD patients:

• Improves exhalation efficiency
• Reduces air trapping in the lungs
• Increases oxygen levels in the blood
• Helps control breathing rate
• Reduces anxiety associated with breathlessness

How does pursed-lip breathing work? When you exhale through pursed lips, it creates resistance in your airways. This resistance helps keep the airways open during exhalation, allowing more air to escape from the lungs. As a result, there’s less air trapping, which is a common issue in COPD that leads to shortness of breath.

Practicing Pursed-Lip Breathing

To practice pursed-lip breathing:

1. Inhale slowly through your nose for about 2 seconds, keeping your mouth closed.
2. Purse your lips as if you’re about to whistle or blow out a candle.
3. Exhale slowly and gently through your pursed lips for about 4 seconds – twice as long as your inhalation.

Is pursed-lip breathing effective during physical activity? Research published in the European Journal of Physical and Rehabilitation Medicine in April 2014 found that COPD patients who used pursed-lip breathing during exercise experienced improved endurance, more controlled breathing rates, higher blood oxygen levels, and reduced lung hyperinflation.

Diaphragmatic Breathing: Strengthening Your Primary Breathing Muscle

Diaphragmatic breathing, also known as belly breathing, focuses on strengthening the diaphragm – the most important muscle used in breathing. For COPD patients, this technique is particularly beneficial as it can help counteract the diaphragm’s weakening due to trapped air in the lungs.

How does diaphragmatic breathing benefit COPD patients? This technique:

• Strengthens the diaphragm
• Improves overall breathing efficiency
• Reduces the work of breathing
• Helps expel more air from the lungs
• Can reduce anxiety and promote relaxation

Steps to Practice Diaphragmatic Breathing

To practice diaphragmatic breathing:

1. Lie on your back with one hand on your upper chest and the other on your belly.
2. Inhale slowly through your nose, focusing on expanding your stomach while keeping your chest still.
3. Exhale through pursed lips, contracting your stomach muscles.
4. Repeat this process, gradually increasing the duration of your practice sessions.

Can diaphragmatic breathing be done in other positions? As you become more comfortable with the technique, you can practice it while sitting or standing. The goal is to incorporate diaphragmatic breathing into your daily life, making it your default breathing pattern.

Combining Breathing Techniques with Pulmonary Rehabilitation

While these breathing techniques can be practiced independently, working with a pulmonary rehabilitation specialist can significantly enhance their effectiveness. These professionals can guide you in properly executing the techniques and help you incorporate them into your daily routine.

What does a pulmonary rehabilitation program typically include? These programs often combine:

• Breathing technique training
• Exercise programs tailored for COPD patients
• Nutritional counseling
• Education about COPD management
• Psychological support

How effective is pulmonary rehabilitation for COPD patients? A 2014 study published in BMC Pulmonary Medicine found that patients who participated in pulmonary rehabilitation programs experienced improved quality of life and reduced COPD symptoms, including breathlessness.

Integrating Breathing Techniques into Daily Life

For maximum benefit, it’s crucial to integrate these breathing techniques into your daily routine. Start by practicing for short periods several times a day, gradually increasing the duration as you become more comfortable with the techniques.

When should you use these breathing techniques? Consider incorporating them:

• During periods of increased breathlessness
• Before and during physical activities
• When feeling anxious or stressed
• As part of your regular exercise routine
• Throughout the day to reinforce proper breathing habits

How long does it take to see results from these breathing techniques? While individual experiences may vary, many COPD patients report feeling improvements in their breathing within a few weeks of consistent practice. However, it’s important to remember that these techniques are most effective when used consistently over the long term.

The Role of Breathing Techniques in Managing COPD-Related Anxiety

Anxiety is a common companion to COPD, often exacerbating breathlessness and creating a vicious cycle of panic and respiratory distress. Breathing techniques can play a crucial role in breaking this cycle and managing COPD-related anxiety.

How do breathing techniques help reduce anxiety in COPD patients? These techniques:

• Provide a sense of control over breathing
• Help slow down rapid breathing associated with panic
• Improve oxygenation, reducing physical symptoms of anxiety
• Serve as a focus point, distracting from anxious thoughts
• Promote overall relaxation

Can breathing techniques replace anxiety medication for COPD patients? While breathing techniques can be highly effective in managing anxiety, they should be viewed as a complementary approach rather than a replacement for prescribed medications. Always consult with your healthcare provider before making any changes to your treatment plan.

Adapting Breathing Techniques for Different Stages of COPD

COPD is a progressive disease, and as it advances, patients may need to adapt their breathing techniques to accommodate changes in their lung function. Working closely with healthcare providers and pulmonary rehabilitation specialists is crucial to ensure that breathing techniques remain effective throughout the course of the disease.

How might breathing techniques need to be modified in advanced COPD? Adaptations might include:

• Shorter practice sessions to avoid fatigue
• More frequent use of pursed-lip breathing during daily activities
• Greater emphasis on relaxation techniques to manage increased anxiety
• Incorporation of assistive devices, such as handheld fans, to aid breathing
• Combining breathing techniques with energy conservation strategies

Is it ever too late to start learning breathing techniques for COPD? It’s never too late to benefit from proper breathing techniques. Even patients with advanced COPD can experience improvements in their symptoms and quality of life by incorporating these techniques into their daily routine.

The Future of Breathing Techniques in COPD Management

As research in COPD management continues to evolve, new approaches to breathing techniques are being explored. These advancements aim to further improve the effectiveness of these techniques and make them more accessible to a broader range of patients.

What new developments are on the horizon for COPD breathing techniques? Some areas of ongoing research include:

• Digital health applications to guide and monitor breathing exercises
• Virtual reality-based pulmonary rehabilitation programs
• Personalized breathing technique protocols based on individual patient data
• Integration of wearable technology to provide real-time feedback on breathing patterns
• Exploration of mind-body techniques, such as mindfulness and yoga, to complement traditional breathing exercises

How might these advancements impact COPD management in the future? These developments have the potential to make breathing techniques more effective, personalized, and accessible, potentially leading to improved outcomes for COPD patients across all stages of the disease.

In conclusion, mastering breathing techniques such as pursed-lip and diaphragmatic breathing can significantly improve the quality of life for COPD patients. By incorporating these techniques into daily life, working with healthcare professionals, and staying informed about new developments, individuals with COPD can take an active role in managing their symptoms and maintaining their respiratory health.

Breathing Techniques for COPD Patients

Shortness of breath is a common symptom for people with chronic obstructive pulmonary disease (COPD), but working with a therapist to essentially retrain the way you breathe can offer relief. Two breathing techniques in particular, pursed-lip breathing and diaphragmatic breathing, are especially beneficial to people with COPD. Practice them correctly and you can improve quality of life and reduce COPD symptoms such as breathlessness, according to research published in 2014 in BMC Pulmonary Medicine.

“There is a great deal of anxiety associated with this condition,” explains COPD expert Steven M. Scharf, MD, PhD, a professor of medicine and director of the Sleep Disorders Center at the University of Maryland School of Medicine in Baltimore. Specifically, breathing techniques can help lessen anxiety about the most common symptom, of CODP, breathlessness.

To get these benefits, you might need to work with a pulmonary rehabilitation specialist who can “retrain” you in how to breathe, Dr. Scharf says.

Pursed-Lip Breathing for COPD Pursed-lip breathing is basically breathing in through the nose and out through pursed lips. This technique is particularly useful when your shortness of breath flares up. It’s also helpful when you work out: In a recent study, people who used pursed-lip breathing during had more endurance, a more controlled breathing rate, more oxygen in their blood, and less lung hyperinflation during exerise. These findings were published in Arpil 2014 in the European Journal of Physical and Rehabilitation Medicine.

When you have COPD, irritated airways and lungs that have lost elasticity work less efficiently when you exhale, leaving air trapped in your lungs. This trapped air is what leads to shortness of breath. When you exhale with your lips pursed, there is increased resistance in your airways, which helps them stay open during exhalation. Pursed-lip breathing also helps calm you down and slows your breathing.

Practice this technique by inhaling through your nose, making sure to keep your mouth closed. Then purse your lips and exhale softly for at least twice the amount of time that your inhaled. Doing this forces you to use the correct breathing muscles and ensures you exhale as much air as possible so that it does not get trapped in your lungs. With less air trapped in your lungs, more oxygen will be able to get into your bloodstream.

Diaphragmatic Breathing for COPD Diaphragmatic breathing is a breathing exercise that helps to strengthen your diaphragm, which is the most important muscle used in breathing. Your diaphragm, located under your lungs, helps you expel air from your lungs when you exhale. When air gets trapped in the airways in COPD patients, the diaphragm has difficulty functioning properly and eventually becomes less useful.

The first step in learning diaphragmatic breathing is to become more aware of the muscles you are using when you breathe so that you can use your diaphragm more. “Sometimes we will start [with] COPD patients lying down on their back so they’ll feel their diaphragm moving,” says Dibbern.

You can practice diaphragmatic breathing by lying on your back and placing one hand on the upper portion of your chest and the other on your belly. While you inhale through your nose, expand and push out your stomach muscles so that your chest does not move out. When you exhale, do so through pursed lips and contract your stomach muscles. After you have been practicing this technique regularly, you will automatically begin to use your diaphragm more. The goal is to use diaphragmatic breathing continuously. If you practice diaphragmatic breathing regularly, your diaphragm will begin to function better and your breathing will improve.

Practice makes perfect: The more you do these breathing techniques, the more natural they will begin to feel and the easier your breathing will become.

Breathing Exercises & Techniques | Managing COPD

Learning new breathing techniques will help you move air into and out of your lungs.

It is helpful to use effective breathing techniques with exercise to minimize shortness of breath and assure adequate oxygen to your working muscles. These breathing exercises have the added benefit of helping you relax when you are anxious or stressed. Three types or breathing techniques are pursed lip breathing, coordinated breathing with exercise and diaphragmatic breathing. Diaphragmatic breathing is also sometimes called “belly breathing.”

Learn more about our pulmonary rehabilitation program.

Pursed Lip Breathing

The purpose of pursed lip breathing is to help keep your airways open. This helps your airways to remain open. Pursed lip breathing also slows down your breathing rate and calms you down.

Here are the steps for pursed lip breathing:

• Inhale slowly through your nose with your mouth closed; try to take in a normal amount of air.

• Exhale slowly through your mouth with your lips in the whistling or kissing position.

• Breathe out for twice as long as you breathe in.

Do not take in a large deep breath. Never try to force out the air.

Coordinated Breathing

The purpose of coordinated breathing is to help assure adequate oxygen to your working muscles and to prevent you from holding your breath.

Here are the steps for coordinated breathing.

If coordinating your breathing with exercise is difficult, as you perform the movement, count out loud. This helps prevent you from holding your breath. If you become very short of breath, stop the exercise, use pursed lip breathing to help control your breathing, then start exercising again.

Diaphragmatic Breathing

The diaphragm is a major muscle used in breathing and is located beneath the lowest two ribs. At rest, the diaphragm muscle is bell shaped. During inspiration, it lowers and flattens out.

Optimizing the use of the diaphragm is beneficial because it pulls air into the lower lobes of the lungs where more gas exchange takes place. Not only is the diaphragm the most efficient of all respiratory muscles, but using it tends to be very relaxing and calming.

Here are the instructions for diaphragmatic breathing, also called “belly breathing.”:

• Sit or lie in a comfortable position. Relax your shoulders.

• Place one hand on your chest and one on your belly.

• Breathe in slowly and deeply through your nose. You should feel your belly moving out, and your chest should move very little.

• Relax your stomach and breathe out slowly through your mouth. 

Practice these breathing techniques daily so they become routine. When you feel short of breath, anxious or just wound up, use these breathing techniques.

Breathing Exercises for COPD – Global Allergy & Airways Patient Platform

For people with COPD , exercising may not always seem easy but not exercising at all can make things worse. In fact, there are a variety of breathing exercises you can do that could help alleviate COPD symptoms, boost the strength of your lungs, and help improve your ability to do daily activities and physical exercise.

What are the benefits of exercise for COPD?

When you’re diagnosed with COPD , it’s easy to fall into a cycle of inactivity. You may avoid activities that make you feel breathless or worry about how you’ll cope if you experience breathing difficulties whilst exercising. However, not exercising or doing physical activity can cause more harm.

• Reduced activity will result in your muscles becoming weaker. Having weak muscles means that your body will need to work harder and use more oxygen to operate. In turn, this can make you feel more breathless.

If you remain active, learn breathing methods, and do COPD-friendly exercises, this should have a positive effect on your health and wellbeing:

• Your muscles will become stronger, including the muscles involved in breathing – you’ll get less breathless when you move, it will be easier to be active.
• Regular exercise can also help you maintain or lose weight, which can be important for those with COPD.
• Physical activity can help you feel better mentally too. It can have a positive impact on self-confidence and help keep you motivated to continue with good lifestyle habits.

Breathing exercises for COPD

Breathing exercises are particularly beneficial for COPD as they help to improve and strengthen your lungs and put you in a better position for trying more physical forms of exercise. Breathing exercises help to strengthen the muscles you use for breathing, enabling you to get more oxygen and breathe more easily with less effort.

There are several breathing techniques and methods, and you don’t have to choose just one to help you manage your COPD. Some studies have found that combining the techniques and practicing several methods can have improved benefits for COPD symptoms.

Pursed lip breathing for COPD

Pursed lip breathing is a simple and easy technique to learn. It helps slow down your breathing, making it easier for the lungs to function, and helps keep your airways open for longer. It can be practiced at any time and used to help regulate your breathing when exercising.

• Sit or stand and breathe in slowly through your nose
• Purse your lips, as if you were about to whistle
• Breathe out as slowly as you can through your pursed lips and aim to blow out for twice as long as you breathed in – it may help to count as you do this
• Repeat the exercise five times, building up over time to doing 10 repetitions.

Diaphragmatic breathing for COPD

Diaphragmatic breathing is a technique where you aim to breathe from your diaphragm, rather than your upper chest. It’s often also called ‘breathing from your belly’. This technique helps to strengthen the muscles of the diaphragm, which are often weaker and less functional with COPD.

• Sit or lie down comfortably and relax your body as much as possible
• Place one hand on your chest and one on your stomach
• Inhale through your nose for up to five seconds, feeling the air move into your abdomen and your stomach raise up – ideally, you should be able to feel your stomach move more than your chest does
• Hold it for two seconds, then breathe out again for up to five seconds through your nose
• Repeat the exercise five times.

Paced breathing for COPD

Paced breathing is an exercise to use while you’re active, such as when you’re walking or climbing stairs. The idea is that you pace your breathing to match your steps.

• As you’re walking, count to yourself
• Breathe in for one step, then take one or two steps as you breathe out
• Find a pace of breathing and counting that works for you.

Breathing out hard or the ‘blow-as-you-go’ method for COPD

The breathing out hard technique is another technique to use when you’re being active as it can make it easier to cope with tasks that require effort.

• Before you make the effort (such as standing up), breathe in
• Whilst you’re making the effort, breathe out hard
• You may find it easier to breathe out hard whilst pursing your lips.

What is the best exercise for someone with COPD?

There’s no single best exercise for someone with COPD, but there are plenty of good options you can try.

• Walking. If you’ve not exercised for a while, walking is a good starting point, as it’s free to do and you can move at your own pace. Try going out for a short walk at least once a day and gradually build up how far you go. You could incorporate walking with other activities, such as shopping or attending medical appointments.
• Tai chi. Gentle forms of exercise such as tai chi are ideal for COPD, as they focus on slow and flowing movements. Tai chi can help tone your muscles and ease stress and anxiety.
• Cycling. Cycling on an exercise bike at home or at a gym can help build up strength in your legs, aid circulation and boost stamina.
• Weights. Using hand weights to do arm curls is good to strengthen the muscles in your arms and upper body. If you don’t have weights, use filled water bottles or tins of canned fruit or vegetables instead.
• Stretching. Simple movements and stretches are beneficial too – try forward arm raises, calf raises, leg extensions, or moving from sitting to standing positions. If you have limited movement, chair yoga is an option too.

If you need motivation to exercise, find an exercise buddy – or a friend who you can go for a walk with. Having company can help distract you from the fact that you’re exercising and may boost your confidence if you’re concerned about getting out of breath whilst on your own.

Before starting a new exercise regime, especially if you use oxygen, speak to your medical practitioner for advice. They may even recommend a structured pulmonary rehabilitation exercise program if your symptoms are severe.

How do you strengthen your lungs with COPD?

Being active can help to strengthen your lungs. COPD-appropriate exercises can help boost the strength of your breathing muscles and improve your circulation and your heart. When your muscles are stronger, it will help your body to use oxygen more efficiently, so you won’t end up getting so breathless in your daily life.

Can COPD be reversed with exercise?

Exercise alone is not powerful enough to reverse lung damage. However, exercise has been shown to help relieve COPD symptoms and improve your quality of life, which is why it’s highly beneficial for anyone with COPD to do.

Exercise can help improve your physical stamina and endurance, plus it can strengthen the muscles you use to breathe. When these muscles are stronger, you won’t need to use so much oxygen, which will help reduce your breathlessness during physical activity.

The key is to not stop exercising when your COPD symptoms improve, as stopping your level of activity could worsen symptoms again.

How to exercise easier with COPD

You can help yourself to exercise easier with COPD by using the following tips:

• Learn to breathe slowly using the pursed lip breathing method during physical activity. If you’re doing activities that need a lot of effort, breathing out hard may be beneficial.
• Whilst you’re exercising, make sure you drink plenty of water to stay hydrated. Avoid non-caffeinated drinks as they’re better for keeping the mucus in your airways thinner.
• If you use oxygen and your medical practitioner has given you the go-ahead to exercise, you can make things easier for yourself by using some extra-long tubing on your tank. This can help give you more space and capacity for moving around, without the worry of falling over your tank. It’s also beneficial to use smaller travel-sized oxygen tanks whilst you’re active.

When to stop exercising

If your COPD symptoms – such as wheezing, breathlessness, or coughing – seem worse than usual, stop exercising. Likewise, if you feel dizzy or lightheaded, stop and have a break. Although exercise is important, it’s not good to push yourself to exercise when you’re not feeling well or your COPD symptoms are especially bad. Be sensible and, if you have any concerns about your symptoms, consult a medical practitioner.

You may also be interested in our guides to managing your COPD and COPD treatment.

Sources

British Lung Foundation. 2020. Keeping active with a lung condition.

COPD Foundation. Breathing techniques.

Li J, Lu Y, Li N et al. 2020. Muscle metabolomics analysis reveals potential biomarkers of exercise‑dependent improvement of the diaphragm function in chronic obstructive pulmonary disease. International journal of molecular medicine, 45(6), 1644–1660. https://doi.org/10.3892/ijmm.2020.4537

Nair A, Alaparthi GK, Krishnan S et al. 2019. Comparison of Diaphragmatic Stretch Technique and Manual Diaphragm Release Technique on Diaphragmatic Excursion in Chronic Obstructive Pulmonary Disease: A Randomized Crossover Trial. Pulm Med. Jan 3;2019:6364376. doi: 10.1155/2019/6364376. PMID: 30719351; PMCID: PMC6335861.

Ubolnuar N, Tantisuwat A, Thaveeratitham P et al. 2020. Effects of pursed-lip breathing and forward trunk lean postures on total and compartmental lung volumes and ventilation in patients with mild to moderate chronic obstructive pulmonary disease: An observational study. Medicine (Baltimore). Dec 18;99(51):e23646. doi: 10. 1097/MD.0000000000023646. PMID: 33371099; PMCID: PMC7748318.

Ubolnuar N, Tantisuwat A, Thaveeratitham P et al. 2019. Effects of Breathing Exercises in Patients With Chronic Obstructive Pulmonary Disease: Systematic Review and Meta-Analysis. Ann Rehabil Med. Aug;43(4):509-523. doi: 10.5535/arm.2019.43.4.509. Epub 2019 Aug 31. PMID: 31499605; PMCID: PMC6734022.

Yancey JR and Chaffee MD. 2014. The role of breathing exercises in the treatment of COPD. Am Fam Physician. Jan 1; 89(1): 15-16.

Yun R, Bai Y, Lu Y et al. 2021. How Breathing Exercises Influence on Respiratory Muscles and Quality of Life among Patients with COPD? A Systematic Review and Meta-Analysis. Can Respir J. Jan 29;2021:1904231. doi: 10.1155/2021/1904231. PMID: 33574969; PMCID: PMC7864742.

Role of Breathing Exercises in the Treatment of COPD – Cochrane for Clinicians

Clinical Question

Do breathing exercises lead to improvements in dyspnea, exercise capacity, and health-related quality of life in patients with chronic obstructive pulmonary disease (COPD)?

Evidence-Based Answer

Patients with COPD who are treated with breathing exercises vs. standard care showed an improvement in exercise capacity, with inconsistent changes in dyspnea and health-related quality of life. Adding breathing exercises to a pulmonary rehabilitation program did not show any increased benefit. Breathing exercises may be helpful for those without access to a pulmonary rehabilitation program. (Strength of Recommendation: B, based on inconsistent or limited-quality patient-oriented evidence.)

Practice Pointers

Pulmonary rehabilitation is recommended for all patients with COPD to improve physical function and quality of life. This multidisciplinary approach, which includes exercise training, education, nutritional intervention, and psychosocial support, improves dyspnea and functional capacity, and lowers the rates of hospital admission and mortality.1,2 Breathing exercises are commonly used as part of such programs, but data supporting their use alone are limited.

Breathing exercises are intended to reverse the typical COPD pattern of increased accessory muscle and rib cage use. This Cochrane review, which included 16 randomized controlled trials, evaluated breathing exercise techniques such as pursed lip breathing, diaphragmatic breathing, and pranayama yoga.

Pursed lip breathing improved outcomes of a six-minute walk test by 50.1 m (95% confidence interval [CI], 37.2 to 63.0) after eight weeks of an intervention involving 15 minutes of breathing exercises three times daily. However, there was no significant improvement in dyspnea using the University of California–San Diego Shortness of Breath Questionnaire after four weeks or 12 weeks when pursed lip breathing was taught using pulse oximetry for feedback with daily home practice. In a study comparing health-related quality of life for pursed lip breathing vs. placebo, pursed lip breathing showed a significant improvement in the dyspnea domain following eight to 12 weeks of training (mean difference = –12.9 units; 95% CI, –22.3 to –3.6), but no significant improvement in any other domain, including mood, social function, and well being.

Diaphragmatic breathing encourages patients to use their abdominal wall when breathing to reduce chest wall motion.1 This technique increased dyspnea in one study, whereas it significantly improved dyspnea after four weeks of training in another study. There was also an increase in functional capacity of 34.7 m (95% CI, 4.1 to 65.3) as measured by a six-minute walk test, and improvement in quality of life as measured by the St. George’s Respiratory Questionnaire (mean difference = –10.5 points; 95% CI, –17.7 to –3.3). One study found no significant difference in peak oxygen consumption, 12-minute walk distance, peak work, or endurance work with diaphragmatic breathing.

Results of yoga training on dyspnea and quality of life for patients with COPD are mixed. A meta-analysis of two studies noted a significant improvement in the six-minute walk test of 44.5 m after 12 weeks of yoga training, but one of the studies found no improvement in distress levels after the six-minute walk test. The same studies had conflicting conclusions about quality of life; one showed improvement, whereas the other did not.

Some of the included studies examined a combination of techniques. One study found that combining pursed lip breathing, diaphragmatic breathing, and nutritional supplementation improved total quality of life compared with usual care. Another study found that combining pursed lip breathing, diaphragmatic breathing, and walking improved symptom-related quality of life on the St. George’s Respiratory Questionnaire. Yet, there was no significant difference in functional capacity as measured by the six-minute walk test (mean difference = 0.6 m; 95% CI, –23.4 to 24.2).

The Institute for Clinical Systems Improvement suggests using pulmonary rehabilitation programs to improve symptoms in those with moderate to severe COPD.3 Breathing exercises can be easily taught in the clinic; online resources are also available (e.g., http://www.webmd.com/lung/copd/copd-breathlessness-9/exercise). Although breathing exercises may be useful as an adjunct treatment for patients with COPD, family physicians should keep in mind that these exercises cannot replace full pulmonary rehabilitation for improvements in dyspnea or quality of life.

How Does COPD Affect the Diaphragm?

The diaphragm is a large, dome-shaped muscle located directly below the lungs. You use it to breathe.

When you take a breath, the diaphragm contracts and flattens, which causes your chest cavity to expand. This creates a vacuum, which pulls air through your nose, down your windpipe, and into your lungs. When you exhale, meanwhile, your diaphragm relaxes and returns to its previous shape. This forces air back out of your lungs.

Healthy adults take between 12 to 28 breaths a minute or as many as 40,000 breaths in a day. Your diaphragm does much of the work involved in breathing, but your intercostal muscles—a group of 22 pairs of very small muscles located between your ribs—also play an important role by helping to expand and shrink the chest cavity with every breath.

OpenStax / Wikimedia Commons / CC BY 4.0

Your Diaphragm and COPD

In people with chronic obstructive pulmonary disease (COPD), the diaphragm is weakened and doesn’t work as well as it should during the breathing process. This seems to be due to changes in the cells of the diaphragm muscle that cause the muscle fibers to lose some of the force needed to contract and relax. These changes start to occur when you’re first developing COPD.

When your diaphragm isn’t working as well as it should, your body uses other muscles in your neck, back, and shoulders to do the work of contracting and expanding your chest. However, these muscles don’t compensate fully for your weakened diaphragm, so you have trouble breathing.

Research shows that a very weak diaphragm muscle can worsen your COPD, potentially leading to exacerbations. People with COPD—even severe COPD—who have weaker diaphragms don’t do as well as people who have stronger diaphragms.

Improving Your Diaphragm Strength

It’s possible to exercise your respiratory muscles, which can help you breathe more easily. 

The COPD Foundation recommends two breathing techniques to people with COPD: pursed-lips breathing and diaphragmatic (abdominal/belly) breathing. Both can help you feel less short of breath, but diaphragmic breathing can also help to strengthen your respiratory muscles and enable them to take on more of the very necessary work of breathing.

The diaphragmic breathing technique is a bit tricky to learn. Therefore, you should get some instruction from a respiratory therapist or physical therapist who understands the technique and can teach it to you.

The Effects of Controlled Breathing during Pulmonary Rehabilitation in Patients with COPD – FullText – Respiration 2012, Vol. 83, No. 2

Abstract

Background: Conventional pulmonary rehabilitation programs improve exercise tolerance but have no effect on pulmonary function in patients with chronic obstructive pulmonary disease (COPD). The role of controlled breathing using respiratory biofeedback during rehabilitation of patients with COPD remains unclear. Objectives: To compare the effects of a conventional 4-week pulmonary rehabilitation program with those of rehabilitation plus controlled breathing interventions. Methods: A randomized controlled trial was performed. Pulmonary function (FEV₁), exercise capacity (6-min walking distance, 6MWD), health-related quality of life (chronic respiratory questionnaire, CRQ) and cardiac autonomic function (rMSSD) were evaluated. Results: Forty COPD patients (mean ± SD age 66.1 ± 6.4, FEV₁ 45.9 ± 17.4% predicted) were randomized to rehabilitation (n = 20) or rehabilitation plus controlled breathing (n = 20). There were no statistically significant differences between the two groups regarding the change in FEV₁ (mean difference –0.8% predicted, 95% CI –4.4 to 2.9% predicted, p = 0.33), 6MWD (mean difference 12.2 m, 95% CI –37.4 to 12.2 m, p = 0.16), CRQ (mean difference in total score 0.2, 95% CI –0.1 to 0.4, p = 0.11) and rMSSD (mean difference 2. 2 ms, 95% CI –20.8 to 25.1 ms, p = 0.51). Conclusions: In patients with COPD undergoing a pulmonary rehabilitation program, controlled breathing using respiratory biofeedback has no effect on exercise capacity, pulmonary function, quality of life or cardiac autonomic function.

© 2011 S. Karger AG, Basel

Introduction

Expiratory flow limitation in patients with chronic obstructive pulmonary disease (COPD) results from progressive airway inflammation causing parenchymal destruction, mucosal oedema, airway remodelling, mucous impaction and increased cholinergic airway smooth muscle tone [1]. Advanced COPD is associated with reduced exercise tolerance and daily physical activity resulting in impaired health-related quality of life [2], high health care use [3] and increased mortality [4]. Furthermore, patients with advanced COPD have a pathological breathing pattern with enhanced intrathoracic pressure swings due to severe airway obstruction [5]. Previous studies have shown that pulmonary rehabilitation programs improve exercise tolerance [6,7] and peripheral muscle strength [8], reduce exacerbation rate [9] and improve health-related quality of life, but not pulmonary function in patients with COPD [10,11].

Predominantly diaphragmatic breathing (DB), pursed-lips breathing (PLB) and prolonged exhalation are the most commonly used controlled breathing techniques and the use of each of these modalities has certain clinical benefits. PLB appears to be an effective way to decrease dyspnoea [12], improve walking distance [13] and gas exchange [14,15]. DB in patients with COPD has been associated with improvement in blood gases [16]. However, the relative contribution of each of these modalities to the overall improvement of the patients is not clear. Previous studies assessing the effectiveness of controlled breathing included small numbers of heterogeneous patients and lacked a control group [15].

To address the question whether controlled breathing improves outcome of rehabilitation in COPD patients, we performed a randomized controlled trial (RCT) using respiratory feedback training (RBF) to assess the effects of a 4-week rehabilitation program using outcome parameters including pulmonary function tests, cardiopulmonary exercise capacity, health-related quality of life and cardiac autonomic modulation. We hypothesized that COPD patients who undergo pulmonary rehabilitation plus controlled breathing will benefit more than patients participating in conventional pulmonary rehabilitation classes.

Methods and Materials

Study Subjects

Patients with COPD referred to the Department of Respiratory Medicine, Ruhrlandklinik, University of Duisburg-Essen, Germany, between November 2008 and July 2009 were considered for participation in the study. Inclusion criteria were: clinically stable disease (no changes in medication dosage or frequency of administration, no clinical signs or symptoms of acute exacerbations and no hospital admissions in the preceding 6 weeks), age between 40 and 75 years, postbronchodilator FEV₁ of less than 80% predicted and an FEV₁/FVC ratio of less than 0.7, and a BMI of more than 18 and less than 25 kg/m². We excluded patients with respiratory disorders other than COPD, α₁-antitrypsin deficiency, a history of significant inflammatory disease other than COPD, cardiac diseases such as heart failure, cardiac arrhythmia and/or coronary artery disease, patients with a history of lung surgery, patients with diagnosis of cancer and patients who were unable to walk. Patients with oral corticosteroids and/or vasoactive medication at inclusion were also excluded from the study. Each participant signed and dated a written informed consent form prior to participation.

The study was approved by the Research Ethics Committee of the Medical Faculty, University of Essen-Duisburg, Germany (No. 07-3524) and written informed consent was obtained from all patients.

Study Design

We performed a RCT with sequential analysis of the clinical training effects; tests were performed prior to and following completion of cardiopulmonary exercise training.

Methods

Cardiopulmonary Exercise Training

Cardiopulmonary exercise training was performed according to publishedguidelines [17,18,19]. Participants attended the outpatient clinic 3 times per week (1.5-hour sessions) for 3–4 weeks performing 10 sessions of physical training. The session included dynamic strength training for the following muscles: quadriceps femoris, hamstrings, triceps surae, pectoralis major, deltoid, latissimus dorsi and triceps brachi. The dynamic strength training exercises were performed while seated. Patients started at 70% of their initial 1-repetition maximum (1RM) and fulfilled 3 cycles of 10 repetitions of isotonic muscle contractions [17,18,19] with a resting period of 2 min between the series. 1RM is the maximum amount of weight one can lift during a single repetition of a given exercise.

When the patients were able to perform 3 sets of 10 repetitions without any difficulty, effort was increased stepwise by 5% of the 1RM. Cardiopulmonary endurance training was performed on a cycle ergometer, using stepping exercises and arm cranking [17,18,19]. The initial intensity for cycling was set at 30% peak workload for 20 min. Increases in workload were based upon symptom scores.

Controlled Breathing Training

Twenty patients allocated to the RBF group participated in 10 supplemental 30-min sessions of controlled breathing using techniques of respiratory biofeedback training and were instructed on its performance during the first training session [20,21,22]. The respiratory biofeedback training system visually displays the desired respiratory pattern: the patients were trained to voluntarily improve their breathing pattern at rest for 10 min while seated with instructions for daily home practice. Furthermore, the patients were trained to improve their breathing pattern during the 20 min of cardiopulmonary endurance training which was performed on a cycle ergometer.

The patients were trained to modify four respiratory characteristics: rapid shallow breathing (increased respiratory rate and low tidal volume), breath-to-breath irregularity in rate and depth and predominant thoracic breathing. DB was performed as described by Gosselink [23,24] by ‘facilitating outward motion of the abdominal wall while reducing upper rib cage motion during inspiration’.

Dynamic hyperinflation occurs when inspiration commences prior to completion of the preceding exhalation so that air is trapped ‘upstream’ at the small bronchiolar and alveolar levels. To reduce dynamic hyperinflation, the patients were encouraged by prolonging the expiration prior to the initiation of the next breath while using PLB.

The breathing pattern was monitored by respiration sensors that measure the patient’s breathing rhythm at both umbilical and abdominal level. The respiration sensors were connected to an amplifier (Nexus-10™ medical device class IIa; TMS International BV, Enschede, The Netherlands) that converts the electrical impulses into acoustical and visual outputs. BioTrace+ software was used for physiological monitoring and signal processing.

The RBF training works with simple acoustic tones and visual graphic signals in order to inform the patient precisely about their actual breathing pattern. Both signals were simultaneously used as a feedback for the patient via an earphone and an overhead screen. Both signals increase and decrease in volume and intensity as the patient breathes in and out.

Measurements

Pulmonary Function

Spirometry, whole body plethysmography and diffusion capacity measurements were performed according to the American Thoracic Society and the European Respiratory Society guidelines with a commercially available system (Body 500™; ZAN, Oberthulba, Germany) [25]. Postbronchodilator spirometry was performed on the same day as the exercise tests (6-min walk test, 6MWT). Maximal inspiratory mouth occlusion pressure after 100 ms was measured as previously described [26].

Six-Minute Walk Test

All patients performed the 6MWT following pulmonary function testing. 6MWT distance was measured according to the guidelines of the American Thoracic Society [27,28]. Oxygen saturation and pulse rate were recorded using a standard pulse oximeter (Nexus-10™ medical device class IIa; TMS International BV). Additionally, scored sensations of breathlessness and leg fatigue were assessed using a modified Borg scale [29]. The 6MWT was performed on a 30-meter indoor track by an experienced investigator using standardized encouragement strategy [30], and the results were recorded in absolute values and in percent predicted [27]. To control for any learning effect, all patients performed two 6MWTs on two separate days, and the results of the second test were used for analysis.

Health-Related Quality of Life

The Chronic Respiratory Questionnaire (CRQ) is an established measure of health status for chronic obstructive pulmonary disease [31,32]. Previous studies have shown that an improvement in score in any domain of the CRQ of ≥0.5 represents the minimal clinically important difference that is noticeable to patients [31], changes in any domain of the CRQ >1.0 represent moderate improvements and changes in any domain of the CRQ >1.5 represent large improvements in health-related quality of life [32].

Cardiac Autonomic Function

Analysis of heart rate variability (HRV) is a powerful method to assess the autonomic nervous system. HRV is a physiological phenomenon describing the variation of the time interval between heart beats which is related to the relative acitivity of the sympathetic and parasympathetic nervous system. A reduced HRV implies an impaired ability of the heart to alter its own beat frequency and therefore a pathological condition of the cardiovascular system [33,37,38,39]. Cardiovascular autonomic function was assessed by measuring the standard time and frequency domain measures of HRV from 5 min of the R-R interval recordings in the ECG, with the patients in seated. HRV was obtained via 3-channel ECG recording (Nexus-10™ medical device class IIa; TMS International BV) as recommended by the Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology [33]. To eliminate artefacts an automatic filter excluded RR sequence differing by more than 30% from the previous interval [33]. Time domain measures of HRV were calculated from the R-R interval tachograms. The following time domain measures of HRV were calculated: mean R-R (NN mean) in milliseconds, the standard deviation of R-R intervals (SDNN) in milliseconds and the root mean square successive difference of R-R intervals (rMSSD) in milliseconds.

The following standard frequency domain measures of HRV were computed: high-frequency spectral power (HF power, the density of the beat-to-beat oscillation in the R-R interval of HRV in the high-frequency band; HF = 0. 15–0.4 Hz), low-frequency spectral power (LF power, the density of the beat-to-beat oscillation in the R-R interval of HRV in the low-frequency band; LF = 0.04–0.15 Hz), the ratio of LF to HF power (LF/HF ratio). LF/HF ratio has been described as a marker of sympathetic to parasympathetic balance [34,35,36]. Spectral components were expressed both as absolute values in milliseconds and as normalized units. To reflect the degree of parasympathetic modulation of heart rate, we used both HF power (%) and rMSSD (ms) [33,37,38,39].

Data Analysis

We performed an RCT (ClinicalTrials.gov identifier: NCT01175265) with sequential analysis of the clinical training effects; tests were performed prior to and following completion of cardiopulmonary exercise training. Twenty patients were assigned to receive 10 sessions of 1.5 h of physical exercise training plus additional ten 30-min RBF sessions (RBF group). In the other group, 20 patients were assigned to receive ten 1.5-hour sessions of physical exercise training only (control group) over 4 weeks. The technicians, who performed the pulmonary function tests and 6MWTs, were blinded for the randomization. In order to control for any residual learning effect, the patients performed two 6MWTs at baseline on separate days; the second 6MWT was used for analysis.

Data on pulmonary function, cardiopulmonary exercise capacity, health-related quality of life and cardiac autonomic modulation were collected prior to and following completion of 4 weeks of pulmonary rehabilitation.

A statistical software package was used for statistical analysis (SPSS for Windows, version 11.0; SPSS Inc., Chicago, Ill., USA). Descriptive data for continuous variables are expressed as mean ± SD. Effects of pulmonary rehabilitation were evaluated by within-group comparisons of changes over 4 weeks, using paired Student’s ttests. Differences in changes from baseline to follow-up between the two groups were compared using unpaired Student’s t tests. A p value of <0.05 was considered to be significant.

Results

Patients

Sixty-three patients with COPD (GOLD class I–IV) were evaluated for study participation. Forty-three patients were eligible for the study and agreed to participate. Twenty-two patients were randomized to the RBF group and 21 to the control group. Three patients withdrew from the study due to an acute COPD exacerbation during the training period.

Baseline anthropometrical characteristics and pulmonary function data of the 40 patients (23 females) with COPD are presented in table 1. Twenty-two patients had mild to moderate disease (GOLD I n = 4; GOLD II n = 18), and 18 patients had severe or very severe COPD (GOLD III n = 16; GOLD IV n = 2). There were no significant differences in the baseline anthropometrical characteristics and pulmonary function test results between the group receiving RBF and the control group.

Table 1

Anthropometric and pulmonary function data

Changes in Pulmonary Function, Cardiopulmonary Exercise Capacity and Health-Related Quality of Life

Between-group comparisons of changes in pulmonary function, health-related quality of life and cardiopulmonary exercise capacity over the 4 weeks of pulmonary rehabilitation are shown in table 2. There was no change in lung function test results during the 4-week program in any of the groups, and the groups did not differ (fig. 1).

Table 2

Changes of pulmonary function,cardiopulmonary exercise capacity and health-related quality of life

Fig. 1

There was no statistically significant difference in the change of FEV₁ between the RBF group (left) and the control group (right) after the 4 weeks of pulmonary rehabilitation.

Cardiopulmonary exercise capacity (6MWD) over the 4 weeks of pulmonary rehabilitation showed no significant differences between the groups (fig. 2). Within-group comparison for both study groups revealed a significant improvement in exercise capacity over the 4 weeks of pulmonary rehabilitation (fig. 2): the 6-min walking distance increased in both groups [RBF group: Δ6MWD = +23.63 (30.70) m, p = 0.002** vs. control group: Δ6MWD = +36.21 (43.54) m, p = 0.0005**].

Fig. 2

There was no statistically significant difference in the change of cardiopulmonary exercise capacity as assessed by the 6MWD between the RBF group (left) and the control group (right) after the 4 weeks of pulmonary rehabilitation. Within both groups, there was a statistically significant improvement in 6MWD after pulmonary rehabilitation. ** = highly significant.

No significant differences were found in the quality of life between the two groups (fig. 3). Within-group comparisons for both study groups showed highly significant improvements in health-related quality of life after 4 weeks of pulmonary rehabilitation [RBF group: ΔCRQ score = +0.64 (0.85), p < 0.001** vs. control group: ΔCRQ score = +0.48 (0.85), p < 0.001**].

Fig. 3

There was no statistically significant difference in the change of health-related quality of life as assessed by the CRQ between the RBF group (left) and the control group (right). A statistically significant improvement in health-related quality of life was observed in both groups after 4 weeks. ** = highly significant.

Changes in Cardiac Autonomic Function

Between-group statistical comparisons of improvements in time and frequency domain measures of parasympathetic-induced HRV are shown in table 3. No significant differences between changes in the mean values of R-R interval and R-R interval variability were found between both groups.

Table 3

Changes of R-R interval and R-R interval variability

Within-group comparisons analyses showed improvements in the measurements of parasympathetic-induced HRV in both time and frequency domains (table 3; fig. 4). However, compared to baseline, no significant differences in any measurement of parasympathetic-induced HRV in frequency domains were found over the 4 weeks of pulmonary rehabilitation in the control group. Only the RBF group showed significant improvements in resting SDNN (ms) over the 4 weeks of pulmonary rehabilitation; SDNN increased from 32.0 (23.7) ms to 48.0 (52.8) ms (p = 0.037*).

Fig. 4

There was no statistically significant difference in the change of cardiac autonomic function as assessed by rMSSD between the RBF group (left) and the control group (right).

Discussion

This is the first RCT comparing the effects of a 4-week rehabilitation program including controlled breathing using respiratory biofeedback to a 4-week rehabilitation program alone on pulmonary function (pulmonary function tests), cardiopulmonary exercise capacity, health-related quality of life and cardiac autonomic modulation. The initial hypothesis is not corroborated by the present observations; controlled breathing using a technique of RBF does not produce additional benefits compared to conventional pulmonary rehabilitation programs.

Pulmonary Function, Health-Related Quality of Life and Cardiopulmonary Exercise Capacity

It has been established that pulmonary rehabilitation in patients with COPD results in increased exercise tolerance, peripheral muscle force and health-related quality of life without any effects on pulmonary function or arterial blood gas levels [40,41,42,43]. Accordingly, we found significant improvements in both health-related quality of live (Chronic Respiratory Questionnaire) and exercise tolerance (6MWD) but not on any pulmonary function parameters reflecting airflow limitation, inspiratory lung capacity or lung hyperinflation over the 4 weeks of pulmonary rehabilitation.

Reviewing of the literature on controlled breathing techniques, such as DB, PLB and prolonged exhalation in patients with COPD, reveals that the use of each of these modalities has certain clinical benefits: PLB appears to be an effective way to decrease dyspnoea [12,13], improve the walking distance in the 6MWT [13] and improve gas exchange [15,44]. Furthermore, PLB has been shown to provide sustained improvement in exertional dyspnoea and physical performance [45]. DB in patients with COPD is associated with improvement of blood gases at the expense of a greater inspiratory muscle loading [16,23,46]. Several studies have demonstrated that COPD patients are able to voluntarily change their breathing pattern to more abdominal movement and less thoracic excursion [24,47,48]; however, no changes in ventilation distribution could be observed [48].

However, contradictory evidence exists about the effectiveness of controlled breathing techniques: Garrod [49] found that pursed lips breathing did not improve walking distance in nonspontaneous pursed-lips breathing COPD patients and Gosselink et al. [24] found that DB was associated with a decrease in mechanical efficiency in comparison with natural breathing in patients with COPD. Further analysis of the literature to date does not support the use of DB to improve ventilation, gas exchange, or the work of breathing in patients with COPD [57,58,59]. In summary, DB seems to have negative and positive effects, but the latter appears to be caused by simply slowing the respiratory rate [15].

To date, no trials have been published that investigated patients’ ability to train these breathing techniques all together and evaluate their overall effects over a prolonged period of time. In this study, no additional benefits from controlled breathing interventions in pulmonary function, health-related quality of life and cardiopulmonary exercise capacity were observed over the 4 weeks of pulmonary rehabilitation.

Cardiac Autonomic Function

Giardino et al. [22] found that after 10 weeks of controlled breathing, patients with COPD showed statistically and clinically significant improvements in parasympathetic tone [22]. These results suggest that breathing interventions per se can produce long-term changes in multiple organ systems that are affected by autonomic control. Although the improvement in parasympathetic-induced HRV in time domain of the RBF group in this study was significant, there seems to be no significant additional benefit from controlled breathing on parasympathetic tone over the 4 weeks of pulmonary rehabilitation.

Previous studies have established that patients with COPD have predominant sympathetic tone at rest, as assessed by increased resting heart rate and reduced HRV [50], and that the presence of cardiac autonomic dysfunction is generally associated with worse prognosis [51,52,53]. Predominant resting sympathetic tone in COPD may even have negative consequences on inflammation, cachexia and skeletal muscle dysfunction [54]. In accordance with this, we found that mean resting HR was elevated [89.1 (20.7) beats/min] and HRV was reduced [34.50 (31.10) ms] compared to published control data [55,56], underlining increased sympathetic tone at rest in the patients of this study.

HF power, SDNN and rMSSD are widely accepted to reflect the degree of parasympathetic induced modulation of heart rate [33,37,38]. Interestingly we found that, after 4 weeks of intensive cardio-pulmonary exercise training, all variables reflecting parasympathetic tone increased. The increase in SDNN of the RBF group was statistically significant. These results show that cardiac autonomic dysfunction can be positively influenced by intensive physical exercise training in patients with COPD. However, the pathophysiological mechanism underlying the substantially enhanced resting parasympathetic tone due to cardiopulmonary exercise training in patients with COPD remains unclear.

Limitations of the Study

It should be stressed that a number of patients found it difficult to change their breathing pattern during exercise performance. The controlled breathing techniques used in this study might be more beneficial if trained separately. It could be possible that pursed-lips breathing might be counteracted by those which might increase the work of breathing, such as deep DB [24]. In addition, a number of patients found it difficult to change their breathing pattern during exercise performance and thus the controlled breathing techniques used in this study may be more effective if trained separately rather than in combination. Furthermore, we cannot exclude that controlled breathing has some long-term effects. As rehabilitation is a relatively powerful intervention, it is difficult to secure improvements over and above those observed by rehabilitation alone. Some clinically relevant parameters were not assessed, that is, tidal volume, inspiration time/expiration time ratio and dynamic hyperinflation during exercise; thus we cannot exclude that controlled breathing has a positive effect on hyperinflation. Future studies should assess the effects of controlled breathing on dynamic hyperinflation and assess the long-term effects of controlled breathing. Long-term effects of controlled breathing might be helpful to develop appropriate therapeutic strategies and to improve long-term therapeutic management in COPD.

The number of patients included in our study was relatively small (n = 40). However, the 95% confidence intervals of the difference in ΔFEV₁ between the two groups were –100 to 80 ml, thus we have excluded a significantly larger ΔFEV₁ in the RBF group of more than 80 ml which is within the range of the minimal clinical importance. Similarly, the 95% confidence intervals of the difference in Δ6MWD between the two groups were –37 to 12 m, thus we have excluded a significantly larger Δ6MWD in the RBF group of more than 12 m, again well within the range of the minimal clinical importance.

Conclusions

The initial hypothesis is not corroborated by the present observations that controlled breathing sessions using a technique of RBF has any influence on pulmonary function, cardiopulmonary exercise capacity, health-related quality of life and cardiac autonomic function. The improvements on resting HRV observed in both groups show that cardiac autonomic dysfunction can be positively influenced by 4 weeks of intensive physical exercise training in patients with COPD.

Financial Disclosure and Conflicts of Interest

None of the authors has a conflict of interest related to the content of the manuscript.

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Author Contacts

Dr. rer. medic. Arnoldus J.R. van Gestel

Zurich University of Applied Sciences

Technikumstrasse 71

CH–8401 Winterthur (Switzerland)

Tel. +41 79 833 8275, E-Mail [email protected]

Article / Publication Details

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Received: October 21, 2010
Accepted: December 21, 2010
Published online: April 07, 2011

Issue release date: January 2012

Number of Print Pages: 10

Number of Figures: 4

Number of Tables: 3

ISSN: 0025-7931 (Print)
eISSN: 1423-0356 (Online)

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Diaphragmatic Breathing, and Other Exercises for COPD

Chronic obstructive pulmonary disease (COPD) causes the individual’s lungs to gradually lose their ability to get enough oxygen to the body. This can result in a feeling of breathlessness, making people with COPD reluctant to engage in exercise.

But exercise is extremely important for people with COPD. The less active you are, the less you’ll be able to do. The weaker your muscles are, the more oxygen you will need for everyday activities like cooking or shopping.

The key to slowing down the progression of COPD is to strengthen your body with proper exercise. It’s important to focus on exercises that help your chest muscles stay active. And it’s also important to keep up strength in your legs and arms so that regular routine activities won’t be so challenging.

Breathing Exercises for COPD Patients

Breathing exercises are an important way to strengthen your breathing muscles when you have COPD. With the proper breathing exercises, you will be able to get more oxygen into your lungs – enabling you to breathe easier and with less effort.

Below are two deep breathing exercise examples: pursed-lip and diaphragmatic breathing. Individuals who suffer from COPD will want to do these exercises for 5 – 10 minutes, 3 – 4 times a day.

1- The Pursed-Lip Breathing Exercise

The pursed-lip breathing exercise is a method used to help prevent air from getting trapped in your lungs. This breathing exercise can also help relieve stress and anxiety, including stress related to the feelings you might have due to being short of breath.

Here are the 4 pursed-lip breathing exercise steps:

1. Relax your shoulders and neck.
2. Breathe in through your nose for a count of three.
3. Purse your lips like you are about to whistle and release the air through your lips.
4. Exhale for about twice as long as you inhaled, but avoid forcing the air out.

2- Diaphragmatic Breathing

The diaphragmatic breathing exercise helps COPD patients to strengthen their diaphragm. Your diaphragm is a dome-shaped muscle that moves up and down beneath your lungs as you breathe.

For this exercise, you will want to start slowly with just a few breaths. The end goal is to get up to 12 deep breaths without getting tired.

Here are the 4 steps to diaphragmatic breathing:

1. Lie on your back with a pillow under your knees.
2. Place one hand on your chest, and the other hand on your stomach.
3. Try to keep your chest still, but as you breathe allow your stomach to rise.
4. Breathe in for a count of three, then breathe out slowly through pursed lips for a count of six.

Coughing Techniques

Coughing due to excess mucus buildup is one of the main symptoms of COPD. Keeping hydrated can help to thin the mucus, making it easier to clear from the lungs. Practicing and using the following coughing techniques can also help to clear the airways more effectively without overtiring you.

1- The Huff-Cough

• Sit in a chair and take several deep breaths as you would in diaphragmatic breathing.
• Have your hand on your stomach, and breathe normally.
• Tighten your stomach and chest muscles, and have your mouth open.
• Force air out while whispering “huff”.

2- Controlled Coughing

• Have your feet on the floor while sitting down, and slightly lean forward.
• Your arms should be folded across your stomach while you breathe in through your nose.
• Lean forward against your folded arms, and exhale.
• Produce 3 short coughs with your mouth partially open.
• Breathe in through your nose again, and take a rest.

Try to avoid taking deep quick breaths through your mouth. Instead, try to use deep breathing techniques through your nose.

Staying Active With COPD

Staying active is so imperative to COPD patients. Inactivity causes your muscles to slowly lose their strength. Weak muscles need more oxygen, so by not fitting proper exercise into your weekly routine, you may be worsening your COPD symptoms. Exercising can help slow down the progression of symptoms.

Below are some types of exercises you should be considering in order to stay active. It is always best to speak to a health care professional before starting a new exercise program. Start slowly and sit down for a few minutes if you’re out of breath. Go at your own pace.

Walking

Walking is a great exercise for anyone with COPD, especially if you haven’t been active for awhile. Start by walking at a slow pace and add a little extra distance each week in order to build up your strength. Walk indoors (e.g., in a shopping mall), on a treadmill, or take a walk outside on a nice day.

Ride a Bike

Adding a stationary bike to your weekly routine is a great way for COPD patients to stay active. You can join a gym, or ride in the privacy of your home. Once you’re feeling confident, you might try to go outside for a bike ride and get some fresh air.

Weights and Home Exercises

Exercises that strengthen your arms and legs can be done at home or in the gym. You can use light hand weights, elastic bands, or even water bottles to exercise your arms. Calf raises and leg extensions are easy exercises that you can do at home to help build and strengthen your leg muscles.

Tai Chi

This ancient Chinese practice is perfect for COPD patients. It’s slow and meditative, helps tone muscles, and focuses on the heart and lungs. The meditative nature of this practice can also help with your anxieties and stress.

The exercises described above can help you to take the first steps towards better fitness. Once you start to feel more confident, you may want to switch things up so you don’t get bored. Consider joining a walking or biking club to avoid social isolation.

And if you use oxygen, that’s okay, most workouts can still be done with your oxygen. Longer tubing can be used at home, and “travel tanks” can help you to more easily get out and about.

Always talk to your doctor before starting a new workout routine.

Pulmonary Rehabilitation Programs

Your doctor might recommend joining a pulmonary rehabilitation program. These programs have nurses and trained professionals there to supervise and help teach COPD patients how to properly exercise. They also offer support with quitting smoking and other lifestyle changes and treatment strategies that can help you to cope with COPD.

Precautions When Exercising  with COPD

Be sure to monitor your condition when exercising, especially when beginning a new workout routine. If you experience any of the following signs or symptoms, stop exercising right away. Sit down, and keep your feet elevated while resting. If you don’t feel better right away, call 911. Even if you do feel better, make sure you tell your doctor right away about any of these symptoms.

Stop exercising if these symptoms occur: 

• Nausea
• Dizziness
• Weakness
• Rapid or irregular heartbeat
• Severe shortness of breath
• Pain
• Pressure or pain in your chest, arm, neck, jaw, or shoulder

If you or a loved one has COPD and would like to learn more, see our 11 Guidelines for For Managing COPD at Home.

The information in this article should not be taken as professional medical advice. If you are having issues or have health-related concerns, you should see your personal physician.

90,000 Rehabilitation of chronic obstructive pulmonary disease (COPD)

Chronic obstructive pulmonary disease (COPD) is a chronic disease that is the final stage of the progressive course of pulmonary emphysema and chronic obstructive bronchitis.

It should be noted that the disease that provoked COPD loses its individuality. The following signs indicate the development of chronic obstructive pulmonary disease in a patient:

• progressive obstructive respiratory failure;
• diffuse nature of damage to the respiratory system.

The main aspect that acts as a limiter of the daily activity of patients with COPD is the almost complete intolerance to physical exertion, which distinguishes this type of disease from bronchial asthma.

This phenomenon occurs under the influence of a number of both direct and indirect factors, the key ones of which are:

• cardiac dysfunction;
• violation of gas exchange processes;
• changes in the muscles of the skeleton and the respiratory system.

These are the hallmarks of chronic obstructive pulmonary disease, since the above symptoms do not bother patients with bronchial asthma.

Pulmonologists recommend regular physical exercises to increase the level of mobility of the chest and diaphragm, increase the strength and endurance of the muscles of the respiratory organs, and establish the correct breathing mechanism. Properly selected and performed on an ongoing basis, exercises help restore drainage function and bronchial patency, increase the degree of lung compliance, optimize gas exchange processes, correct respiratory failure, improve overall well-being and, as a result, improve the quality of life.

Pulmonary Rehabilitation: Basic Tasks

Pulmonary rehabilitation aims at:

• increasing the activity of the cardiorespiratory system;
• improvement of the condition and functioning of the muscular system;
• increase in exercise tolerance;
• decrease in the severity of symptoms of the disease;
• reduction in the frequency and duration of exacerbations;
• improvement of the patient’s psycho-emotional state.

Today, various forms and means are used for pulmonary rehabilitation:

• breathing simulators;
• therapeutic massage;
• exercise bikes;
• medical gymnastics;
• treadmill;
• moderate walking;
• physiotherapy.

Patients begin therapeutic exercises at the stage of attenuation of the exacerbation of the disease. They can be performed in a sitting or lying position and include:

1. General developmental exercises:

• with a gymnastic stick or ball;
• to increase the mobility of the chest and spine;
• isometric muscle tension of the upper shoulder girdle, upper and lower extremities.

2. Breathing exercises:

• with forced expiration;
• drainage exercises;
• diaphragmatic breathing;
• “with closed lips”;
• with extended expiration.

3. Techniques aimed at relaxing muscles.

To achieve the maximum effect of LH training, it is recommended to repeat each exercise at least 4-6 times. The optimal duration of classes is 10-15 minutes.

Pursed Lip Breathing, which can help reduce shortness of breath in patients with COPD, is a simple and effective way to slow the breathing rate down as quickly as possible. This exercise contributes to:

• improvement of pulmonary ventilation;
• elimination of air traps in the lungs;
• to facilitate the work of breathing;
• longer keeping the airways open;
• lengthening expiration and slowing down the respiratory rate;
• Optimization of respiratory processes by moving old air out of the lungs, which contributes to the unimpeded flow of new air.

A combination of nebulizer treatment and Ventum Vest Vibration is used to reduce the intensity of chronic cough.

Correct breathing technique

First of all, you should relax the muscles of the shoulder girdle and neck, and then take a shallow breath through the nose for 2 counts. Keep your mouth closed. After that, stretch your lips into a “tube” (just like you do during a whistle) and make a quick short exhalation, as if blowing out a candle flame.Then slowly exhale the remaining air for 4 counts through your closed lips.

A breathing technique of this kind is recommended for patients with COPD during physical activity, including lifting weights, bending and climbing stairs. Initially, it is worth doing daily workouts at least 4-5 times. This will lead to the formation of the correct breathing exercise technique.

At the stage of improving the patient’s condition, as well as in remission, aerobic training takes place, aimed at increasing endurance.Physical exercise is considered a key activity in the rehabilitation of patients with COPD, which aims to increase the level of physical performance. For this, a dynamic load for large muscle groups is applied:

• trainings on a bicycle ergometer or treadmill;
• dosed walking.

It should be noted that with dosed walking, the patient should pay special attention to prolonged exhalation, which should exceed the duration of inspiration by 1.5-2 times.It is also worth making sure that the walking distance gradually increases, and its pace is within 60-90 steps per minute. Dosed walking is most effective when done daily.

The introductory part of physical training consists of 2-4 general tonic and breathing exercises, followed by exercises on a bicycle ergometer simulator with a physical load power of 25-30% of the individual threshold load, lasting for 3-5 minutes.

The main part of the lesson lasts 10-25 minutes.It is aimed at obtaining, by means of an interval or constant method, a load performed in a sitting position with a pedaling frequency of 50-70 rpm. Indicators such as duration, power and shape are individual in nature and are determined based on the tasks of the functional group.

The final part includes breathing exercises, as well as relaxation exercises, the duration of which should not exceed 8-10 minutes.

Some experts have suggested that interval training, which consists of repeated periods of submaximal work followed by periods of rest, has the same effect as continuous training, but at the same time provokes less shortness of breath.

Physical training, performed taking into account the functional reserves of the cardiorespiratory system and the patient’s motivation during their implementation, are the most significant for patients with severe COPD, chronic DN (I-II degree) and signs of chronic heart failure. In the case of the above diseases, it is recommended to grant the right to “free choice of load parameters”. This means that the power of the load can be adjusted at the request of the patient, and FT should be stopped as his subjective need for movement is satisfied.The exceptions are cases of inadequate load.

As a rule, training is carried out weekly from 2 to 5 times for 6-12 weeks. The duration of one lesson is from 10 to 40 minutes, and depends on the physical abilities of the patient and related conditions.

It is customary to practice remedial gymnastics 3-4 times a week at the stage of disease remission. In this case, the duration of the lesson is 40-45 minutes, and the exercises are performed 8-12 times in a lying position, sitting and standing.The pace of execution varies.

It is recommended to add elements of sports games, dosed walking and general developmental exercises to remedial gymnastics:

• for a variety of muscle groups;
• respiratory;
• on simulators.

Therapeutic exercises can also be diluted with physical exercises aimed at training the muscles of the upper shoulder girdle and upper limbs. For this purpose, the following elements are used:

• hand-held ergometer;
• dumbbells weighing 0.2-1.4 kg.;
• resistance bands;
• wrist weights.

In order to achieve an increase in muscle mass, 2-4 exercises on strength machines are added to LH training. Each exercise should be repeated 6-12 times.

In the course of studies carried out in 2006, a high degree of effectiveness of the increasing threshold load on exhalation and inhalation (when exercising with breathing simulators) was proven, provoking an increase in exercise tolerance and improved lung function.

A key factor in prescribing physiotherapy and applying a private massage technique is the form of COPD (bronchitic or emphysematous).

Due to the fact that respiratory failure is the main cause of death in patients with COPD, oxygen therapy is indicated for almost every patient. Correction of hypoxemia with oxygen is a pathophysiologically sound treatment for respiratory failure.

90,000 Breathing Exercises for COPD That Prolong and Improve Life | Pathologist

Hello everyone!

Chronic obstructive pulmonary disease is a pathology that inevitably leads to a decrease in the functionality of the lungs.For some, hypofunction comes very quickly, for others it may take decades.

The essence of the disease lies in the fact that when exposed to damaging substances (tobacco smoke, chemical aerosols at work or dust), inflammation occurs in the bronchi. In turn, the latter leads to the formation of scar tissue in the walls of the respiratory tract, damage to the mucous membrane and narrowing of the lumen of the bronchi.

It follows from this that it is much more difficult to exhale through the smaller diameter of the bronchi. Because of this, excess air remains in the lungs, which overstresses the organ.The walls of the alveoli become thinner and torn, leading to the formation of emphysema.

Consequently, the surface area through which gas exchange between air and blood occurs – the body begins to receive less oxygen – because of this, shortness of breath appears.

This is how we come to the main manifestation of the disease. Shortness of breath prevents people from fully moving, doing household chores and physical activity, but along with drug treatment, breathing exercises have a good effect.They are designed to strengthen the muscles involved in breathing. This allows much less energy to be expended on a regular inhalation.

Exercise number 1. Pursed Lip Breathing

• Relax the muscles in the neck and upper shoulder girdle;

• Inhale through your nose with your mouth closed for at least 2 seconds;
• Exhale through pursed lips, taking at least 4 seconds or just 2 times longer than inhalation;

Exercise # 2.Diaphragmatic breathing

• Lie on your back and bend your knees;
• Place one hand on your chest and the other on your stomach just below the costal arch;
• Take a slow deep breath so that only the hand that is on the stomach is raised;
• Exhale through pursed lips. It is also necessary to exhale with the stomach, while straining the muscles of the anterior abdominal wall;

These exercises may seem quite simple.I agree with you, but only if they are performed by a healthy person. For someone with COPD, this can seem like a serious burden. These exercises must be performed for 10-15 minutes 3-4 times a day.

But besides the fact that you need to do the right exercises, you should also avoid some types of stress:

• Lifting weights, such as exercises with a barbell, dumbbells or kettlebells;
• Push-ups;
• Exercise outdoors when the air is too cold, humid or hot.
• Climbs on slopes or mountains;

In conclusion, I would like to remind you once again that it is always better to consult with your doctor about the presence of indications and contraindications for performing a particular exercise. Be healthy!

How is breathing exercise different from COPD?

Chronic obstructive pulmonary disease (COPD) is a condition in which the airways narrow, causing shortness of breath. Simple activities such as getting dressed or eating in the kitchen can be confusing.COPD breathing exercises can help the sufferer recover quickly and restore normal breathing. The two most effective breathing exercises for COPD are pursed lips and diaphragmatic breathing.

Pursed-lip breathing is one of the most common breathing exercises for COPD, instinctively used by most people when they are short of breath, and is an effective technique for restoring natural breathing rates.This method can be used to slow the rate and depth of breathing until it returns to normal. To perform pursed-lip breathing, the victim must sit up straight and relax, inhale through the nose, and then purse the lips, as if whistling and exhaling. This will cause the sufferer’s cheeks to swell. He or she should not throw air strongly, but should breathe out naturally.

Deliberate exhalation through pursed lips promotes longer exhalation and also removes more old air from the lungs, improving ventilation.Removing more air creates counterpressure, drawing in more fresh air with each breath. COPD breathing exercises, such as pursed-lip breathing, slow down the breathing rate and help the patient to relax.

Diaphragmatic breathing is another useful exercise. The diaphragm is a muscle located under the lungs and is responsible for helping breathing. Often COPD sufferers no longer use this muscle effectively and need to retrain the body to use it properly.Breathing exercises associated with COPD, such as diaphragmatic breathing, are likely to make the sufferer tired at first, but with practice these breathing exercises with COPD will become easier.

To perform diaphragmatic breathing, the patient must lie on his back with bent knees. One hand should rest on your stomach and the other on your upper chest. The COPD sufferer should breathe in through the nose and focus on allowing the abdomen to lift while the chest remains still.He or she should exhale through pursed lips and allow the abdomen to fall while the ribcage remains motionless. Initially, these diaphragm exercises should be performed no more than three or four times a day, each time for five to ten minutes, but this can be increased with practice.

Some caution may be required when performing COPD breathing exercises. For example, breathing exercises with COPD can cause lightheadedness. This is a sign of excessive ventilation, a signal that breathing should be slowed down.Of course, anyone with a serious medical condition such as COPD should talk to a doctor regarding any medication or exercise plan.

OTHER LANGUAGES

Treatment of respiratory organs

The greatest effect is obtained by complex spa treatment against the background of basic drug supportive therapy of the disease.

Climatotherapy is very important for the prevention of respiratory diseases . The sanatorium is located in a forested area (Park im.Gruzovsky), not far from the Volga river embankment. Located within the city limits, it is easily accessible by public transport.
The sanatorium conducts regular walks in the fresh air in the forest park area, health path, Scandinavian walking, which are very effective methods of physical rehabilitation, involving dosed physical activity, which is most important for respiratory diseases.

Separately, it should be said about physiotherapy exercises and breathing exercises which are carried out by instructors of physiotherapy exercises in the “Chuvashiyakurort” sanatorium.
There are many types of breathing exercises available to treat a variety of conditions that promote the development of the muscles of the diaphragm and reduce respiratory impairment.
Correct breathing reduces the likelihood of developing diseases of the respiratory tract, while improper breathing, on the contrary, increases their risk. If you breathe correctly through your nose, then the air heats up, and also thanks to the ciliated epithelium, which is lined with the nasal mucosa, it is cleared of microorganisms, allergens and other impurities unnecessary for the body.They simply linger on these cilia, and then sneeze out of the body. If a person breathes through the mouth, cold, polluted air enters his respiratory tract, which undoubtedly increases the risk of developing diseases.

Also in case of respiratory injury, chest massage is used in combination with postural drainage (special position) in order to improve sputum discharge and restore airway patency.It also improves blood circulation, increases the tone of the chest muscles, and restores the normal movement of the diaphragmatic muscle. We offer all types of manual massage, mechanotherapy, vacuum roller massage.

Balneotherapy for patients with respiratory diseases in the sanatorium “Chuvashiyakurort” is used quite often. Carbonic baths, sodium chloride baths with mineral water, radon baths, in addition to relieving bronchospasm and relaxing other muscle groups, expand capillaries, which helps to improve blood circulation, starts restorative and immunomodulating processes and cellular metabolism.In various types of general and local baths (hand, foot), mineral water is used from its own well on the territory of the Chuvashiyakurort sanatorium.
Some patients are shown dry carbon dioxide baths , which can also be obtained in our sanatorium. These baths increase blood oxygenation, improve microcirculation, normalize the tone of the vascular wall, bronchial muscles, prevent congestion, regulate the functional state of the respiratory system, nervous system, metabolic processes.

Mud procedures (peloid therapy) in the sanatorium are carried out using therapeutic sapropel mud. For respiratory diseases, local mud applications are used, as well as mud therapy in combination with electrotherapy and ultrasound therapy. It contains many active ingredients and trace elements, vitamins and natural antibiotics, which have an anti-inflammatory, immunomodulatory effect, improve metabolism, and also have a desensitizing effect.

In physiotherapy for the treatment of respiratory organs there is such a direction of climatotherapy as speleotherapy (halotherapy) , or the climate treatment of salt caves . The air saturated with salt disinfects the respiratory tract, increases the body’s resistance to the effects of allergens, soothes, and improves the secretion of phlegm. Such air is very easy and pleasant to breathe.
Salt caves can be located in areas of salt deposits. Our sanatorium is equipped with a special room for speleotherapy, the walls and ceiling of which are made of salt, and there is also an apparatus for spraying salt suspension over the entire area of ​​the room.

Aromatherapy can also be used to prevent diseases of the respiratory system. Essential oils of pine, juniper, cypress and other plants of this genus will help to enrich the air with volatile needles. They perfectly clean the air from pathogens, preventing them from entering our respiratory tract.
We use essential oils in special aroma lamps, and it is also possible to combine the bath with aromatherapy by adding special oils to the bath.A bath with natural sea salt will help to saturate the air with iodine and other useful microelements, which will also have a beneficial effect on the respiratory system.

Also, inhalation therapy can be used for prophylaxis. We do not mean steam inhalation (breathing over a bowl of hot potatoes), but the use of special devices – nebulizers . Through a nebulizer in the sanatorium, inhalations with saline and other drugs are used, this is very important for maintaining remission and preventing complications.In such cases, drugs, dosages and frequency of procedures are prescribed by the doctor on an individual basis. Essential oils and herbal solutions are used in ultrasonic inhalers in patients without allergic manifestations.

Of the numerous methods of physiotherapy for respiratory diseases in the sanatorium “Chuvashiyakurort” magnetotherapy on devices “Multimag”, “Polymag”, electrophoresis, amplipulse, paraffin applications, etc. are used. They are prescribed in combination with the above methods of treatment and contribute to the fastest recovery …

Acupuncture. By acting on biologically active points on the human body with special needles, it improves microcirculation in organs and systems, normalizes muscle tone, blood pressure, brain and heart function, increases immunity and resistance to infections, has a sedative and antidepressant effect.

Pool. Pool swimming and aqua aerobics work harmoniously to develop all muscle groups, including the upper shoulder girdle, diaphragm and pectoral muscles, and helps to keep the body toned and breathe well.If you still failed to avoid respiratory tract disease and you have any symptoms, your first priority is to see a doctor in a timely manner.

A diagnosis made at an early stage and adequate treatment started on time will help prevent the chronicity of the disease, and if it is initially chronic, it will help prevent the development of complications.

Do not self-medicate, but contact the professional specialists of the Chuvashiyakurort sanatorium, they will help you improve your well-being.

Expected therapeutic effect:
– Reduction or complete disappearance of shortness of breath, cough, difficulty breathing, etc. World Day Against COPD 11/18/2020 | Page 2

Correct breathing

During the day, a person commits up to 20 thousand.inhalation and exhalation, it happens naturally and unconsciously. But not everyone knows that with the help of proper breathing, you can significantly improve your well-being.

Most people breathe shallowly, or “vertically”, while deep, or “horizontal” breathing is practiced only by those who specifically concentrate on this process in yoga or breathing practices. How to Improve Health with Proper Breathing?

Correct and incorrect breathing

Observing children, you will notice that they breathe from the belly.With age, people lose this habit and begin to breathe through the chest. This is the main mistake. The lung capacity is designed for 4-6 liters of air. During chest breathing, a person inhales only 400-500 ml, while breathing with a diaphragm – 2-3 liters.

The habit of breathing through the chest does not saturate the lungs with oxygen, leads to a weakening of the diaphragm muscles and deterioration of posture: if the abdomen is not included in the breathing process, the pelvis and ribs begin to “tighten” with age, and the stomach falls inward.

Diaphragm breathing allows you to increase the volume of air inhaled by the lungs and improve the saturation of body cells with oxygen.This normalizes the body’s work at all levels: it stabilizes blood pressure, heart function, relieves feelings of anxiety and nervousness.

What is conscious breathing

To help your lungs breathe fully, you will have to re-learn this process. First you need to understand that the diaphragm helps in the process of “horizontal” breathing. A person does not breathe air in his stomach, but by connecting it to the breathing process, he allows him to fill his lungs to the maximum. Research has shown that practicing mindful breathing according to the 4-7-8 principle (inhale for four counts, hold for seven, and exhale for eight) allows the body to relax more quickly, improves digestion, and strengthens the immune system.

To feel the work of the diaphragm, sit in a comfortable position or lie on the floor, place your left hand on your chest and your right on your stomach. Feel the belly rise and fall, while the chest remains motionless. Practicing “horizontal” breathing regularly, try to slow it down to 10 breathing cycles per minute (1 cycle – inhalation and exhalation), gradually increasing the exhalation.

How Often To Practice Mindful Breathing

Get in the habit of paying attention to your breath several times a day.For example, take a few minutes to observe your breaths in and out in the morning before getting out of bed and in the evening before bed. If you can, remind yourself of “horizontal” breathing throughout the day and notice how you breathe in everyday life.