BREATHING EXERCISE

LAILY HIDAYATI
DIVISION OF MEDICAL SURGICAL NURSING
DEPARTMENT OF BASIC, MEDICAL SURGICAL, AND
CRITICAL NURSING
FACULTY OF NURSING
AIRLANGGA UNIVERSITY

Definition
Breathing exercise is techniques that used to helping

patient in improve pulmonary status/function and

endurance, increased effectivity-efficiency and
reduced respiratorys work.

Aims
1.
2.
3.
4.

5.
6.

7.
8.

Increase ventilation
Increase effectivity of coughing mechanism
Prevent atelectasis
Improves strength, endurance, and coordination of
respiratory muscles
Maintain and/or increase mobility of chest and
thoracal spine
Correction on ineffective and abnormal breathing
patterns
Improves relaxation
Teach patients how to take an action in respiratory
disorders

Benefits
Improved function of respiratory

Improved pulmonary/respiratory status

Increased oxygen level in cells
Increased expand lung
Increased lung capacity
Reduced symptoms on respiratory (dyspnea, etc)
Reduced respiratory stress
Increased ADL (Activity Daily Living)
Increased quality of life

Facts
Lifestyle factor:
Energy level

Body oxygen < 30 s

Medium, low, or very low

Body oxygen > 50 s

High

Desire to exercise

Not strong, but possible

Craving and joy of exercise

Intensive exercise with nose

breathing
Typical mind states

Hard or impossible

Easy and effortless

Confusion, anxiety,
depression

Focus, concentration, clarity

Craving for coffee, sugar and

junk foods

Present

Absent

Addictions to smoking,
alcohol, and drugs

Possible

Absent

Desire to eat raw foods

Weak and rare

Very common and natural

Correct posture

Rare and requires efforts

Natural and automatic

Sleep

Often of poor quality; > 7

hours

Excellent quality; < 5 hours

naturally

Indications
Acute and/or chronic lung disease
COPD
Pneumonia
Atelectasis
Pulmonary Embolism
Acute impaired respiratory
Pain on thorax and abdomen area (post trauma or post surgical)
Airway obstruction due to bronchospasm or secretions restrain.
CNS disease leading to muscle weakness :
High spinal cord injury.
Acute or chronic Progressive Myophatic , or neuropathic disease.
Severe Abnormalities Orthopedic berat that affects respiratory

function, such as scoliosis and kiposis.

Stress treatment.

Breathing techniques

When
created
Who
created

Hatha yoga

Pursed lip
breathing

Strelnikova
breathing
gymnastic

Buteyko
breathing
method

Frolov
breathing
device

Prior to 16-th
century
Yogi
Swatmarama

Before 1910

Late 1930s-early
1970s
Alexandra
Nikolaevna
Strelnikova

1960s

1990s

Number of Many tens of

students millions
Which
Chronic
condition diseases

Patients

Konstantin
Vladimir
Pavlovich Buteyko Frolov &
Eugeniy
Kustov
>100,000
>50,000 (mainly in >500,000 (half in >1,000,000
(worldwide)
Russia)
Russia)
(over 95% in
Russia)
COPD, asthma, Some chronic
Chronic diseases Chronic
asthma in
diseases
diseases
children,
emphysema,
stroke,
autonomic
failure,

RESPeRATE
guidedbreathing
device
1990s
Benjamin
Gavish

100,000 (in
western
countries)
Hypertension

How to choose proper breathing techniques?

Proper breathing techniques should satisfy certain

criteria in order to be useful for health of the

breathing retraining student.
One of the things to consider is that the general

approach of any breathing technique should take our

automatic or unconscious breathing pattern 24/7
into consideration, and not only suggest doing some
breathing exercises.

Condition

Number of
people
>400
22
11
11

All references

Normal breathing
Healthy Subjects
Heart disease
Heart disease
Pulm hypertension

Minute
ventilation
6 L/min
6-7 L/min
15 (4) L/min
16 (2) L/min
12 (2) L/min

Cancer
Diabetes
Diabetes
Asthma
COPD
COPD
Sleep apnea
Liver cirrhosis
Hyperthyroidism
Cystic fibrosis
CF and diabetes*
Epilepsy
CHV
Panic disorder

12 (2) L/min
12-17 L/min
15 (2) L/min
13 (2) L/min
14 (2) L/min
12 (2) L/min
15 (3) L/min
11-18 L/min
15 (1) L/min
15 L/min
10 L/min
13 L/min
13 (2) L/min
12 (5) L/min

40
26
45
16
12
10
20
24
42
15
7
12
134
12

Travers et al, 2008

Bottini et al, 2003
Tantucci et al, 2001
Chalupa et al, 2004
Palange et al, 2001
Sinderby et al, 2001
Radwan et al, 2001
Epstein et al, 1998
Kahaly, 1998
Fauroux et al, 2006
Ward et al, 1999
Esquivel et al, 1991
Han et al, 1997
Pain et al, 1991

Medical textbooks
Results of 14 studies
Dimopoulou et al, 2001
Johnson et al, 2000
D'Alonzo et al, 1987

Breathing techniques should also have answers to the

following questions:
What is ideal breathing (or the ideal unconscious
breathing pattern) for maximum body-oxygen content?
Note that it is not enough to only think about the
maximum oxygen content in the lungs or arterial blood.
Oxygen is required in all body cells.
Which breathing techniques improve or increase oxygen
content in cells?
What are the common breathing patterns and what are
their effects on body-oxygen content?
What is the exact direction of the breathing techniques?
What are the effects of lifestyle factors?

 Breathing techniques can improve one's health only

if they make one's breathing pattern after the

breathing session lighter and slower in terms of
minute ventilation.

General Principles
1.
2.
3.

4.
5.

6.
7.

If possible, do in quiet place without any interference

or noisy
Explain to patient what the aims and benefits breathing
exercise.
Place patient in a proper positions, comfort, and relax.
Observe and evaluate patient for normal breathing
patterns on activity and relax situation.
Teach relaxation techniques if needed.
Show patient the goal breathing pattern.
Ask patient to show normal breathing patterns in
various positions and conditions, even in activity or rest

Attention!
Dont do force expiration

Dont do prolonged expiration

Dont use accessory muscles when initial inspiration
3 or 4 times inspiration-expiration in one session.

Thorax Mobilisation Exercise

Definition

An active movement exercise on trunk and extremities that do with

deep breathing.
Aims

a. maintain and improves mobility of trunk and shoulder that affects

respiratory conditions.
b. strengthen deep inspiration and expiration.
Specific Exercises :
a. Mobilisation on one side chest.
b. Mobilisation on upper chest and strech pectoralis muscles.
c. Mobilisation on upper chest dan shoulders.
d. Increase expiration along deep breathing.
Addition Activity

1. Posture correction
2. Manual stretching on trunk
3. ROM exercise to improves joints movements

Pursed-lip breathing
Pursed-lip breathing (mengeluarkan napas

perlahan seperti bersiul atau melalui peluit)

Pursed-lip breathing dapat membantu
mengontrol frekuensi pernafasan (rate
respirasi) dan napas pendek (shortness of
breath). Membantu memasukkan udara kedalam
paru dengan demikian menyertakan energi untuk
bernapas.
Teknik ini akan membantu mengontrol dan juga
akan membantu lebih mudah beraktifitas

Pursed-lip breathing

Goal & Benefits:

Improves ventilation
Decreases air trapping in the lungs
Decreases the work of breathing
Improves breathing patterns
Relieves shortness of breath
Causes general relaxation

Pursed-lip breathing

How is the process?

Prolongs exhalation slows down the breathing rate.
Causes a slight back pressure in the lungs that keeps
the airways open longer.
Improves the movement of old air out of the lungs
and allows for more new air to get into the lungs.

Pursed-lip breathing

Procedure
REMEMBER Exhalation must be 3-4 times longer than inhalation,

so do not force the air out.

1. Sit down but sit up straight, relaxed.
2. Breath in, preferably through the nose.
3. Purse lips slightly (as if to whistle).
4. Breath out slowly through pursed lips.
5. Do not force the air out.

Practice this procedure 4-5 times a day initially to get the correct

breathing pattern. You should utilize pursed lip breathing when you
are experiencing shortness of breath either at rest or with exertion, or
if you feel nervous or apprehensive.

IMPORTANT You may experience a light-headed feeling while doing

pursed lip breathing. This indicates that you are over ventilating
yourself and you should breathe more slowly.

Abdominal Breathing Technique

Abdominal breathing is also known as diaphragmatic breathing.
The diaphragm is a large muscle located between the chest and the

abdomen. When it contracts it is forced downward causing the

abdomen to expand. This causes a negative pressure within the
chest forcing air into the lungs. The negative pressure also pulls
blood into the chest improving the venous return to the heart.

This leads to improved stamina in both disease and athletic activity.

Like blood, the flow of lymph, which is rich in immune cells, is also
improved. By expanding the lung's air pockets and improving the
flow of blood and lymph, abdominal breathing also helps prevent
infection of the lung and other tissues.

But most of all it is an excellent tool to stimulate the relaxation

response that results in less tension and an overall sense of well

being.

Abdominal Breathing Tech

Should be done twice a day or whenever you find your mind

dwelling on upsetting thoughts or when you are experiencing pain.

Place one hand on your chest and the other on your abdomen.

When you take a deep breath in, the hand on the abdomen should
rise higher than the one on the chest. This insures that the
diaphragm is pulling air into the bases of the lungs.

After exhaling through the mouth, take a slow deep breath in

through your nose imagining that you are sucking in all the air in
the room and hold it for a count of 7 (or as long as you are able, not
exceeding 7)

Slowly exhale through your mouth for a count of 8. As all the air is

released with relaxation, gently contract your abdominal muscles to

completely evacuate the remaining air from the lungs. It is
important to remember that we deepen respirations not by inhaling
more air but through completely exhaling it.

Abdominal Breathing Tech..

Repeat the cycle four more times for a total of 5 deep breaths and try to

breathe at a rate of one breath every 10 seconds (or 6 breaths per minute).
At this rate our heart rate variability increases which has a positive effect
on cardiac health.

In the beginning, practice this procedure for 5-10 minutes. You can

gradually increase the length of your exercises period and perhaps the
effort required by placing a book on the abdomen.

Once you feel comfortable with the above technique, you may want to

incorporate words that can enhance the exercise. Examples would be to say
to yourself the word, relaxation (with inhalation) and stress or anger (with
exhalation). The idea being to bring in the feeling/emotion you want with
inhalation and release those you don't want with exhalation.

After you feel comfortable with this procedure, practice while sitting in a

chair or while standing.

The Bellows Breathing Technique

(The Stimulating Breath)
This is one of yogic technique
This can be used to help stimulate energy when needed
This exercise can be used each morning upon awakening or when needed for an

energy boost.

Sit in a comfortable up-right position with your spine straight.

With your mouth gently closed, breath in and out of your nose as fast as possible. To

give an idea of how this is done, think of someone using a bicycle pump (a bellows)
to quickly pump up a tire. The upstroke is inspiration and the downstroke is
exhalation and both are equal in length.
The rate of breathing is rapid with as many as 2-3 cycles of inspiration/expiration
per second.
While doing the exercise, you should feel effort at the base of the neck, chest and
abdomen. The muscles in these areas will increase in strength the more this
technique is practiced. This is truly an exercise.
Do this for no longer than 15 seconds when first starting. With practice, slowly
increase the length of the exercise by 5 seconds each time. Do it as long as you are
comfortably able, not exceeding one full minute.
There is a risk for hyperventilation that can result in loss of consciousness if this
exercise is done too much in the beginning. For this reason, it should be practiced in
a safe place such as a bed or chair.

The Bellows Breathing Tech

Steps :
Sit in a comfortable up-right position with your spine straight.
With your mouth gently closed, breath in and out of your nose as fast as possible.
To give an idea of how this is done, think of someone using a bicycle pump (a
bellows) to quickly pump up a tire. The upstroke is inspiration and the downstroke
is exhalation and both are equal in length.
The rate of breathing is rapid with as many as 2-3 cycles of inspiration/expiration
per second.
While doing the exercise, you should feel effort at the base of the neck, chest and
abdomen. The muscles in these areas will increase in strength the more this
technique is practiced.
Do this for no longer than 15 seconds when first starting. With practice, slowly
increase the length of the exercise by 5 seconds each time. Do it as long as you are
comfortably able, not exceeding one full minute.
There is a risk for hyperventilation that can result in loss of consciousness if this
exercise is done too much in the beginning.
For this reason, it should be practiced in a safe place such as a bed or chair.

Active Cycle of Breathing Techniques

(ACTB)
ACBT is a technique which uses breathing exercises

to remove phlegm from your lungs.

ACBT can be performed in sitting, lying or side-lying
positions. Initially you should start in a sitting
position until you are comfortable and confident to
try different ones.
ACBT uses an alternating depth of breathing to move
phlegm from the small airways at the bottom of your
lungs to the larger airways near the top where they
can be cleared more easily with huffing/coughing.

ACTB

General Principles
Try to maintain a good breathing pattern with
relaxed shoulders and neck.
Try to breathe in through your nose and out through
your mouth. Breathing should be slow, like sighing
out. This can help minimise any wheezing.
Try to remember the principles of Diaphragmatic
breathing.

ACTB

Combine 2 breathing techniques:

1) Deep Breathing Exercise
Take 3-4 deep breaths in allowing the lower rib cage

to expand.
Try to ensure your neck and shoulders remain
relaxed.
At the end of the breath in, hold the air in your lungs
for 3 seconds (This is an inspiratory hold).
Let the air out gently.

ACTB

2) Forced Expiratory Technique

1 or 2 huffs combined with diaphragmatic breathing.
Take half a breath in and blow the air out quickly through
an open mouth.
Follow this with diaphragmatic breathing.
Repeat.
As the phlegm moves into the larger airways take a deep
breath in and blow it out again through an open mouth,
huff which should help clear the phlegm out of the back of
your throat.

ACTB

A typical cycle of ACBT consist of: Diaphragmatic

breathing
1) 4 deep breaths (+/- 3 second inspiratory hold)
2) Diaphragmatic breathing4 deep breaths (+/- 3
second inspiratory hold)
3) Diaphragmatic breathing
4) Forced expiratory technique

Inspiratory Muscle Training

Inspiratory Muscle Training for Sports Performance, Asthma,

COPD, Cystic Fibrosis and Other Conditions

Clinical trials have found benefits of inspiratory muscle training on

sports performance in rowers (Volianitis et al, 2001; Klusiewicz et

al, 2008; Riganas et al, 2008), cyclists (Romer et al, 2002a; Romer
et al, 2002b), and swimmers (Kilding et al, 2010; Wells et al, 2005;
Mickleborough et al, 2008)

Clinical trials also tested the effects of inspiratory muscle training

on asthma, COPD, bronchiectasis, cystic fibrosis, diabetes, pre- and

postsurgery, chronic heart failure, ischaemic heart disease, stroke,
ventilator weaning, and neuromuscular diseases

The goal of respiratory and inspiratory muscle training is to

improve oxygen transport.

Inspiratory Muscle Training

Most of these studies have demonstrated the

following benefits:
1) reduction in dyspnea (a sensation of
breathlessness) during exercise in athletes and at
rest or during very light exercise in patients
2) increase in the force of inspiratory muscles during
intensive exercise training for athletes
3) increased endurance in patients with
improvements in some lung function parameters
4) reduced medication and improved quality of life in
people with chronic diseases.

 Training inspiratory muscles can be an independent purpose

for breathing exercises.

This training (improved strength of the inspiratory muscles,
does not address the mechanism of reduced oxygen transport
during dyspnea (breathlessness or shortness of breath).
Therefore, the main physiological potential and benefit of
breathing training is improved breathing patterns, VO2max
and body oxygenation test results at rest (slower and lighter
breathing with reduced respiratory frequency and minute
ventilation rate).
All these effects can be achieved with longer exhalations
during inspiratory muscle training. Lifestyle corrections will
improve benefits of inspiratory muscle training as well

COUGHING
HOW TO TEACH
AN EFFECTIVE COUGH

COUGH
An effective cough is needed to eliminate respiratory obstructions (especially

caused by secretions retention) and keep the lungs clear.

The Normal Cough Pump
A cough may be reflexive or voluntary
When a person coughs, a series of actions occurs as follows:
Deep inspiration occurs Glottis closes Vocal cords tighten Abdominal
muscles contract diaphragm elevates causing an increase in intrathoracic
and intra-abdominal pressures Glottis opens Explosive expiration of air
occurs.
Under normal conditions, the cough pump is effective to the 7th generation of

bronchi. (There are a total of 23 generations of bronchi in the tracheobronchial

tree.)
Ciliated epithelial cells are present up to the terminal bronchiole and raise
secretions from the smaller to the larger airways in the absence of pathology.

Factors that Decrease the Effectiveness of the

Cough Mechanism and Cough Pump

The effectiveness of the cough mechanism can be

compromised for a number of reasons including the
following:
Decreased inspiratory capacity
2. Inability to forcibly expel air
3. Decreased action of the cilia in the bronchial tree.
4. Increase in the amount or thickness of mucus.
1.

1. Decreased Inspiratory Capacity...

Inspiratory capacity can be reduced because of:
Pain due to acute lung disease
Rib fracture
Trauma to the chest
Recent thoracic or abdominal surgery
Weakness of the diaphragm or accessory muscles of

inspiration as a result of a high spinal cord injury or

neuropathic or myopathic disease
Postoperatively, the respiratory center may be
depressed as the result of general anesthesia, pain, or
medication.

2. Inability to Forcibly Expel Air

The following factors contribute to a weak cough:
A spinal cord injury above T12 and myopathic

disease, such as muscular dystrophy, cause

weakness of the abdominal muscles, which are
vital for a strong cough.
Excessive fatigue as the result of critical illness
A chest wall or abdominal incision causing pain
A patient who has had a tracheostomy, even when
the tracheostomy site is covered.

3. Decreased Action of The Cilia in The Bronchial Tree

Action of the ciliated cells may be compromised
because of:
Physical interventions such as general anesthesia

and intubation
Pathologies such as COPD including chronic
bronchitis
Smoking also depresses the action of the cilia.

4. Increase in the amount or thickness of mucus

Occurs in:
Pathologies (e.g., cystic fibrosis, chronic

bronchitis) and pulmonary infections (e.g.,

pneumonia)
Intubation irriates the lumen of the airways and
causes increased mucus production
Dehydration thickens mucus.

Cough as therapy
Generate pressures >80 mmHg
Mobilises and expels secretions
High pressures may assist in
expanding collapsed alveoli
Comparable pressures delivered
by positive pressure devices are
associated with barotrauma
Not a problem with controlled
cough manoeuvres
Fink 2007

Cough as therapy
In patients with unstable airways,
The high pressure and flow during a normal cough can
cause dynamic compression of the airways
Air and secretion trapping
reduced expiratory flow
Limited effectiveness of cough

Patients with unstable airways should avoid coughing

as far as possible.

HOW TO COUGH EFFECTIVELY

1) Assess the patients voluntary or reflexive cough.
2) Use patients brochodilators (inhaler) prior to coughing.
3) Drink a warm liquid before patient trying to cough (this will help to liquefy and loosen sputum)
4) Use the controlled cough technique below:
Sit upright on a chair or side of bed and bend forward slightly, comfort, and relax.
The patients neck should be slightly flexed to make coughing more comfortable.
Inhale slowly through patients nose using your diaphragmatic breathing

Hold the deep breath for 2-3 seconds.

Cough twice with mouth slightly open.
Demonstrate the proper muscle action of coughing (contraction of the abdominals). Have the

patient place the hands on the abdomen and make three huffs with expiration to feel the
contraction of the abdominals. Have the patient practice making a K sound to experience
tightening the vocal cords, closing the glottis, and contracting the abdominals.
Pause.
Inhale by sniffing gently. Then take a rest.
Repeat again if needed.
If there is little or no sputum, dont keep trying to cough something up. Try again later.
Avoid cough, cough, cough, cough.... (continuous cough). This will only tire you out and cause
breathlessness.

Precautions for Teaching an Effective Cough

Never allow a patient to gasp in air, because this increases the work (energy

expenditure) of breathing, causing the patient to fatigue more easily. It also

increases turbulence and resistance in the airways, possibly leading to increased
bronchospasm and further constriction of airways.
A gasping action also may push mucus or a foreign object deep into air passages.
Avoid uncontrolled coughing spasms (paroxysmal coughing).
Avoid forceful coughing if a patient has a history of a cerebrovascular accident or

an aneurysm. Have these patients huff several times to clear the airways, rather
than cough.
Be sure that the patient coughs while in a somewhat erect or side-lying posture.

Others..
Additional Techniques to Facilitate a Cough and

Improve Airway Clearance

To maximize airway clearance, several techniques can be
used to stimulate a stronger cough, make coughing more
comfortable or improve the clearance of secretions.

Manual-Assisted Cough

If a patient has abdominal weakness (e.g., as the result of a

mid-thoracic or cervical spinal cord injury), manual
pressure on the abdominal area assists in developing
greater intra-abdominal pressure for a more forceful cough.
Manual pressure for cough assistance can be applied by the
therapist or the patient.

Others ...
Therapist-Assisted Techniques
o With the patient in a supine or semireclining position, the therapist places

o
o

the heel of one hand on the patients abdomen at the epigastric area just
distal to the xiphoid process.
The other hand is placed on top of the first, keeping the fingers open or
interlocking them
After the patient inhales as deeply as possible,the therapist manually assists
the patient as he or she attempts to cough. The abdomen is compressed
with an inward and upward force, which pushes the diaphragm upward to
cause a more forceful and effective cough.
This same maneuver can be performed with the patient in a chair
The therapist or family member can stand in back of the patient and apply
manual pressure during expiration.
P R E C A U T I O N : Avoid direct pressure on the xiphoid process during
the maneuver.

Others...
Self-Assisted Technique
o While in a sitting position, the patient crosses the arms across the
abdomen or places the interlocked hands below the xiphoid process
o After a deep inspiration, the patient pushes inward and upward on

the abdomen with the wrists or forearms and simultaneously leans

forward while attempting to cough

Terima kasih
Surely.. We Can Be
Excellent With Morality