BREATHING

 The process that moves air in and out of

the lungs called breathing or pulmonary
ventilation.

 Breathing is only one of the processes

that deliver oxygen to where it is needed
in the body and remove carbon dioxide.
ORGANS THAT INVOLVED IN
BREATHING
 Nose
 Trachea
 Bronchi
 Bronchioles
 Lungs
 Muscles along with diaphragm
 NOSE

 The beginning of the respiratory tract.

 Function :-
 Warm

 Moisten

 Filter fine particles

 TRACHEA

 Tube like structure.

 Function :-
 Responsible for transporting air for respiration from the
larynx to the bronchi.
 DIAPHRAGM

 Is a sheet of internal skeletal muscle.

 It separates the thoracic cavity containing
heart & lungs , from the abdominal cavity
 LUNGS

 The lungs are a pair of spongy, air-filled organs

located on either side of the chest (thorax).
 BREATHING PROCESS

 Breathing starts at the nose. You inhale air into your nose, and
it travels down the back of your throat and into your windpipe
or trachea.
 Trachea then divides into air passages called bronchial tubes.
 Bronchial tubes pass through the lungs, they divided into
smaller air passages called bronchioles or bronchial tree.
 The bronchioles end in tiny balloon-like air sacs called alveoli.
 The body has over 300 million alveoli.
 The alveoli are surrounded by a mesh of tiny blood vessels
called capillaries.
 Here, oxygen from the inhaled air passes through the alveoli
walls and into the blood and carbon dioxide passes out of the
blood into the air in the alveoli.
MUSCLES OF INSPIRATION
 Diaphragm (primary m/s of inhale)
 Scalene (elevates 1st two ribs)
 Sternocleidomastoid (elevates sternum)
 Serratus anterior( supporting m/s)
 External intercostal( moves upward and
outward)

MUSCLES OF EXPIRATION
 External oblique
 Rectoabdominal
 Internal oblique
 Transverse abdominal
BREATHING EXERCISES
 Breathing ex and ventilatory training are the
fundamental interventions for the prevention for
acute and chronic pulmonary disease patients
with high spinal cord lesion and who underwent
thoracic and abdominal surgery and bedridden
patients.
 Studies indicate that breathing exercise and
ventilatory training have affect and alter a
patients rate and depth of ventilation ,so these
technique is used to improve the pulmonary
status and increase patients overall endurance.
GOALS OF BREATHING EXERCISE

 Improve ventilation
 Increase the effectiveness of cough and promote
airway clearance
 To prevent post operative pulmonary
complications
 To improve the strength endurance coordination
of the muscles of ventilation
 Maintain and improve chest and thoracic spine
mobility
 Promote relaxation and relive stress
 To teach the patient how to deal with episodes of
dyspnea
Cont…

 Assisting in removal of secretions.

 Correct abnormal breathing patterns and decrease
the work of breathing.
 Aid in bronchial hygiene---Prevent accumulation of
pulmonary secretions, mobilization of these
secretions, and improve the cough mechanism.
 Principles

 Area of exercises
 Explanation & Instructions to the patient
 Patients position
 Evaluate the patient
 Demonstration of exercise
 Patient practice
 GUIDELINE FOR TEACHING
BREATHING EXERCISES

 Choose a quiet area-to get a proper interaction with

minimal distraction
 Explain the patient about the aim and how it works
for his impairment
 Have the pat: in relaxed position and loosen the
clothes, make him in semi-fowlers position with head
and trunk elevated approx: 45˚ (total support to the
head and trunk and flexing the hip and knees with
pillow support) the abdominal muscle become
relaxed.
 Other positions, such as supine, sitting, or standing,
may be used as the patient progresses during
treatment.
 Observe and access the patients spontaneous
breathing pattern while at rest and during activity
 Determine whether Rx is indicated or not
 If necessary teach the patient relaxation techniques,
relax the muscles of upper thorax neck and shoulder
to minimize the use of accessory muscle work.
 Special attention on sternocleidomastoids, upper
trapezius and levator scapulae.
 Demonstrate the breathing pattern to the patient
 Have the patient practice the correct technique in
verity of positions at rest and with activity.
 PRECUATIONS

 Never allow the patient to force expiration-it may

increase the turbulence in the air way which leads to
bronchospasm and airway resistance.
 Avoid prolonged expiration-it cause the patient to
gasp with the next inspiration and the breathing
pattern become irregular and inefficient.
 Do not allow the patient to initiate inspiration with
accessory muscles and upper chest ,advise him that
upper chest should be quiet during breathing
 Allow the patient to perform deep breathing only for
3-4 times (inspiration and expirations) to avoid
Hyperventilation.
 INDICATIONS
 Cystic fibrosis
 Bronchiectasis
 Atelectasis
 Lung abscess
 Pneumonias
 Acute lung disease
 For patients with a
high spinal cord
lesion/ spinal cord
injury, myopathies etc.
 COPD –emphysema,
chronic bronchitis
 After surgeries (thoracic
or abdominal surgery)
 For patients who must
remain in bed for an
extended period of
time.(obstruction due to
retained secretions)
 As relaxation procedure.
 CONTRAINDICATIONS

 Severe pain and discomfort

 Acute medical or surgical emergency
 Patients with reduced conscious level
 Increased ICP
 Unstable head or neck injury
 Active hemorrhage with hemodynamic instability or
hemoptysis
 Flail chest
 Uncontrolled hypertension
 Anticoagulation
 Rib or vertebral fractures or osteoporosis
 Acute asthma or tuberculosis
 Patients who have recently experienced a heart
attack.
 Patients with skin grafts or spinal fusions will have
undue stress placed on areas of repair.
 Bony metastases, brittle bones, bronchial
hemorrhage, and emphysema are contraindications
for undue stress to the thoracic area.
 Verify that patient has not eaten for at least one hour.
 Recent (within one hour) meal or tube feed
 Untreated pneumothorax
TYPES OF BREATHING EXERCISES

 Diaphragmatic breathing
 Glossophryngeal breathing
 Pursed lip breathing
 Segmental breathing(costal expansion
exercise)
a) Apical breathing
b) Lateral costal expansion
c) Posterior basal expansion
DIAPHRAGMATIC BREATHING

 Diaphragm is the primary muscle for

breathing (inspiration)
 Diaphragm controls breathing at an
involuntary level ,a patient with primary
pulmonary disease like COPD can be
taught breathing control by optimal use of
diaphragm and relaxation of accessory
muscles.
 Diaphragmatic breathing ex: are also use
to mobilize lung secretion in PD.
 PROCEDURE

 Prepare the patient in relaxed and comfortable

position in which the gravity assist the
diaphragm such as semifowlers position.
 If you notice any accessory muscle activation
stop him and do relaxation techniques (shoulder
roll or shrugs coupled with relaxation)
 Place your hands over the rectus abdominis just
below the ant: costal margin ask the patient to
breath slowly and deeply via nose by keeping the
shoulder relaxed and upper chest quiet allowing
the abdominal to rise now ask him to slowly let
all the air out using controlled expiration
through mouth.
 Have him to practice this for 2-4 times if he finds any
difficulty in using diaphragm have the patient inhale
several times in succession through the nose by using
sniffing action this facilitates the diaphragm
 For self monitor have the patients hand over the ant
costal margin and feel the movt: (hand rise and fall)
by placing one hand over abdomen he can also feel the
contraction of abdominal muscles which occurs with
controlled expiration or coughing
 After he understands and able to do the controlled
breathing using a diaphragmatic pattern keep the
shoulder relaxed and practice in verity of positions
(supine sitting standing) and during activity (walking
and climbing stair).
 Resisted diaphragmatic breathing
 PT use small weight, such as sandbag to strengthen
and improve the endurance of the diaphragm
 Have the patient in a head up position
 Place a small weight (1.30- 2.20 kg or 3-5 lb) over the
epigastric region of his abdomen.
 Tell the patient to breath in deeply while trying to
keep the upper chest quiet
 Gradually increase the time that the patient breaths
against the resistance of weight
 Weight can be increased when he can sustain
diaphragmatic breathing pattern with out the use of
any accessory muscles of inspiration for 15minuts.
 Glossopharyngeal breathing

 It is a means of increasing a patients inspiratory capacity

when there is a severe weakness of the muscle of
inspiration
 It is taught to patients who have difficulty in deep
breathing.
 It is used primarily for ventilatory dependent patients
due to absent or incomplete innervation of diaphragm
because of high cervical cord injury or neuromuscular
disorders.
 Glossopharyngeal breathing with inspiratory action of
neck muscles can reduce ventilatory dependence or can
be used as an emergency procedure for malfunctioning
of ventilator.
 PROCEDURE

 Patient take several gulp of air (6 to 10), then by closing the

mouth the tongue pushes the air back and trap it in the pharynx
the air is then forced to lungs when the glottis is opened.

 This increases the depth of inspiration & patient’s inspiratory &

vital capacity.
 PURSED LIP BREATHING

 Pursed-lip breathing is a strategy that involves

lightly pursing the lips together during controlled
exhalation.
 Taught to patients with COPD to deal with episodes
of dyspnea.
 It helps to Improves ventilation and Releases
trapped air in the lungs.
 Keeps the airways open longer and Prolonged
exhalation slows the breathing rate.
 It moves old air out of the lungs and allow new air to
enter the lungs.
 PROCEDURE

 Patient in a comfortable position and relaxed, explain the

patent about the expiration phase (it should be relaxed and
passive).
 Abdominal muscle contraction must be avoided (therapist hand
over the patients abdominal to check for contraction).
 Ask the patient to breathe in slowly and deeply through the
nose and then breathe out gently through lightly pursed lips
(blowing on and bending the flame of a candle ).
 By providing slight resistance an increased positive pressure
will generate with in the airway which helps to keep open small
bronchioles that otherwise collapse.
 It can be applied as a 3-5 minutes “rescue exercise” or an
Emergency Procedure to counteract acute exacerbations or
dyspnea (shortage of air or breathlessness) in COPD and
asthma.
 SEGMENTAL BREATHING

 It is performed on a segment of lung, or a section of

chest wall that needs increased ventilation or
movement.
 Hypoventilation occur in certain areas of the lungs
because of chest wall fibrosis, pain after surgery,
atelectasis , trauma to chest wall, pneumonia and
post mastectomy scar
 Therefore, it will be important to emphasize
expansion of such areas of the lungs and chest wall
 ADVANTAGES OF SEGMENTAL BREATHING

 Prevent accumulation of pleural fluid and secretions

 Decreases paradoxical breathing
 Decrease panic episode
 Improve chest mobility
 Techniques

 Lateral costal expansion

 Posterior basal expansion
 Right middle lobe or lingula expansion
 Apical expansion
 Lateral costal expansion

 This is sometimes called lateral basal expansion and may

be done unilaterally or bilaterally.
 The patient may be sitting or in a hook lying position.
 Place your hands along the lateral aspect of the lower
ribs.
 Ask the patient to breathe out, and feel the rib cage move
downward and inward.
 As the patient breathes out, place firm downward
pressure into the ribs with the palms of your hands.
 Just prior to inspiration, apply a quick downward and
inward stretch to the chest. This places a quick stretch
on the external intercostals to facilitate their contraction.
These muscles move the ribs outward and upward
during inspiration.
 Apply light manual resistance to the lower ribs to
increase sensory awareness as the patient breathes in
deeply and the chest expands.
 When the patient breathes out, assist by gently
squeezing the rib cage in a downward and inward
direction.
 The patient may then taught to perform the
maneuver independently, ask him to apply resistance
with his hand or with a towel.
BELT EXERCISES TO REINFORCE LATERAL COSTAL
BREATHING
(A) by applying resistance during inspiration
(B) by assisting with pressure along the rib cage during expiration.
Posterior basal expansion
 This form of segmental breathing is important for
the post surgical patients who is in bed in a semi-
reclining position for an extended period of time.
 Secretion often accumulate over the posterior
segments of lower lobes.

Procedure
 Have the patient sit and lean forward on a pillow,
slightly bending the hips.
 Place the PT hand over the posterior aspect of the
lower rib and do the same procedure in lateral costal
expansion.
Right middle lobe or lingula expansion
 While the patient in sitting place your hand at either
the right or left side of the patient’s chest just below
the axilla, and follow the same procedure in lateral
costal expansion.
 Apical expansion