Breathing exercises, lung expansion and breathing retraining

1Types and aims

2Diaphragmatic breathing and diaphragm recruitment (W18; 7 marks in S21)

Technique

1. Position: half-lying with the head and knees supported (the diaphragm is dome-shaped and at a good length here); later sitting, standing and walking.
2. Relax the shoulders and upper chest. The therapist's (or patient's) hand rests on the upper abdomen just below the front of the ribs.
3. Breathe in slowly through the nose, letting the hand rise as the abdomen moves out; the upper chest stays quiet.
4. Breathe out gently and relaxed; do not force the air out.
5. About 5–10 breaths at a time, several times a day, then rest with normal breathing (watch for dizziness from over-breathing).

Recruiting and strengthening the diaphragm (S21)

• Facilitation: a quick stretch inwards and upwards on the upper abdomen at the end of expiration, then light resistance as the patient breathes in; a short sniff in also recruits the diaphragm strongly.
• Positioning: half-lying or supine first (easiest), progressing to sitting and standing as it gets stronger; in tetraplegia an abdominal binder helps in sitting.
• Resistance: manual resistance on the upper abdomen; the classic method of small weights on the abdomen in supine; best evidence for inspiratory muscle training with a threshold device at 30% or more of maximal inspiratory pressure.
• Function: diaphragmatic breathing during walking, stairs and speech; combine with breathing control.
• Indications: post-operative patients, neuromuscular disease and spinal cord injury (the diaphragm may be the main breathing muscle left), weaning from the ventilator, dysfunctional upper-chest breathing.

3Pursed-lip breathing (3 marks in S20, W21, W22)

Breathe in through the nose; breathe out slowly through loosely pursed lips (as if blowing on hot tea), taking about twice as long to breathe out as to breathe in, without forcing.

• Effects and rationale: back-pressure splints small airways open during expiration, so less air is trapped; breathing becomes slower and deeper; tidal volume and oxygen saturation improve; breathlessness and anxiety fall; it helps during walking and stairs.
• Most patients with COPD find it themselves. More detail on the COPD page.

4Thoracic expansion (localised) exercises

• Hand placement over the area to be expanded gives feedback: lateral costal (lower ribs at the side), posterior basal (lower ribs at the back), apical (below the clavicle), unilateral or bilateral.
• Technique: gentle pressure at the end of expiration; ask the patient to "breathe into my hand"; hold for 3 seconds at the top; relaxed breath out. 3–4 breaths, then breathing control.
• Uses: after surgery, pleural effusion and empyema, collapse, chest wall stiffness, scoliosis (concave side).

5Lung expansion therapy: SMI and incentive spirometry

• Sustained maximal inspiration (SMI): a slow, deep breath in to the top of the lungs, held for 3–5 seconds, then a relaxed breath out. The hold lets air reach collapsed areas through collateral channels.
• Incentive spirometer: a device that shows the breath as a rising piston or ball, encouraging a slow, deep SMI. Volume-oriented devices (piston shows volume) encourage slow deep breaths better than flow-oriented ones (balls rise with flow, which tempts patients to breathe fast).
• Dose: commonly 5–10 breaths every hour while awake after surgery, with early walking.
• Not suitable when the patient cannot be taught or supervised, will not co-operate, or cannot breathe deeply enough to use it (vital capacity below about 10 mL/kg or inspiratory capacity below a third of predicted); then use IPPB or CPAP as the team decides.
• Other lung expansion methods: deep breathing exercises and early mobilisation (first choice), PEP, IPPB, CPAP by mask.

6Exercises to increase thoracic wall mobility (3 marks in W17)

1. Trunk rotation with breathing: sitting, hands behind the head or arms crossed; rotate the trunk and breathe out, return to the middle and breathe in. 10 each way.
2. Side-bending with arm overhead: sitting, lift one arm overhead and bend to the other side while breathing in, to stretch the lengthened side. Useful after thoracotomy, pleural disease and in scoliosis.
3. Bilateral arm elevation with breathing: raise both arms forward and up while breathing in; lower them while breathing out.
4. Pectoral stretch: in a doorway or corner, arms at shoulder height, lean forward and breathe in deeply; hold 20–30 seconds.
5. Thoracic extension: lying over a rolled towel placed across the upper back, arms overhead, deep breaths; or sitting, hands behind the head, extend over the chair back.

Uses: ankylosing spondylitis, kyphosis, scoliosis, after thoracic surgery and burns of the chest, long-standing COPD posture.

7Breathing retraining (7 marks in S23)

Breathing retraining teaches a slower, calmer, more efficient breathing pattern to people whose breathing has become dysfunctional: fast, upper-chest, mouth breathing with frequent sighs or over-breathing (hyperventilation). It is common in asthma and with anxiety, and causes breathlessness, chest tightness, dizziness and tingling out of proportion to lung disease. The Nijmegen questionnaire helps screen for it.

Components

• Education: how over-breathing lowers CO₂ and causes the symptoms; reassurance.
• Nose breathing at rest and during light activity (warms and humidifies air, slows breathing).
• Lower-chest (diaphragmatic) breathing with relaxed shoulders.
• Slower rate and smaller, gentler breaths; a pause after breathing out.
• Relaxation and control of sighs and yawns; speech with breathing (phrasing).
• Practice: about 10–15 minutes once or twice a day, then in daily activities (Papworth method; Buteyko-based methods add reduced-breathing exercises).

Evidence: in asthma, breathing exercises improve quality of life and symptoms (Cochrane, 2020), and a physiotherapy breathing retraining programme, including a DVD version, improved asthma quality of life in a large UK trial (2018). They do not replace inhaled medicines.

8Exam corner

Past questions (MUHS, 2016–2026)

• 7-mark questionsDiaphragm recruitment and strengthening (S21). Breathing retraining (S23).
• 3-mark questionsThree exercises to increase thoracic wall mobility (W17). Diaphragmatic breathing exercises (W18). Effects of pursed-lip breathing (S20). Rationale of pursed-lip breathing in COPD (W21, W22).