Breathing Exercise.pptx

Breathing exercise are indicated in any pathological state, which cauuse the patient to use his muscles of respiration insufficiently resulting in an impotent of pulmonary function. Generally any patient with an abdominal pattern of breathing or increased work of breathing. Breathing exercise are form of exercise that can be used for a variety of health related reasons. improper breathing can upset the oxygen and carbon dioxide exchange and contribute to anxiety, panic attacks, fatigue, and other physical and emotion disturbance. diaphragmatic breathing is a type of breathing

1. BRE A THING EXERCISES 1 Dr. Minhaj Tahir MPT(CARDIO-THORACIC) Assistant professor RAMA UNIVERSITY, KANPUR

2. 2 I N TR OD U C TION It is also known as “Ventilatory Training” . Breathing exercises are fundamental interventions for the prevention or comprehensive management related to acute or chronic pulmonary disorders. An aspect of management to improve pulmonary status and to increase a Patient’s overall endurance and function during daily living activities.

3. 3 Simply, breathing exercise were designed to retrain the muscles of respiration, improve ventilation, lessen the work of breathing(WOB), and improve gaseous exchange and patient’s overall function in daily living activities. Depending on a patient’s underlying pathology and impairments, exercises are done to improve ventilation often are combined with medication, airway clearance, the use of respiratory therapy devices, and a graded exercise (aerobic conditioning) program. C ont.

4. 4 “GOALS OF BREATHING EXERCISES” Improve or redistribute ventilation. Increase the effectiveness of the cough mechanism & promote airway clearance. Prevent postoperative pulmonary complications. Improve the strength, endurance & coordination of the muscles of ventilation. Maintain or improve chest & thoracic spine mobility.

5. 6. Correct inefficient or abnormal breathing patterns & decrease the work of breathing. 7. Promote relaxation & relieve stress. 8. Teach the patient how to deal with episodes of dyspnea. 9. Improve a patient’s overall functional capacity for daily living, occupational, & recreational activities. 10. Aid in bronchial hygiene—Prevent accumulation of pulmo. secretions, mobilisation of these secretions, & improve the cough mechanism. C ont .

6. 6 I N D IC A TIO N S Cystic Fibrosis Bronchiectasis Atelectasis Lung abscess Neuromuscular diseases Pneumonia in dependent lung regions Acute or chronic lung diseases COPD

7. 7 For patients with high spinal cord lesion/ Deficits in CNS: SCI & Myopathies etc. Prophylactic care of preoperative patient with history of pulmonary disorders. Postoperative (thoracic & abdominal surgeries) Airway obstructions due to retained secretions. For long duration bedridden patients. As relaxed procedure. C ont .

8. 8 C O N TR A I N D IC A TIO N S Increased ICP Unstable head or neck injury Active haemorrhage with haemodynamic instability or haemoptysis Recent spinal injury Empyema Bronchoplueral fistula Flail chest

9. 9 Uncontrolled HTN Anticoagulants Rib or vertebral fractures or osteoporosis Untreated pneumothorax Bony metastases, brittle bones, bronchial haemorrhage & emphysema Recent(within 1 hour) meal or RT feed. C ont.

10. 10 GUIDELINES FOR BREATHING EXERCISES Choose a quiet area for instruction . Explain to the patient the aims & rationale of breathing exercises. The patient’s position is important in order to achieve relaxation, concentration & freedom of thoracic & abdominal movement.The position most commonly used are: Semi-Fowler’s or Half lying position Side lying or high side lying with the upper arm supported on a pillow Supine Sitting in a comfortable upright chair Standing

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12. Observe & assess the patient’s breathing pattern. Determine whether ventilatory training is indicated. Establish a baseline for assessing changes, progress & outcomes of intervention. If necessary, teach the patient relaxation techniques. Pay particular attention to relaxation of the SCM, upper trapezius, & levator scapulae muscles. POINTS TO PONDER 12

13. 13 Depending on the patient’s underlying pathology & impairments, determine whether to emphasise the inspiratory or expiratory phase of ventilation. Demonstrate the desired breathing pattern to the patient. Have the patient practice the correct breathing pattern in a variety of positions at rest & with activity. POINTS TO PONDER…CONT.

14. 14 PR EC A U TIO N S Never allow the patient to force expiration it may increase the turbulence in the airway which leads to bronchospasm and airway resistance. Avoid prolonged expiration as 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 be quiet during breathing. Allow the patient to perform deep breathing only for 3-4 times(inspiration & expiration) to avoid hyperventilation.

15. TYPES OF BREATHING EXERCISES 15 Diaphragmatic Breathing Pursed Lip Breathing Glossopharyngeal Breathing Localised Expansion Exercises

16. DIAPHRAGMATIC BREATHING Diaphragm is the primary muscle of breathing (inspiration) diaphragm control breathing at an involuntary level, a patient with primary pulmonary disease like COPD can be taught breathing control by optimal use of diaphragm & relaxation of accessory muscles. It is also used to mobilise lung secretion in PD. 16

17. 17 Prepare the patient in relaxed & comfortable position in which the gravity assist the diaphragm such as Semi-Fowler’s position. Notice any accessory muscle activation,Stop,& Teach relaxation techniques. Place your hands over the rectus abdominis just below the ant. costal margin ask the patient to breath slowly & deeply via nose by keeping the shoulders relaxed & upper chest quiet allowing the abdominal to use now ask him to slowly let all the air out using controlled expiration through mouth. C O N T .

18. 18 It should be practiced 2-4 times, if patient 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 & feel the movement ( hand rise & fall) by placing one hand over abdomen patient can also feel the contraction of abdominal muscles which occurs with controlled expiration or coughing. As patient understands; practice it in various positions ( supine, sitting & standing) & during activity ( walking & climbing stairs). C O N T .

19. RE-EDUCATION OF DIAPHRAGM Place the index & middle finger below the lower costal margin anteriorly in half lying position over the insertion of diaphragm (central tendon) At the end of expiration when diaphragm is relaxed, stretch stimulus is given to the diaphragm to elicit stretch reflex of the diaphragm & patient is instructed to take breath in. 19

20. RESISTED DIAPHRAGMATIC BREATHING Patient use a small weight such as sandbag to strengthen and to improve the endurance of the diaphragm. Have the patient in a head up position. Place a small Weight (3.5lb) over the epigastric region of his abdomen (1.30-2.20kg). 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 without the use of any accessory muscles of inspiration for 15 minutes 20

21. 21 G L OSSOPH A R Y N GEA L BREATHING It is a means of increasing 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. This type of breathing pattern was originally developed to assist post-polio patients with severe muscle weakness. PROCEDURE: Patient take several gulp of air by closing the mouth ,the tongue pushes the air back and trap it in the pharynx then air is then forced to lungs when the glottis is opened.

22. C O N T . 22

23. 23 PURSED LIP BREATHING It is a strategy that involves lightly pursing the lips together during controlled exhalation. Taught to patients with COPD to deal with episodes of dyspnoea. It helps to improve ventilation and releases trapped air in the lungs. Keeps the airways open longer and prolong exhalation slow the breathing rate. It moves old air out of the lungs & allow new air to enter the lungs.

24. 24 PROCEDURE FOR PLB Patient in a comfortable position and relaxed, explain the patient about the expiration phase (it should be relaxed and passive) Abdominal muscle contraction must be avoided Ask the patient to breath in slowly and deeply through the nose and then breath 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 (SOB) in COPD & asthma.

25. PLB 25

26. LOCALISED EXPANSION EXERCISES These are useful for assisting in the removal of secretions and improving movement of the thoracic cage. Individual lobes of the lungs are ventilated by these exercises. Pressure is applied to appropriate areas of the chest wall; utilising proprioceptive stimuli , more efficient expansion of these areas may be obtained.

27. LOCALISED EXPANSION EXERCISES VARIOUS TYPES: Lateral Basal Expansion Apical Expansion Posterior Basal Expansion Upper Lateral Expansion 27

28. 28 LATERAL COSTAL EXPANSION It is also known as “lateral basal expansion”. It is performed both unilaterally or bilaterally. The patient may be sitting or in semi-Fowler’s position. Place your hands along the lateral aspect of the lower ribs. Ask the patient in breath 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.

29. 29 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 breeds 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 manoeuver independently, ask him to apply resistance with his hand or with a towel or belt. C O N T .

30. LATERAL COSTAL EX P A N SION IN SUPINE POSITION 30

31. LATERAL COSTAL EX P A N SION IN SITTING POSITION 31

32. BELT EXERCISES TO REINFORCE LATERAL COSTAL BREATHING IN SITTING POSITION By applying resistance during inspiration 32

33. APICAL EXPANSION This is useful when there is restricted upper chest movement, or incomplete expansion of lung tissue, particularly where there is an apical pneumothorax e.g. following lobectomy. Pressure is applied below the clavicle using the tips of the fingers. The patient breathes in, expanding the chest forwards and upwards against the pressure of the fingers. The shoulders should be relaxed, and the expansion held momentarily before expiration.

34. APICAL EXPANSION 34

35. 35 POSTERIOR BASAL EXPANSION The patient should sit leaning forward from the hips with a straight back. Have the patient sit and lean forward on a pillow, slightly bending the hips. Place your hands over the posterior aspect of the lower ribs, and follow the same procedure just described for lateral coastal expansion.

36. C O N T . 36

37. 37 For the left side: the belt is placed round the back of the chest at the level of the xiphisternum.The piece of belt coming round from the left side is held forward with the right hand in order to give pressure to the posterior part of the ribs. The other end of the belt is crossed over the thighs and is fixed under the left thigh. The patient breathes out, and pull the belt firmly forwards, and he then breathes in and expands the ribs backwards against the resistance of the belt. SELF TECHNIQUE

38. At full inspiration and the pressure is released and expansion is maintained for a moment before expiration. The procedure is reversed for the right side. C O N T .

39. UPPER LATERAL EXPANSION The technique used is similar to that for lateral basal expansion. The pressure is applied just below the axilla (not more than 2inch or 5 cm).

40. RELAXATION POSITIONS FOR THE BREATHLESS PATIENTS 40

41. 41 Whenever a patient’s normal breathing pattern is interrupted shortness of breath can occur. It is helpful to teach a patient how to monitor his or her level of SOB and to prevent episodes of dyspnoea by CONTROLLED BREATHING TECHNIQUES, PACING ACTIVITIES and becoming aware of what activity or situation precipitates a SOB attack. Pacing is the performance of functional activities such as walking, stair-climbing or work related task within the limits of patients ventilatory capacity. Although some patients may understand intuitively the limits to which functional activities can be pushed, others must be taught to recognise the early signs of dyspnea. POINTS TO PONDER

42. 42 HIGH SIDE-LYING : Five or six pillows are used to raise the patient shoulders while lying on his side. 1pillow should be placed between the waist and axilla to keep the spine straight and prevent slipping down the bed. The top pillow must be above the shoulders so that only the head and neck are supported. The underneath forearm can be placed under the head pillow, or resting on the bed underneath the pillow in the waist . It is more comfortable if the knees are bent and the top leg placed in front of the one beneath. The position is helpful for patients in acute respiratory distress or those who suffer from acute breathlessness during the night. C O N T .

43. 43 Forward lean sitting: The patient sits at the table leaning forward from the hips with the head and upper chest supported on several pillows. The back must be kept a straight, so that diaphragmatic movement is not inhibited. Children can sit or kneel with the head and upper chest resting against pillows. Relaxed Sitting: This is an unobtrusive position that can be taken up easily. The back should be kept a straight, with the forearm is resting on the thighs and the wrists relaxed. C O N T .

44. 44 Forwardly lean standing: The patient should lean forward with the forearm resting on an object of suitable height, such as the windowsill or banisters. Relaxed standing: The patient can lean back against the wall with the feet please slightly apart and approximately 30 cm away from it. The shoulders and arms should be relaxed. C O N T .

45. VARIOUS R E L A X A TION POSITIONS 45