Lab 3: Breathing Exercise

If you want to target the diaphragm you should {{c1::posteriorly}} tilt the pelvis

If you want to target the accessory muscles, you should {{c1::anteriorly}} tilt the pelvis

What is the best positioning for dyspnea relief?

• Posterior tilt to optimize diaphragm
• UE in CKC positiojn

Describe the positioning progression for breathing exercises.

1. Resting Supine or Side-lying (easiest) 
2. Sitting
3. Standing
4. Dynamic Activity (hardest)

What breathing exercises help improve chest expansion?

• Lateral Costal Breathing
• Deep Breathing with Breath Stacking
• Deep Breathing with Inspiratory Hold
• Diaphragmatic Breathing
• Segmental Breathing

What is lateral costal breathing?

"

• Improves chest expansion
• Patient should be in an upright position
• PT hands over lower, lateral chest wall; encourage costal expansion of diaphragm (and minimal upper chest movement)
• You can apply gentle pressure through expiration, with quick stretch before inspiration
  
• For unilateral costal breathing -- have patient sidelying with un-involved side down

"

What is deep breathing with breath stack?

"

• Improves chest expansion
• Series of deep breaths building on the next without expiration until max volume tolerated by patient is reached
• Each inspiration should last for a few seconds
• Good for patients who have pain with one deep inspiration

"

What is deep breathing with inspiratory hold?

• Improves chest expansion
• Full inspiration with inspiratory hold for 3-5 seconds to maximize alveolar expansion
• More uniform distribution of ventilation

What is diaphragmatic breathing?

"

• Improves chest expansion
• Have patient sitting in a posterior tilt (or semi-reclined hand on stomach below rib cage)
• Apply gentle pressure with expiration with transition from light to firm pressure with inspiration (resistance for strengthening)
• Slow deep breath with stomach expansion
• Repeat 3-5x and rest; repeat
• Breathe in nose and out mouth
• If you having dificulty activating diaphragm --> try sidelying with 1-3 sniffs to achieve increased diaphragmatic activation

"

What is segmental breathing?

"

• Improves chest expansion
• With segmental breathing, speicifc areas are targeted, manual cues
• Use your hand to target an area
• Place hand on chest and ""breath into my hand""

"

What are the breathing exercises for COPD?

• Diaphragmatic Breathing
• Pursed Lip Breathing

What is diaphragmatic breathing (for COPD)?

"

• Have patient place hand on stomach, just below the rib cage
• Patient should slowly deep breath with stomach expansion
• Breath in throuh nose and out mouth
• Repeat 3-5x and rest, repeat
• Encourage full expiration

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What is pursed lip breathing?

"

•  Inspiration through nose; expire through pursed lips
• Expire 2-3x longer than inspiration

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What is chest wall mobility with PNF (DII UE Pattern)?

• Have patient sitting, and will do two movements
• Trunk flexion, IR/pronation/elbow extension with expiration
• Trunk extension, ER/supination/elbow extension with inspiration
• Exhale During:
• Trunk Flexion, IR, etc.
• Inhale During:
• Trunk Extension, ER, etc.
• This is especially important for patients with neurologic deficits

What is a nebulizer treatment?

"

• Breathing treatment that converts medication into a mist that can be inhaled into the lungs
• Optimal effectiveness; 15-20 minutes after administration
• ""It is something that broncho-dilates""

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What is glossopharyngeal breathing?

"

•  ""Frog Breathing""
• Method of positive pressure breathing technique that can be utilized with extreme weakness in primary muscles of inspiration (e.g., cervical lesion SCI)
• Patient gulps boluses of air, traps air in mouth whcih forces air into lungs when patient opens glottis with subsequent gulp

"

What is paced breathing?

• Pacing an activity by purposefully coordinating breathing with components of an activity
• Break the activity into manageable parts; inhale while resting and complete task on exhalation
• For Example:
• Take a hard task like going up the stairs
• Maybe patient can only do 3-4 stairs before they are out of breath
• Want the patient to do stairs during exhalation 
• Thus, want to breath in before you begin the activity 
• Do the activity during the exhalation

What is the active cycle of breathing?

"Useful for loosening and clearing secretions from the chest

1. Breathing Control -- to start cycle and in between cycles, designed for relaxation of airways; instruction to breath in/out nose (mouth if cannot through mouth); slowing breaths down
• Instruct patient to breathe easily/normally
• Get 3-4 breath controls 
• It is the ""reset""
2. Deep Breathing -- 3-5 deep slows breaths; add breath holds 3-5 seconds, postural drainage positioning, and percussion as indicated
• Some may say to add a hold to the last couple breaths
• You can do it with or without postural drainage positioning
3. Huffing -- exhalation through open mouth (NOT coughing), preventing wheezing and chest tightness; huffing is followed by breathing control
• After a deep breath, HUFF (almost like a sigh, lower velocity / lower volume)
• Purpose is to move secretions from deeper in the airways
• An individual who is coughing so much (that they feel like they are going to throw up) -- huffing is very beneficial for them
4. Breathing Control -- (5 - 10 s)

"

What is autogenic drainage?

"

• Controlled breathing at different lung volumes to loosen and move secretions toward the larger central airways
• 3 Stages:
• Unsticking
• Maximally exhale --> inhale a small breath --> exhale again
• Perform this at least 3x
• Resist the urge to cough (until actually ready to evacuate)
  
• Collecting
• Progress to medium sized breath inhalations
• Feel the breaths more in the middle of the chest
• Perform at least 3x to clear middle airways
• Evacuating
• Progress to full inhalation with shallow breaths (mid to high volumes)
• Perform at least 3x to clear central airways
• Then HUFF COUGH
• Rest 2 minutes --> repeat the three stage cycle
• Uses the least amount of coughing to clear secretions with intention to clear them more easily
• Often described as a treatment technique for bronchiectasis 
  

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What are the different types of cough assistance?

"

• Splinting
• Series of Three Coughs
• Cough 2x in One Breath
• Use Huff / ""Ha-Ha"" Sound
• Manual Assistance

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What is splinting?

"

• For a painful chest with a pillow or the hands
• Can splint with pillow, blanket, hands, etc.
• It will improve their tolerance to pain

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What is a Series of Three Coughs?

• Exactly what it sounds like
1. Small Breath --> Small Cough
2. Larger Breath --> Larger Cough
3. Deep Breath --> Deep Cough
• Good for post-operativ epatients
• This is the person who needs to be clearing secretions but isn't really doing it because it is painful
• For the patient who is anxious of pain (start with small cough and progress)

What is Cough Twice in One Breath?

• Once again -- exactly what it sounds like
• You cough twice in one breath
• The second one is typically stroner and more explosive
• First cough is meant to start the movement of secretions
• Second is to actually get the secretions out

When would huffing be preferred over a cough?

• For a patient who has collapsable airways
• For patients with increased sputum production who have difficulty expectorating mucus

What is huffing / ha ha-ing?

"

• Have patient take a slow, deep breath through the nose, with mouth slightly open
• Have the patient lead forward and cross arms over pillow 
• Whisper the word ""huff"" or ""hahahaha"" several times while rapidly exhaling
• Strop exhalation when most of the inspired air is expelled

"

Differentiate a small-long huff and and a large-short huff.

• Small-Long Huff
•  Clears from deep in the chest 
• Meant for mobilization of secretions toward higher airways
• Small to medium inhalation
• Like a long sigh
• Large-Short Huff
  
•  Clears from upper airways
  
• Meant to clear secretions
  
• Large inhalation
• Like a groan or quick sign
• One step 'below' a cough

What is a manually assisted cough?

"

• Pressure is physically applied by the therapist or patient in an ""up and in"" direction in conjunction with patient expiration
• Have patient take in a slow deep breath
• Hold for one count
• And then patient leans forward and contracts abdominals (or have them braced against something firm)
• Have patient cough twice 
• 1st Cough -- raise secretions
• 2nd Cough -- expel them
• May require suctioning
• Do not encourage patient to exhale beyond normal expiration as it may precipitate small airway collapse. 

"

Who would utilize a manually assisted cough?

• Same individual who needs glossopharyngeal breathing (e.g., SCI)
• Person who is strugglign to clear secretions d/t muscular weakness 

What are the two methods of inspiratory muscle strengthening?

• Incentive Spirometry
• Resisted Inspiration

What is incentive spirometry?

• Used when TV < 500 mL 
• Patient is asked to inspire completely and hold full inspiration (in order to allow time for collateral ventilation to occur in all alveoli)
• Flow: marker reach level with sustained breath as long as flow achieved
• Volume: provides feedback for slow, sustained inspiration and volume
• 10x every 1-2 waking hours (TYPICAL PRESCRIPTION)
• Gives Biofeedback!
• They can SEE the amount of air they are inspiring

What is resisted inspiration?

"

• TV > 500 mL
• Weight placed on diaphragm
• Manual resistence
• Inspiratory muscle trainer device (NOT acapella --> that is for secretions)
• To Increase Strength: high load, low reps
• To Increase Endurance: lower load, long duration

 

Breathing is an endurance

activity (do not forget that)"