By Mary Burns

Pulmonary Education and Research Foundation

     Probably the most important thing that you can learn in pulmonary rehabilitation classes is a more efficient breathing technique. You have been breathing ever since you entered this world so why are you suddenly supposed to "learn" a new way to breathe? Because there have been changes in your body.

     Many of you in this group feel that you "suddenly" had a problem with your breathing after getting that last episode of flu or pneumonia. Actually, emphysema is a disease that slowly progresses over a 20 or 30 year period. The first thing that happens, maybe while you are still a teenage smoker, is that the elastic fibers in your lungs start to deteriorate and lungs start loosing their elastic recoil, their ability to get air out of the lungs efficiently. Over the years this gets worse and you start to develop air trapping or more residual volume (RV). Now, everybody has some air in their lungs even after they breathe out as much as they can. This prevents the alveoli, the little air sacks, from collapsing, flat as an old balloon. But patients with COPD may have a 200% or even larger increase in air trapping or residual volume.

     So why does that matter? That amount of extra air compresses the undamaged alveoli, so that they can't work efficiently, much the way an expanded air bag would compress your body in your car seat. The other thing that happens is that the larger lungs push out your chest walls. Have you noticed that your chest size is larger, or that your bra size has increased? That is why.

     Another effect of air trapping is that the diaphragm becomes flattened, which can be seen on your chest x-ray. When your lungs weren't damaged the diaphragm did about 80% of the work of breathing. Now it can no longer suck air in as it tightens and flattens, because it is already flattened out. The mechanics of breathing are all thrown off. You start to use accessory muscles of respiration such as your shoulder and neck muscles. These muscles are only meant to be used in emergencies. They are inefficient. If you think that you work harder on your breathing than other people do, you are absolutely right! Even at rest you are probably working about 17 times harder to breathe than a person without lung disease. So what can you do about it? Well, if you remember what is wrong it will be easier to make sense of the new breathing techniques we will teach you. Loss of elasticity in the lungs is the first thing for you to remember. What does that mean in practical terms? It means that you now have to work to get air out of you lungs. Think of a balloon. You have to work to get air into a balloon as you have to work to get air into your lungs. But when you let go of the neck of the balloon the air shoots out without any effort on your part. Your lungs do the same thing when they are not damaged. However, when they loose their elastic recoil you have to work to get the air out. It's like breathing into a paper bag. You have to squeeze the air out of the bag since it won't flatten out by itself. You now have to work to get air out of the lungs as well as to get air into the lungs. This will take longer so the first thing to remember is to slow your breathing and concentrate on breathing out. You have been breathing in all your life and you do that automatically so forget about getting air into your lungs. That is not your problem. Your problem now is working on getting air out of your lungs. You now need to breathe out 2 or 3 times longer than you breathe in. If you panic and breathe too fast, or breathe in and out at the same rate, you will cause more air trapping and get more short of breath. In our studies, patients who did good pursed lip breathing (PLB) slowed down to about 10 breaths a minute at rest.

     So, what about PLB. Does it really help? Yes, it does. Good PLB can raise the oxygen level of your blood as much, and faster, than being put on 2 litters of oxygen a minute. Then why don't you feel much better when you use it? Why do you sometimes feel worse? Because you may not be doing it correctly! Done correctly, you breathe in deeply and slowly through your nose. You breathe out 2 or 3 times longer through slightly pursed lips with just a small opening in the center of your lips. Think in terms of blowing out a candle.

     There are several mistakes I see patients make. One is blowing out too forcefully. If you use too much force you can actually LOWER the oxygen level of the blood! If I can hear you, you are working at this too hard! If you feel uncomfortable doing PLB, or feel that you are working too hard, you probably are. Stop and rest a bit. Don't work so hard! Good PLB feels comfortable and natural.

     Another common mistake is breathing in through the mouth before pursing lips. Patients may breathe in through their nose; however, before breathing out through their pursed lips they sometimes take in a little gulp of air through their mouth.

     No matter how good your PLB technique is, it won't work if you are breathing too fast or breathing in and out at the same rate or even doing both! It is essential that you slow down and concentrate on breathing out longer than you breathe in. This can't be repeated too often. How can you tell if you are doing effective PLB? Borrow an oximeter. If your oxygen levels are low, say 88%, with good PLB you will easily blow the numbers up to 93%. Really practiced breathers can get their saturation's much higher, but 93% is a good number to aim for. What happens if you breathe incorrectly? Maybe nothing. Or, if you are breathing too forcefully, you may see for yourself that your oxygen saturation's will drop, and continue to drop, until you stop working so hard.

     Now that we have those techniques in hand let's get on to the next big problem we see in rehab; the use of accessory muscles. Mary demonstrated to a patient during class that lowering those shoulders and not making them go up and down to breathe with, gave immediate relief of shortness of breath. So stop using your shoulders to help your shortness of breath, because it will only make things worse! You are working harder and consuming more oxygen. It may take time to break this habit but it can be done. Watch yourself in the mirror while you breathe. See for yourself how much better you feel when you drop and relax those shoulders. What about diaphragmatic breathing? Well, that's a tough one. Belly breathing, or abdominal breathing may take a long time to master. Weeks in fact. But it can be done. Start out by lying down on the floor. Put one hand on your chest and the other on your abdomen. Keep the hand on your chest free of movement while the one on your abdomen goes up and down. Put a Kleenex box on your abdomen and watch the box go up and down. Practice this often during the day but only for a few minutes at a time. If you get lightheaded, stop. When you can do it lying down progress to trying it while sitting, and then while standing. Advancing to diaphragmatic breathing while walking is the hardest of all but it can be done. Keep working at it. It's worth it.

     The last breathing technique is chest excursion. This is easily learned in class but you probably can also do at home on your own. What is chest excursion and why do it? You have small muscles between each rib. These are called the intercostals. Ordinarily these muscles are used to expand and contract the chest, moving air in and out of the lungs, like bellows. Over the years, as the lungs expand because of trapped air, the ribs become fixed and these muscles no longer work. You can use a belt or tape as a biofeedback tool to help your muscles relearn what they should do. Wrap a belt or tape lightly around your lower ribs crossing the tape over in front as if you were about to tie it. Do Not Tie! Loosen the tape as you inhale and your lungs expand. Pull the tape tighter as you exhale, squeezing the air out of your lungs. Do this several times but stop if you get light headed. After a very few sessions you should feel your chest begin to move, expanding and contracting on its own, helping the abdominal muscles to move air.

     What about readers who suffer from restrictive pulmonary disease such as idiopathic pulmonary fibrosis. Do these breathing techniques work for them also? Very little research has been done. Dr. Brian Tiep and Mary published a small study demonstrating the effectiveness of PLB with restrictive patients, but it has not been validated by other studies. However, those of us who work in the clinical field have seen that PLB works, as have many of our patients. In fact, Mary's patients were the first to prove that they could also raise their oxygen saturations with good PLB before we did that study. Restrictive patients can usually only slow their breathing down to about 16 breaths a minute and they usually needn't work on exhaling longer than they inhale since air trapping isn't a factor for them. There are many kinds of restrictive disease so these patients have more need to experiment as to what works best.

     There is nothing as important as improving breathing techniques. It can give you immediate panic control and prepare you to start improving your exercise tolerance. If you wish to ask questions about these techniques you can send e-mail to PERF or send a letter to the address below.

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Box 1133 Lomita, California 90717-5133
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