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Effects of Diaphragmatic Breathing With and Without
Pursed-Lips Breathing in Subjects With COPD
Liliane PS Mendes, Karoline S Moraes, Mariana Hoffman, Danielle SR Vieira,
Giane A Ribeiro-Samora, Susan M Lage, Raquel R Britto, and Veroˆnica F Parreira
BACKGROUND: Breathing exercises, such as diaphragmatic breathing and pursed-lips breath-
ing, play a role in some individuals with COPD and might be considered for those patients who
are unable to exercise. However, in the literature are reports of some adverse effects of dia-
phragmatic breathing in patients with COPD. Thus, the purpose of this study was to assess the
effects of diaphragmatic breathing and diaphragmatic breathing combined with pursed-lips on
chest wall kinematics, breathlessness, and chest wall asynchrony in subjects with COPD, and
also to assess whether the combination of both exercises reduces the adverse effects of dia-
phragmatic breathing while maintaining its benefits. METHODS: Seventeen subjects with
COPD, mean SD, 65 7 y of age, with a history of smoking and clinical stability without
hospitalization or symptoms of exacerbation in the past 4 wk, were evaluated. On day 1,
participants’ characteristics were collected, and they learned diaphragmatic breathing and its
combination with pursed-lips breathing. On day 2, the participants were evaluated by opto-
electronicplethysmographywiththeparticipantsintheseatedpositionwhileperformingbreath-
ing exercises. RESULTS: Diaphragmatic breathing and diaphragmatic breathing plus pursed-
lips breathing promoted a significant increase in chest wall tidal volume and its compartments
as well as a reduction in breathing frequency compared with quiet breathing. No significant
changes were observed in dyspnea or end-expiratory volume of the chest wall. A significant
increase in asynchrony (inspiratory-expiratory phase ratio) was observed during diaphrag-
matic breathing and diaphragmatic breathing plus pursed-lips breathing compared with quiet
breathing, with no differences observed between the exercises. CONCLUSIONS: Despite the
increase in asynchrony, both breathing exercises were able to improve chest wall volumes
without affecting dyspnea. The combination of exercises maintained the benefits but did not
reducetheadverseeffectsofdiaphragmaticbreathing.Keywords:COPD;diaphragmaticbreath-
ing; pursed-lips; optoelectronic plethysmography; breathing pattern; chest wall motion; asynchrony.
[Respir Care 2019;64(2):136–144. © 2019 Daedalus Enterprises]
Introduction cause of morbidity, is an important public health concern,
and clinical exacerbations are responsible for recurrent
COPD is a treatable disease characterized by chronic hospitalizations and an increase in the related economic
air-flow limitation and persistent symptoms, such as dys- 1,2
health-care costs. Pulmonary rehabilitation is a key
1
pnea, cough, weight loss, and fatigue. COPD, as a leading
MsMendes,MsMoraes,DrHoffman,Dr.Ribeiro-Samora, and Dr Lage
are affiliatted with Rehabilitation Sciences Program, Universidade Fed- Financial support was provided by Coordenac¸a˜o de Aperfeic¸oamento de
eral de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil. Dr Vieira is PessoaldeNívelSuperior,Fundac¸a˜odeAmparoaPesquisadeMinasGerais,
affiliated with Health Science Department, UniversidadeFederaldeSanta and Conselho Nacional de Desenvolvimento Científico e Tecnolo´gico.
Catarina, Ararangua´, Santa Catarina, Brazil. Drs Britto and Parreira are
affiliated with Department of Physiotherapy, Universidade Federal de DrParreira presented a version of this paper at the European Respiratory
Minas Gerais, Belo Horizonte, Minas Gerais, Brazil . Society Annual Congress, September 21, 2010, in Barcelona, Spain, and
136 RESPIRATORY CARE • FEBRUARY 2019 VOL 64 NO 2
DIAPHRAGMATIC AND PURSED-LIPS BREATHING
componentofmanagingCOPDandinvolvesexercisetrain-
ing, education and self-management interventions, encour- QUICKLOOK
aging behavioral change, and stimulus to physical activ- Current knowledge
3
ity. Pulmonary rehabilitation has been shown to improve Breathing exercises, such as diaphragmatic breathing
symptoms, exercise tolerance, and health-related quality and pursed-lips breathing, play a role in some individ-
2-4
of life as well as reduce hospitalizations. Breathing ex- uals with COPD and might be considered for symptom
ercises, such as diaphragmatic breathing and pursed-lips management and for those patients unable to exercise.
breathing, which can be performed separately or in com- Bothexercisespresentbenefitsforpatients with COPD;
5-9
bination, have a role in managing breathlessness in pa- however, there are reports of some adverse effects of
tients with COPD and can also be considered for those diaphragmatic breathing.
1,7
who are unable to undertake exercise training. These
techniques aim to reduce dyspnea, improve ventilation and What this paper contributes to our knowledge
gas exchange, optimize chest wall motion, and reduce hy- Wefound that diaphragmatic breathing with and with-
7,10,11
perinflation. out pursed-lips breathing improved chest wall volumes
Diaphragmatic breathing consists of a smooth and deep andoxygenation,reducedbreathingfrequency,andpro-
nasal inspiration with anterior displacement of the abdom- vided more volume for hematosis without increasing
inal region, which emphasizes the action of the dia- dyspnea. The addition of pursed-lips breathing to dia-
6,10,12 phragmatic breathing provided greater changes in
phragm. Forpatients with COPD, the immediate ben-
efits of diaphragmatic breathing are an increase in the tidal breathing parameters, especially in relation to time vari-
volume and oxygen saturation, reduction in breathing fre- ables. Therefore, our work supports the positive acute
quency, and improvements in ventilation and hemato- effects of these breathing exercises for patients with
12,13 COPD.
sis. Adverse effects include an increase in the asyn-
chronous and paradoxical movement of the chest wall as
well as increased work of breathing and dyspnea in the
6,10,12
subjects with the most severe conditions.
5
Pursed-lips breathing consists of a soft exhalation per- subjects with COPD, Jones et al reported a significant
formedfor4to6sagainsttheresistanceofpartiallyclosed decrease in breathing frequency and oxygen consumption
6,10,14 during the combined exercise compared with the sponta-
lips and clenched teeth. It is frequently adopted spon- neousbreathing.Thebreathingfrequencywassignificantly
taneously and voluntarily by some subjects with COPD to lower during diaphragmatic breathing plus pursed-lips
control and relieve dyspnea and can be performed at rest breathing, even in relation to each technique in isolation,
14-16
or during exercise. Several studies have shown that the although there was no difference in oxygen consumption
benefits of pursed-lips breathing in subjects with COPD 5
include decreased breathing frequency and lung hyperin- among the 3 exercises. According to these findings, a
flation, improvements in the P andoxygenintheblood, combination of these techniques seemed to be more effec-
CO2 tive than performing the exercises separately. However, to
6,10,14,17
and increased tidal volume and oxygen saturation. the best of our knowledge, this was the only study to
However, dyspnea relief remains poorly consistent, be- evaluate the effects of the combination of the techniques
6,10
cause this response is different among subjects. for only these 2 outcomes. Thus, the questions addressed
With regard to the combination of these techniques (di- in this study were the following: What are the effects of
aphragmatic breathing plus pursed-lips breathing) in diaphragmaticbreathingpluspursed-lipsbreathingonchest
wall motion, breathing pattern, dyspnea, and chest wall
asynchrony in subjects with COPD? Could the combina-
tion reduce the adverse effects of diaphragmatic breathing
while maintaining its benefits?
at American Thoracic Society International Conference, May 17, 2014,
in San Diego, California. Methods
The authors have disclosed no conflicts of interest. Participants
Correspondence: Veroˆnica Franco Parreira, Department of Physiother-
apy, Universidade Federal de Minas Gerais, Avenida Antoˆnio Carlos, This was a quasi-experimental study, developed in an
6627, Pampulha, 31270-901 Belo Horizonte, MG Brazil. E-mail: university research laboratory with participants who met
veronicaparreira@yahoo.com.br. the following inclusion criteria: diagnosis of COPD con-
1
DOI: 10.4187/respcare.06319 firmed by pulmonary function test, history of smoking,
RESPIRATORY CARE • FEBRUARY 2019 VOL 64 NO 2 137
DIAPHRAGMATIC AND PURSED-LIPS BREATHING
between 45 and 75 y of age, clinically stable (no exacer- toelectronic plethysmography system, have been pub-
13,14,17 27
bations and/or hospitalization in the past 4 weeks), lished. Toenablethecamerastobettercapturetheimages,
no report of neurological or psychiatric disorders, body the participants were seated with their arms slightly exter-
2 18
mass index between 18.5 and 29.99 kg/m , and no pre- nally rotated. Then, 3 different conditions were registered:
vious participation in a pulmonary rehabilitation program. (1) 6 min of quiet breathing (3 sets of 2 min each), defined
Subjects were excluded if they presented with other pul- as participants’ spontaneous breathing pattern; (2) 6 min
monary diseases or were unable to understand and/or per- of diaphragmatic breathing (3 sets of 2 min each); and (3)
form any procedure of the study. Two investigators (KSM 6 min of diaphragmatic breathing plus pursed-lips breath-
and SML) were previously trained to carry out data col- ing (3 sets of 2 min each).
lection, and the instructions given to the participants were The exercises were performed in a random order. The
performed by one of them (KSM). This study was ap- dyspnea rating was recorded before and immediately after
proved by the ethics committee of the institution (ETIC each condition (quiet breathing, diaphragmatic breathing,
577/08), and all the participants signed a written consent and diaphragmatic breathing plus pursed-lips breathing)
form. The study was performed at Universidade Federal de by using the modified Borg scale (0–10 points, with 0, no
Minas Gerais, Belo Horizonte, Brazil. 28
dyspnea; and 10, maximum dyspnea). Oxygensaturation
Intervention and heart rate were continuously assessed during data col-
lection by using a pulse oximeter (Datex TuffSat Oxime-
Data were collected over 2 d, with a maximum interval ter, GE Healthcare, Helsinki, Finland). A minimum inter-
of1weekbetweenthem.Initially,clinicalanddemographic val of 10 min between the conditions was given to allow
data were collected. Then, the Medical Research Council the return of clinical parameters (heart rate, breathing fre-
19 quency, and dyspnea) to baseline values. The same re-
dyspnea scale was used to assess symptoms. Next,
maximum respiratory pressures were assessed by using a searcher (KSM) provided instructions on how to perform
manovacuometer (Ger-Ar, Sa˜o Paulo, Brazil) according to the breathing exercises on the first and second days. In
20 addition, participants received standard verbal instruction
recommendations. Theparticipants then performed the pul-
monary function test (Vitalograph 2120, Vitalograph, Buck- at the beginning of each series of exercises and were mon-
ingham, United Kingdom).21 After that, the participants itored during data collection to ensure that they were per-
learned how to perform diaphragmatic breathing and the di- forming the exercises correctly.
aphragmatic breathing plus pursed-lips breathing.
For diaphragmatic breathing, they were instructed to Outcome Variables
perform a nasal inspiration moving predominantly the ab-
domen, reducing the movement of the rib cage.6,22 For
diaphragmatic breathing plus pursed-lips breathing, they The breathing pattern variables analyzed were chest
were instructed to perform a diaphragmatic breathing, and wall tidal volume, end-inspiratory chest wall volume,
14,23
then, exhale the air with lips partially closed. Initially, end-inspiratory rib-cage volume, end-inspiratory abdomen
tactile stimulus was used by positioning one of the partic- volume, end-expiratory chest wall volume, end-expiratory
ipant’s hands on his or her abdomen, at the level of the rib-cage volume, end-expiratory abdomen volume, minute
umbilicus, while placing the other hand on the chest, in ventilation, breathing frequency, inspiratory time, expira-
the sternal notch region, to allow comparison of venti- tory time, and duty cycle. The chest wall motion variables
12
lation between both locations. Moreover, during the analyzed were pulmonary rib-cage percentage contribu-
learning period, 2 bands from the respiratory inductive tion, abdominal rib-cage percentage contribution, and ab-
plethysmography (Respitrace, NIMS, Miami, Florida) domen percentage contribution. The asynchrony between
were placed, one on the rib cage and the other on the abdo- chest wall compartments [rib cage (pulmonary rib cage
24
men, and the participants were positioned in front of a abdominal rib cage) abdomen and pulmonary rib
computer screen to follow the movements of the chest wall cage abdominal rib cage] was calculated by using the
for a visual feedback. In addition, standard verbal instruction
was given to ensure correct technique performance. software MatLab (MathWorks, Natick, Massachusetts) by
On the second day, the participants were initially re- using the following variables: the phase angle that reflects
minded about exercise performance. They were then eval- the delay between the excursions of the compared compart-
29
uated by using optoelectronic plethysmography, which is a ments, the inspiratory phase ratio, and the expiratory phase
25,26 ratio that expresses the percentage of time in which the com-
valid and reliable system composed of cameras (6 in
this study) that register movement of the chest wall through partments move in opposite directions during the inspiration
24,30
89 markers placed on the trunk. Technical details, includ- and during expiration, respectively. Perception of dys-
28
ing marker positions and calibration processes of the op- pnea was assessed by using the modified Borg scale.
138 RESPIRATORY CARE • FEBRUARY 2019 VOL 64 NO 2
DIAPHRAGMATIC AND PURSED-LIPS BREATHING
Sample Size Calculation Table 1. Characteristics of the Participants
Sample size calculation was determined after a pilot Characteristics Value
study with the first 10 participants. The following Male sex, % 88
variables were considered: chest wall tidal volume, breathing Age, mean SD y 657
frequency, inspiratory phase ratio, and expiratory phase ratio. BMI, mean SD kg/m2 23.0 2.5
When considering a large effect size (f 0.40) for each Smoking history, mean SD packs/y 57.8 33.6
FEV , mean SD % predicted 31.8 10.7
variable, a power of 0.80, and an alpha error probability of 1
FEV /FVC, mean SD 0.4 0.1
5%, the estimated sample size was 15 subjects. 1
MRCscore, mean SD arbitrary units 2.6 0.9
P , mean SD cm H O 85 30.7
Data Reduction Imax 2
P , mean SD % predicted 81.9 26.3
Imax
P , mean SD cm H O 129.1 43.0
The intermediate minute from each of the 3 series reg- Emax 2
P , mean SD % predicted 92.3 31.5
Emax
istered was used to determine the breathing pattern, chest
wall motion, and chest wall asynchrony variables of quiet N17
breathing and also of the breathing exercises. Thus, all BMIbody mass index
MRCMedical Research Council dyspnea scale
P maximum inspiratory pressure
breathing cycles between 30 and 90 s of each series of Imax
P maximumexpiratory pressure
2 min were used for all the conditions evaluated. Emax
Statistical Analysis
with quiet breathing. From diaphragmatic breathing to di-
Data are presented as measures of central tendency and aphragmatic breathing plus pursed-lips breathing, a signif-
dispersion, and the normality was verified by using the icant increase in expiratory time was associated with a
Shapiro-Wilk test. To compare quiet breathing, diaphrag- significant decrease in the breathing frequency. With re-
matic breathing, and diaphragmatic breathing plus pursed- spect to the duty cycle, a significant decrease was ob-
lips breathing, repeated-measures analysis of variance or served during diaphragmatic breathing plus pursed-lips
the Friedman test was used. Post hoc analyses were per- breathing when compared with quiet breathing and with
formed by using Bonferroni or Wilcoxon tests accord- diaphragmatic breathing.
ing to data distribution. For dyspnea comparisons, the Thechestwallmotionandasynchronydataduringquiet
chi-square test was used. The level of significance was breathing, diaphragmatic breathing, and diaphragmatic
set at 5%. The Statistical Package for the Social Sci- breathing plus pursed-lips breathing are presented in Table
ences, version 17.0 (SPSS, Chicago, Illinois) was used 3. The contribution of the abdominal compartment was
for analyses. 50% on the 3 conditions. A significant increase in the
percentage contribution of pulmonary rib cage was ob-
Results served during diaphragmatic breathing plus pursed-lips
breathing compared with quiet breathing. No other signif-
Initially, 18 participants with COPD were selected to icant change was observed among the 3 conditions for any
participate in the study; 1 participant was excluded from other chest wall contribution variable.
data analysis due to irregularities on data recording. The For the asynchrony variables, no significant differences
demographic, anthropometric, and clinical characteristics wereobservedforthephaseangleamongthe3conditions,
of the participants are shown in Table 1. The sample was whereas a significant increase was observed in the inspira-
composedofsubjectswithmoderate-to-severeCOPD.The tory phase ratio and expiratory phase ratio between all
breathing pattern data during quiet breathing, diaphrag- analyzed compartments during both diaphragmatic breath-
matic breathing, and diaphragmatic breathing plus pursed- ing and diaphragmatic breathing plus pursed-lips breath-
lips breathing are presented in Table 2. Both breathing ing compared with quiet breathing, without differences
exercises (diaphragmatic breathing and diaphragmatic between the breathing exercises. During diaphragmatic
breathing plus pursed-lips breathing) promoted significant breathing and diaphragmatic breathing plus pursed-lips
increases in chest wall tidal volume and end-inspiratory breathing, the participants showed a significant increase in
volume of the chest wall and its compartments compared oxygen saturation compared with quiet breathing (quiet
with quiet breathing. breathing, mean SD 93.39% 3.20%; diaphragmatic
Asignificant decrease in the breathing frequency and a breathing, 95.99% 2.55%; diaphragmatic breathing plus
significant increase in inspiratory time and expiratory time pursed-lips breathing, 95.96% 2.61%; P .01), with no
were observed for diaphragmatic breathing and diaphrag- significant difference between the breathing exercises. No
matic breathing plus pursed-lips breathing when compared significant changes were observed in heart rate for all
RESPIRATORY CARE • FEBRUARY 2019 VOL 64 NO 2 139
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