COPD and Emphysema Self-Care (Part 1)

Introduction

I am Dr. Deane Hillsman, a retired physician who practiced Internal Medicine and the specialty of Pulmonary Diseases. My particular interest is Pulmonary Rehabilitation, and chest physiotherapy and breathing training to help people with COPD and related problems.

In 1987 I wrote the draft of a book RESPIRATORY SELF CARE: A Manual For Patients And Their Families. It was about 60% completed, and I showed it to a half-dozen or so of the major publishers of this type of work. None of them were interested in taking it on. Their concerns were generally that, the material was too technical for most patients and their families, and I therefore abandoned the project.

Times have changed, and in recent years patients and families are now demanding more in-depth understanding of their health concerns, and the concept of patient self-help and empowerment is fast becoming a significant factor in health care. I reject the notion that patients are somehow not capable of using more advanced health care information to their advantage. The contents of this web site are substantially taken from that long abandoned manual.

In the early 1960's during my residency training, quite by accident, I was privileged to see two British trained Physical Therapists work with a patient suffering from Emphysema using  breathing exercises  (which I had never heard of), and achieve significant dyspnea (shortness of breath) relief. I was impressed.

I was later told by many that  breathing exercises  were not of value in COPD. However, when you see such positive results it is difficult to ignore what you have seen. This led to a lifelong interest in trying to understand, and improve, the technology that is generally known as Chest Physical Therapy (or Chest Physiotherapy or simply  Chest Physio ). The modern name for those credentialed in this specialty by the American Association of Physical Therapy is Cardiovascular and Pulmonary Physical Therapist.

A major part of Chest Physiotherapy is  breathing pattern  training. This relates to how to breathe, to achieve more efficient patterns of breathing. To further this interest, in the 1970's I invented a sophisticated computer based device to visually define breathing pattern templates, and to visualize patient's real-time breathing, and their interaction with different breathing templates to achieve maximal breathing comfort. In other modules in this series you will see patient examples from that system. The Breathing Trainer, to be described later, is a simpler version of that original professional and research system, specifically designed for individual home use.

It is quite astonishing, but true, the scientific pulmonary community has never defined, even to this day, in any comprehensive manner, the most efficient way for a COPD / Emphysema patient to breathe. Because of this lack of scientific guidance as to how to program my breathing training system, I had to rely on the general guidelines provided by the Chest Physiotherapy community. And later, I observed a few patients in my practice with very advanced Emphysema, but with only mild complaints of dyspnea. I collected their breathing patterns, and observed they correlated well with the descriptions of Chest Physiotherapy techniques. Indeed, these few patients appeared to be a model of natural adaptation to the altered breathing mechanics of COPD. The lessons learned from these few very instructive patients have substantially guided my design of breathing pattern templates for others with COPD.

The first prototype of my breathing training invention was presented in 1978 before the California Thoracic Society. Since then I have had a great deal of learning experience with experimental adjustment of the various parameters that go into characterizing a breathing pattern for individual patients. Essentially I was trying to understand the optimal manner for the COPD patient to breathe comfortably. I am impressed how even small adjustments can make a significant difference in breathing comfort to many of these patients.

Chest Physiotherapy is substantially a creation of British Physical Therapists, and the subject is routinely taught in the U.K. schools of Physical Therapy. Chest Physiotherapy began there in the mid-1920's and was quite mature by the mid to late 1930's.

This ancient 1935 training manual obtained from the British Library is a quite remarkable document.


It is clear from this document, at a time when the physiologic understanding of COPD clinical problems was primitive, these early Physical Therapists understood the importance of chest overinflation (more later on this very important topic of Dynamic Hyperinflation), and basically how to correct this functional lesion.

How these early Chest Physiotherapists managed to figure this one out is remarkable, and certainly worthy of admiration.

Also quite astonishing is the general lack of awareness of this technology in North America. Surveys of general Physical Therapy training programs have documented usually only minimal time devoted to the subject. In fact, today there are only about 130 credentialed Cardio-Pulmonary Physical Therapy specialists in the United States. If COPD patients seek Chest Physiotherapy training, they are not likely to be able to find these services, at least from these properly qualified experts.

There is also ongoing and substantial physician resistance to the concept of breathing training, as  breathing exercises  are in some disrepute. Perhaps this is related to the many non-physicians offering various breathing services and devices, for many reasons, some of them of dubious value. Physicians instead have understandably relied on the very complex traditional regulatory feedback mechanisms that are essential to maintain life.

Are these traditional breathing control mechanisms infallible? Until recently most physicians appear to have had total faith in these important traditional control mechanisms. However, as we will see, that apparent traditional faith has not been justified. As we shall see, these natural breathing control mechanisms can indeed be tricked into abnormal pathologic behavior, to cause increased shortness of breath.

Recent research has characterized the breathing pattern response to exercising COPD patients, and patients who breathe too rapidly, as a  vicious circle  response, leading to the physiologic problem of progressive so-called  Dynamic Hyperinflation  of the lungs, and this in turn causing severe dyspnea limitation. Simply stated, this rapid breathing pattern causes too much air to become trapped in the lungs, and the lungs can no longer work properly.

This is a pulmonary mechanical defect, and any feedback control system that has a vicious circle mechanism causing failure of the overall system is a flawed system. An obvious option for the COPD patient seeking breathing comfort from a mechanical defect is a proper mechanical breathing control technique, in addition to the usual bronchial dilator drugs and other medications typically prescribed for shortness of breath. Corrective breathing mechanics is what breathing training is all about, and we will discuss this important topic of Dynamic Hyperinflation in a later instruction module.

This breathing training debate should now really be over, though many pulmonary physicians might still dispute that statement. The option of breathing control for patients with COPD and Emphysema, and for Asthma exacerbations, is indeed an important, and in fact necessary option for optimal breathing comfort. By definition, bronchodilator medications can never completely correct the airway obstructive problem in COPD, and in those patients with moderately severe or severe disease, the majority of the mechanical airway obstructive lesion persists after bronchodilator therapy. This residual mechanical problem requires a mechanical solution, and that is what breathing training strategies are all about.

The majority of formal pulmonary rehabilitation programs have a primary exercise focus, or an exercise-centric focus. These programs emphasize reconditioning the legs and other peripheral muscles, by using stationary bicycle ergometers, or treadmills, or stair climbing. Exercise makes these muscles more efficient as to oxygen needs and getting rid of waste carbon dioxide. This requires relatively less breathing, and therefore less dyspnea, to satisfy these metabolic oxygen and carbon dioxide requirements. Considerable research has been done in this approach, and there is no question that this is an effective strategy to get patients ambulating, and to reduce their overall level of dyspnea. And as patients feel more comfortable, they are able to get about more easily. However, exercise training that makes one more short of breath is not a pleasant training experience.

The other general approach, and the one that I personally favor, is a primary breathing training strategy, or a breathing training-centric focus. Ask COPD patients what their major concern is, and very few will complain about the inability to engage in exercise. COPD patients dominant concern is mainly about general and acute shortness of breath, and the large majority are most concerned about acute dyspnea attacks. Acute dyspnea is a very distressing experience, and COPD patients live in constant fear of these attacks. It makes logical sense therefore that initial therapy should concentrate on the patient's primary complaint of dyspnea.

Remember Willie Sutton, the famous bank robber? As Willie Sutton allegedly said, when asked why he robbed banks,"  .....Because that's where the money is....."     Applying this analogy, think of the primary breathing control focus in COPD rehabilitation as the Sutton approach to pulmonary rehabilitation, because that indeed is where the action is.

Teach COPD patients breathing control and their overall breathing comfort improves. But more important, if patients know how to recognize an impending acute breathing attack and prevent the attack, or if having an attack how to control the attack, they will lose their fear of exerting themselves. And if the patient feels they are in control of their breathing, it takes only a little encouragement to get them to be more active, because patients usually want to be more active. And with increased activity, their leg and other peripheral muscles will become reconditioned, and strength will improve, and their overall rehabilitation program will therefore be enhanced. If you will, this is an alternative option to provide exercise reconditioning.

Please do not think that the techniques that I will be showing you are a complete substitute for proper instruction from a qualified therapist. However, if you do not have access to a qualified therapist, the modules of instruction I am providing may be of use to you.

And if you are presently receiving instruction in  "breathing exercises"  or  "diaphragmatic breathing"  perhaps your therapist might be interested in a few of the techniques and tips in these instruction modules.

It is my hope this series will provide information to patients, and their families and caregivers, that will empower them, in a self-help manner, to use these lessons to gain dyspnea control and relief in their activities of daily living. And when you have mastered dyspnea control, that you will then be able to be even more active, and more comfortable.

Throughout these instruction modules, which will require a lot of work on your part, please always remember, neither I nor your doctor or therapist can do dyspnea control for you. We can instruct you, but only you can do dyspnea control for your needs.

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The First Step

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At the end of the consultation with a new COPD / Emphysema patient I usually told them:
 I can't help you, but I can show you how to help yourself.

Yes, this was rather harsh, but it did get their attention. And No, nobody got up and walked out on me, though I did wonder about this possibility a few times.

This deliberate strategy was a realistic technique to hopefully set the stage for the pulmonary rehabilitation program to follow. Patients are usually oriented to the belief that their doctor is simply going to provide them with some pills, and that by taking these medications their health problems will be resolved. True, taking medications in many disease conditions will resolve their problems. However, for the COPD / Emphysema patient nothing could be further from the truth. Effective therapy for these patients is critically dependent on patient understanding, cooperation, and various respiratory skills. It requires the patient to become a part of a team effort, with their doctor and therapists.

I then told them the first crucial lesson to be learned is:
 Every breath of air first begins by getting the old stale air out, to make room for the fresh air.

This is a very counter-intuitive message to patients, as their natural focus is to get air IN, to relieve their dyspnea. To persuade patients as to the importance of properly exhaling their last breath, it is helpful to describe the residual last breath in derogatory terms such as  dead air  or  foul air  or  old bad air  and similar terms. The object is to change the patients focus from inspiration to expiration. Indeed, and as you will learn in greater detail in lessons to come, the expiration phase of breathing is the most crucial and difficult to learn.

And finally, I gave them some simple instructions for a much abbreviated breathing control program. Most of the time patients obtained at least some immediate measure of dyspnea relief, and if they did it was an excellent beginning. I could then advise them this was a favorable sign for better things to come, when they had developed more advanced breathing control skills. The instructions are as follows:

 Sit back in a comfortable easy chair (or if in bed, propped up on at least three pillows). Relax, you can't breathe properly if you are tense and anxious. Breathe gently, and rhythmically. Slow down your breathing. Concentrate on breathing OUT, and MAKE YOUR EXPIRATIONS LONGER. When you breathe in, take in a gentle, slightly larger breath, and try to place, and try to feel the air going down to your lowest lateral ribs, directly in line with the anterior portion of your arm pits.

A good trick to get the very important proper chest movement is as follows. Raise your elbows up, with fingers hanging down. Now, curl your fingers backward, so the back of your fingers are facing the floor. Then, place the back of your fingers on the very lowest ribs (next to your abdomen), directly under your arm pits.

As you breathe in, try to direct your breath toward your fingers, and feel this part of your lower chest moving out and sideways. Try to imagine putting all of your breath into this part of your chest.

Try it. It may not work the first few times, but keep trying. A friend or spouse coaching you with these instructions, and putting their hands on your lower chest in the manner as described above, may help to get you started.

And if you do have some success with these primitive instructions, this is indeed a sign of better things to come, when your chest is mobilized and working better, and you have mastered some breathing skills.

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Understanding Breathing Attacks

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There are several reasons why you might be having a  Breathing Attack  or  Acute Dyspnea Attack.  Essentially this is an exacerbation of dyspnea (shortness of breath) on top of whatever background of chronic dyspnea you might have. The five commonest reasons for these dyspnea attacks are:

    *  Exertion
    *  Coughing up mucus
    *  Bronchospasm ( Asthma ) exacerbation
    *  The Rescue Breathing Pattern
    *  Dynamic Hyperinflation

1.) EXERTION
This is the commonest cause of a dyspnea attack. You have exerted yourself beyond the point where your lungs can provide the necessary increased ventilation to meet your increased metabolic needs (i.e. taking in more Oxygen and getting rid of more Carbon Dioxide) due to increased activity. A crucial skill you must learn is measured pacing of your activities at a slower and lower effort level, for whatever particular activity you are doing. We will discuss this in detail in another module, as well as some breathing strategies to help this problem.

2.) COUGHING UP MUCUS
Coughing is normal and necessary to clear mucus ( phlegm ) from your lungs. However, should you cough up a larger blob of mucus from deep within the lung, and it sticks in the larger airways, this can precipitate a more violent coughing and choking spell. This is particularly common in the hour or two after waking up, as mucus has been accumulating overnight, and tends to be thicker and stickier. We will discuss this in detail in another module, and show you the more efficient Huff Cough technique used in COPD.

3.) BRONCHOSPASM ( ASTHMA ) EXACERBATION
Bronchospasm refers to a spasm contraction of the muscles in the bronchial tubes, thereby making them narrower and therefore more restrictive as to being able to move air freely. It is commonly called an  Asthma Attack,  but technically Asthma is a separate entity from COPD, though indeed there is some overlap of the two conditions. It is better to use the term  bronchospasm  if you have COPD, because directions for treating true Asthma that you might hear of, may, or may not, be appropriate for COPD. We will discuss this in detail in another module, and show you the Metered Dose Inhaler (MDI) technique to inhale so-called  Rescue Medications  into your lungs for faster and more effective asthmatic or bronchospasm relief.

4.) The RESCUE BREATHING PATTERN
This is a very common breathing pattern of rapid and more forceful breathing, which develops when patients get upset or panicky. The basis for this problem is entirely psychological, but the consequences have serious physiological implications. It is often seen when patients develop some shortness of breath for whatever reason, and then become (understandably) upset, acutely precipitating this abnormal breathing pattern. This is most unfortunate, because they will then develop further dyspnea. Rapid and forced breathing is very detrimental to COPD breathing control. We will discuss this in detail in another module, and show you techniques to control this problem.

5.) DYNAMIC HYPERINFLATION
Dynamic Hyperinflation refers to overinflation of the lung, because the air you have inhaled does not have sufficient time to fully exhale, and therefore your lungs progressively inflate into a position where breathing becomes much more difficult.

Dynamic Hyperinflation is commonly seen with acute Asthma attacks, as well as COPD bronchospasm attacks. And as noted above, in COPD patients exerting themselves and breathing faster. Dynamic Hyperinflation prevention and/or correction is a major reason why breathing control techniques work in COPD. It is therefore crucial you understand this concept. We will discuss this in detail in another module, and show you techniques to control this critically important problem.

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Breathing  Control  Overview

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Note: In order to easily follow the description of this diagram, it is suggested that you first print it.
You can do this by right clicking on the diagram, and then use the commands "View as" or "Copy" (or similar words). This will put the diagram in the computer clipboard, and you can print it from there.

Breathing training with the Breathing Trainer for COPD needs to be put in perspective, and the following diagram briefly summarizes some of the major physiologic components.


Breathing training and the Breathing Trainer is only part of the equation in breathing control, though certainly a very important part. It can show you very effectively how to breathe, but no breathing is possible without an effective chest and diaphragm so-called "Bellows" mechanism to make the lungs actually move. All active lung movement is totally dependent on an effective Bellows mechanism to enable more efficient breathing pattern training. It is therefore important you have some understanding of the bellows mechanism. In another module we will describe how the COPD chest becomes deformed into the so-called "Barrel Chest" deformity, the physiologic consequences of this, and how to deal with that problem with chest physiotherapy techniques.

The Bellows mechanism is composed of the "Chest Wall" as noted in the center of the diagram. The Chest Wall in turn has two distinct components, the "Ribs" of the chest, and the "Diaphragm," which is a thin curved muscle between the chest and the abdomen, attached to the lower ribs. The diaphragm is the major driving force of breathing, and in COPD it's function is typically severely compromised, by lung overinflation that pushes the diaphragm downwards into the abdomen, putting it into a position of mechanical inefficiency. It is critically important that diaphragm function be restored as much as possible, in order that you can then effectively use breathing training to learn more efficient breathing patterns.

The breathing pattern parameters are defined in the center of the diagram, by adjusting:

    * Tidal Volume (i.e. the breath volume of air)
    * Respiratory Rate (i.e. the number of breaths per minute)
    * Inspiration : Expiration Time Ratio (i.e. the relative time of the Inspiration and Expiration components)
    * End-Inspiration and End-Expiration Pauses (i.e. slight breath hold times at the end of inspiration and expiration)
    * Inspiration and Expiration Waveforms (i.e. the shape of the inspiration and expiration breathing pattern. NOTE: The complexity of waveform considerations has been omitted from the Breathing Trainer.)

As noted in the small diagram on the right, it is critical the breathing pattern achieve a minimal adequate degree of "Alveolar Ventilation," i.e. the ventilation breath that actually gets down to lung alveoli (air sacks) where gas exchange takes place.

However, as noted in the small diagram on the left, it is also critical that the breathing pattern produce the minimal degree of "Work of Breathing" i.e. a measure of the effort and energy to breathe, as dyspnea is most closely related to the increased Work of Breathing.

It should be apparent that there are conflicting needs involved in developing an optimal breathing pattern, and that balancing these different breathing parameters of adequate Alveolar Ventilation versus minimal Work of Breathing is a delicate task, and one that requires compromises.

Considerable experimental adjustment may be needed to achieve the optimal compromise. I am impressed as to how small adjustments may make substantial differences in patient comfort. The Breathing Trainer is designed to permit very subtle adjustments to permit you to seek out the breathing pattern that is best for you. Another module will go into detail as to how to adjust your Breathing Trainer to make a "Breathing Prescription" individualized for your particular needs.

Be aware there are many therapists who strongly advocate for one or another type of breathing pattern. I would suggest that frequently a strong advocacy position does not take into account the fact that most every breathing parameter adjustment has both positive benefits, and also undesirable negative factors. The trick is to find the optimal balance between these conflicting parameters.

Please do not skip directly to the module on Breathing Trainer adjustment. It is suggested you proceed to the Barrel Chest module, to better understand the underlying problems that must be corrected by chest physiotherapy.

The more you know about these conflicting parameter requirements, the better the results you will achieve in your rehabilitation program.

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The  Barrel  Chest  Deformity

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COPD / Emphysema classically produces the "Barrel Chest Deformity" as noted in this diagram from Dr. Frank Netter.

These changes develop slowly, over many months and years. As such, the early Barrel Chest may be subtle and difficult to recognize, but it is still of importance.

Note the chest is generally overinflated. This is because the lungs are overinflated, and pushing the chest wall out.

Also note the humped back deformity, called Kyphosis, pushing the upper chest and neck forward. Poor general posture is a significant result, and it impacts unfavorably on your ability to breathe.

When pushed out in this manner the normal outward rib movement of the lower / lateral chest becomes limited. And with limited movement comes stiffness, and further movement limitation. This movement limitation will limit your ability to take in a deep breath.

As a result the chest wall becomes "frozen," and the entire chest now is less capable of expanding and therefore further limiting larger breaths. Also, the "frozen" state now results in the chest now moving as a single unit, so-called "Unit Movement," instead of the two distinct chest movements as noted below.

The result is a shift to inefficient abnormal upper chest breathing, using the so-called "Accessory Muscles" of breathing, and therefore a decrease in the normally dominant outward lower / lateral chest breathing. The diaphragm is attached to the lower ribs, and normally has a coordinated and synergistic movement with these ribs. Without this coordinated movement, diaphragm function is significantly impaired. It is therefore very important to restore proper outward lower chest movement in order to allow better diaphragm function. And likewise to minimize the upper chest movement, which should only be used in emergency breathing situations.

Remember, the diaphragm is the major muscular organ that drives breathing, and therefore restoring that function is critically important.

To give you a better understanding of the two distinct chest movements, consider the anatomy of the ribs, as taken from Grant's Atlas of Anatomy.


Note the upper ribs are short and relatively straight. The muscles that move these ribs are centrally placed, and therefore pull the chest directly upward and outward, with the so-called "Pump Handle" movement. With the "frozen" chest, this is what pulls the chest upward and outward with the so-called "Unit Movement."

The lower chest movement is more complex. Other than for the almost straight "short ribs" 12 and 11, the lower ribs are sharply curved. Between these ribs are the "External Intercostal Muscles" which that slant forward and downward to the ribs below. When these muscles contract, the ribs are pulled in an upward and lateral direction, which expands the lower chest. This is the so-called "Bucket Handle" movement.

This outward and lateral Bucket Handle movement is what stretches the attached diaphragm muscle into a more favorable position of movement, and what restores some of the important synergistic movement between ribs and diaphragm.

This diagram taken from Cherniack and Cherniack's text "Respiration in Health and Disease" brilliantly illustrates the complex rib movements of the "Pump Handle" and Bucket Handle" movements.


Note the different actions between the 3rd and 9th ribs.

As the large majority of lung volume is in the lower chest, and considering this illustration of the Bucket Handle movement, can there be any doubt as to the importance of lower / lateral / outward chest movement in restoring diaphragm function?

We will now move on to the topic of chest mobilization, chest movement training and coordination, and chest strengthening, using Chest Physiotherapy techniques. And then the all important topic of Dynamic Hyperinflation, and using breathing strategies to prevent or correct this problem.

With the knowledge you have from these preliminary modules you will then have better understanding of the underlying basics, and why we are asking you to practice certain techniques. And you will be in a better position to learn about effective breathing pattern training.

In other modules we will elaborate on general posture improvement, including neck positioning, as well as some specific posture tricks that will assist your breathing.

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Chest  Physical  Therapy

This is a complex task, and ideally would require a skilled professional Physical Therapist (Chest Physiotherapist) to use "hands on" techniques to augment chest movements and teach corrective and coordinated movements, and enhance joint flexibility with local massage and supplemental heat or diathermy. However, as previously indicated, these services are difficult to find in North America, as indeed there are presently only about 130 credentialed Cardio-Pulmonary Physical Therapists in the United States. We will provide you with self-help instructions that will cover the major points of this technology, but regardless of these instructions, you are encouraged to use them in conjunction with your physician and appropriate other health care providers.

However, there is another option you might consider, and that is Yoga. Dr. Vijai Sharma, a practicing clinical psychologist and credentialed Yoga instructor with a particular interest in COPD, has developed training DVD videos designed specifically for home use by people with COPD. Dr. Sharma is currently offering two DVDs and instruction manuals:
"Stretching Breathing Exercises adapted for people with severe COPD" and
"Stretching Breathing for COPD For all levels of fitness".

The various Yoga spine and neck exercises, coupled with Yoga breathing exercises and breathing coordination with general body movements, seem well suited to substituting and/or complementing traditional Chest Physical Therapy, and some aspects of traditional Occupational Therapy. Dr. Sharma has a web site with many helpful COPD instructions, and in particular as to COPD anxiety and depression. His instruction videos may be purchased at his web site (  www.mindpub.com ).

Physical Therapy is much involved with so-called "Adaptive Substitution Movements or commenly-called "Trick Movements," which basically is the use of different muscular groups to assist the function of impaired neuromuscular groups. There are "Good Trick Movements" (i.e. Adaptive Substitution Movements) which are productive, and "Bad Trick Movements" (i.e. Mal-Adaptive Substitution Movements) which are not efficient or productive.

Bad Trick Movements may develop during the course of a disease, and they may also appear any time one is doing therapeutic neuromuscular training. It is therefore important to watch out for bad trick movements developing, and to correct them. In diaphragmatic breathing training there is one common bad trick movement called the "Belly Puffing Artifact" that must not be allowed to happen.


While standing, breathe IN deeply, and at the same time suck your abdomen IN. Then exhale fully, and while doing so, puff your abdomen OUT. Note this is 180 degrees out of phase with the normal abdominal movement due to diaphragm action. Now, lying flat on your back, do the same Belly Puffing maneuver, and note how easy it is to do. Belly Puffing is not simply a shifting of thoracic-abdominal contents by gravity.

Abdominal Belly Puffing that is 180 degrees out of phase with true diaphragm action is called "Paradoxical Chest Movement," and it is usually easy to detect. However, much more common, and much harder to detect, are partial forms of Belly Puffing, producing various degrees of "Asynchronous Breathing" that may be easily confused for true diaphragm movement. With more severe degrees of Asynchronous Breathing you may think you are getting good diaphragmatic breathing, but in fact your diaphragm movement may be substantially sub-optimal.

The only true abdominal indication of diaphragmatic breathing is the rise of the abdomen that flows naturally from the action of the rib Bucket Handle movement, and this doesn't happen until about 1/4 to 1/3 or more into inspiration. Abdominal puffing prior to this inspiration timing is Belly Puffing. Even more subtle and difficult to detect, is partial Belly Puffing later during inspiration.

There are two commonly practiced diaphragmatic breathing techniques that should not be done, because they have a substantial chance they are in fact teaching Belly Puffing, not true diaphragmatic breathing training.



Note one hand placed on the upper chest, and the other on the abdomen, just below the ribs. Typically this exercise is done from the sitting or lying position.

The patient is instructed to not move the upper chest while breathing in (i.e. to correct the abnormal "Pump Handle" movement), and at the same time to have the abdomen come out with inhalation, to teach diaphragm movement.

Note however, these instructions are in fact likely to teach Belly Puffing, not true diaphragm breathing.

The proper instruction is to have the patient direct their inspiration breathing to the lowest rib margin, directly beneath the anterior margin of the arm pit. This will make the chest move outwards and upwards because of the "Bucket Handle" movement. There should be no abdominal movement for about 1/4 to 1/3 of inspiration, and at that point the abdomen will then begin to protrude outwards. But this time abdominal protrusion is the result of true diaphragm movement.

All abdominal movement on inspiration should flow naturally from correct "Bucket Handle" chest movement.

Another problematic technique which is commonly taught, is, while lying down, to have a weight just below the ribs, and to concentrate on making the weight rise on inspiration. This is similar to the two hand technique noted above.

By focusing on making the weight rise, again, this has obvious potential to teach Belly Puffing.

However, this technique can be a useful one, provided the therapist uses two flat sand-bag type weights, each positioned along the lower-lateral rib margin, with no more than half the weight lying on the abdomen. If the patient watches the weights move in this position, they will now have a visual biofeedback prompt to encourage performance of the Bucket Handle chest movement. In addition, with graded weights this exercise may enhance chest wall strength.

The correct hand position for diaphragm breathing training is as noted.
Note the hands on the lower rib margins, directly below the anterior portion of the arm pits. The fingers, preferably only the distal half of the fingers, are over the lowest ribs and on the abdomen. The inspiration breath should be gently directed towards the palms of the hands, which should rise gently. And try to feel the air moving into this region. Learn to recognize this feeling of correct breathing.

There is an alternate hand placement trick, to guide you to the correct Bucket Handle movement, which some patients find easier to do. Raise the elbows up to shoulder height, and let the hands dangle. Then, curl the fingers until they are facing the floor. Then place the backs of the fingers on the very lowest rib margin, directly under the arm pits.

As the ribs swing outward and upwards, with a little practice about 1/3 of the way through inspiration you should be able to feel the diaphragm gently rising against your finger tips. And about this time the abdomen should gently rise, but this time because of true diaphragm movement. The hand positioning is providing the signal to train you in correct diaphragm breathing. With only a month or so of diligent practice you should be able to do this type of breathing naturally, and without using the hand prompting signal.

Note that I have made no mention of inhibiting the abnormal upper-anterior "Pump Handle" chest movement, which commonly taught, and which causes the upward "Unit Movement" of the chest. This is seldom needed. If indeed you correctly focus on the correct "Bucket Handle" movement this upper chest movement will gradually disappear. Occasionally however, some directed voluntary suppression of this upper chest movement is needed.

Generally you should teach yourself to recognize this abnormal upper chest movement, and during quiet breathing, to voluntarily suppress this upper chest movement.

However, If your breathing reserves are low, and at times of breathing distress, you may need to use your accessory muscles of respiration to employ the Pump Handle movement as an emergency breathing mechanism. This is an advanced breathing technique. The important point to remember, is to let any upper chest movement flow naturally from the dominant lower chest Bucket Handle movement. The Bucket Handle movement is always primary, and the key to success. Just as abdominal diaphragmatic movement flows later from the Bucket Handle movement, so to does the upper chest Pump Handle movement flow later from the Bucket Handle rib action.

You will need this upper chest suppression skill to help correct the Rescue Breathing Pattern. More on this subject in a later module.

The Video for this is in the Chest Physical Therapy module