Probably the most important thing that you can learn in a pulmonary rehabilitation class is a more efficient way of breathing. 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 may feel that you “suddenly” developed a problem with your breathing after getting that last episode of flu or pneumonia. Actually, COPD is a disease that slowly progresses over a twenty or thirty-year period. The first thing that happens, maybe while you were still a teenage smoker, is that the elastic fibers in your lungs start to deteriorate, and lungs start losing their elastic recoil. Just like our skin gets less ‘springy’ with age, your lungs can also get less springy as a result of smoking or of simply getting older. This loss of elasticity causes the lungs to lose their ability to get air out efficiently. This may get worse age you get older, especially if you continued to smoke, and some people start to develop air trapping in their lungs. Air trapping describes areas of the lung where air get in but can’t get out.
Everybody has some air in their lungs, even after they breathe out as much as they can. This is normal and prevents the alveoli, the little air sacks, from collapsing flat as an old balloon. The air left in the lungs after you breathe all the way out is called residual volume (RV). Patients with COPD who have air trapping may have an RV that is 200% or more compared to a healthy individual of the same age. Why does that matter? This trapped air can compress some of the undamaged alveoli (the good parts of your lungs) so that they don’t work efficiently. The other thing that happens is that those larger lungs, full of trapped air, start to push your chest outwards. Have you noticed that your chest size is larger, or that your bra size has increased? A change in the elastic recoil of your lungs may be why.
Another effect of air trapping is that the diaphragm becomes flattened. The diaphragm, which does about 80% of the work of breathing, is normally dome-shaped – a bit like the shape of an old fashioned parachute. When you breathe in, the diaphragm contracts and flattens out, which helps to suck air into your lungs. But in a COPD patient, the diaphragm may be already flat to begin with (to make room for all that trapped air), which makes breathing in harder work. The mechanics of breathing are all thrown off. A flat diaphragm can be seen on your chest x-ray. In this position, you start to use accessory muscles of breathing, such as your shoulder and neck muscles. Normally these muscles are only meant for use in emergencies, like when running fast. These muscles are inefficient, and using them makes you feel more short of breath. 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 many times harder to breathe than a person without lung disease.
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.
That loss of elasticity in your lungs is the first thing for you to remember. In practical terms, it means you now have to work to get air out of your lungs. Think of a balloon. You work to get air into a balloon, but when you let go of the neck of the balloon, elastic recoil shoots the air out of the balloon without any effort on your part. Healthy lungs do the same thing. However, lungs that have lost elastic recoil by years of smoking or simply by older age have to work to get the air out. It’s like blowing air into a paper bag. You have to squeeze the air out of the bag since it won’t flatten out by itself. Now you also have to work to get air out of your lungs, as well work to get air into the lungs as you have always done in the past.
Getting air out of the lungs will take longer, so the next thing to remember is to slow your breathing and concentrate on breathing out. You have been breathing in all your life. You do that automatically, so forget about getting air into your lungs! That is not your problem. Your problem now is working to get air out, which you never had to do before. That is why 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 as your lungs fill with trapped air. In our studies, patients who did good pursed lip breathing (PLB) sometimes slowed down to as little as 10 breaths a minute while resting.
So, what about PLB. Does it really help? Yes, it does! Correctly done, PLB can raise the oxygen level of your blood as much, and faster, than breathing with supplemental oxygen set to 2 liters per minute.
Then why do some of you not feel much better when you use PLB? 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 slowly breathe out about 2 to 3 times longer through slightly pursed lips; you should have just a small opening in the center of your lips. Think in terms of gently blowing air out, just hard enough to make a candle flame flicker, but not hard enough to blow out the candle completely. Remember, it is very important to slow your breathing and concentrate on breathing out. Pursing your lips is one of the techniques that helps you to do that.
There are several mistakes patients make when trying PLB for the first time. One is blowing out too forcefully. If you use too much force, you can actually lower the oxygen saturation level of your blood and feel worse! If someone can hear you breathe out, you are working at this too hard! If you breathe out too forcefully, you may even wheeze; a sign that some airways are collapsing and the air is having to ‘squeak’ out. 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 gulping a little air in through the mouth before breathing out, or while trying to breathe out, so watch to make sure you are not doing that.
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! It is essential that you slow down and concentrate on breathing out longer than you breathe in. This message can’t be repeated too often.
How can you tell if you are doing effective PLB? Using a pulse oximeter (see our other article on “oximetry” in this series) is one of the easiest ways of telling whether or not you are doing effective PLB. Borrow one to try if you can. Pulse oximeters also are now widely available to purchase and are relatively inexpensive. It is a good investment. If your oxygen level is low, say 88%; with good PLB you can usually “blow the number up” to 93%. Practiced breathers can sometimes get their oxygen saturation all the way up to 98%, but 93% or higher is a good number to aim for. What happens if you breathe incorrectly? Maybe nothing, except that you don’t feel less short of breath. With the oximeter, you will see for yourself that your oxygen saturation levels will drop and continue to drop until you stop blowing out so hard. With the correct PLB technique, breathing will feel natural, your oxygen saturation numbers will increase, and you should feel less short of breath.
Now that you have learned those new breathing techniques let’s move on to the next big problem we see in pulmonary rehabilitation classes: the use of accessory muscles. Lowering those shoulders and not making them go up and down to breathe with can give immediate relief of shortness of breath. Stop using your shoulders to help you breathe, because it will only make things worse! Raising and lowering the shoulders means that you are working harder and consuming more oxygen, which means you have to breathe even harder! It may take time to break this habit, but it can be done. Relax the shoulders, calm the breathing, and breathe out slowly through pursed lips. Watch yourself in the mirror while you breathe. See for yourself how much better you feel when you drop and relax your 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 or on the bed. Put one hand on your chest and the other on your belly. Keep the hand on your chest free of movement while the one on your belly goes up and down. Put a Kleenex box on your belly and watch the box go up and down without moving the hand on your chest. 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 we’ve seen so many people master it during their pulmonary rehabilitation classes. 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 intercostal muscles. Ordinarily, these muscles are used to expand and contract the chest, moving air in and out of the lungs, like bellows. In COPD patients, the lungs lose elastic recoil and expand because of trapped air over the years, which causes the ribs to become fixed in one position, and the intercostal muscles stop doing the work of breathing. You can use a belt or a tie to help your muscles relearn what they should be doing naturally. Wrap a belt or tie (or any soft length of material) lightly around your lower ribs crossing the tape over in front as if you were about to tie it in a bow. But Do Not Tie It! Inhale. And as you inhale, loosen the tape as your lungs expand. Exhale and pull the tape tighter as you exhale, gently 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 those who suffer from restrictive pulmonary diseases such as idiopathic pulmonary fibrosis? Do these breathing techniques work for them also? Very little research has been done on that since, at one time, it was felt that PLB only worked with COPD. Dr. Brian Tiep and Mary Burns published a small study demonstrating the effectiveness of PLB in patients with restrictive lung disease, but their results have not been widely validated by other studies that we know of. However, we have seen that PLB also works for restrictive lung diseases. In fact, Mary’s patients were the first to show that they could also raise their oxygen saturation with good PLB technique. Patients with a restrictive disease usually only need to slow their breathing down to about 16 breaths a minute. And they needn’t work on exhaling longer than they inhale since air trapping isn’t a problem for most of them. However, there are many kinds of restrictive disease, so these patients have a greater need to experiment to see what works best for them.
For patients with respiratory diseases, there is nothing as important as improving your breathing techniques. It can give you immediate relief for shortness of breath and help you control panic. It will also prepare you to start improving your exercise tolerance as part of a pulmonary rehabilitation program, which is the most effective therapy we know for COPD and many other lung diseases. If you wish to ask questions about these techniques, you can send an email to the PERF website.
Best wishes for better breathing!
By Mary Burns, RN, BS
PERF Executive Vice President