Skip to main content
SpringerLink
Log in
Book cover

Textbook of Pulmonary Rehabilitation pp 205–216Cite as

Breathing Exercises and Mucus Clearance Techniques in Pulmonary Rehabilitation

  • Chapter
  • First Online:

Abstract

Introduction: Patients with chronic respiratory conditions suffer from alterations in the mechanics of breathing and mucociliary clearance with symptoms of dyspnoea, cough and reduced exercise capacity. Pulmonary rehabilitation aims to improve these symptoms and subsequently reduce the associated morbidity and improve quality of life.

Methods: Techniques for breathing exercises and mucus clearance techniques are described and the rationale and evidence for their inclusion in pulmonary rehabilitation is explored.

Results: The most common breathing exercises included in pulmonary rehabilitation are diaphragmatic breathing and pursed lips breathing. While there is evidence for benefit in some individuals in terms of breathing pattern, not all patients respond to breathing exercises, with some experiencing a worsening in symptoms and work of breathing. The application of mucus clearance techniques requires individual assessment for indication, efficacy and preference for technique.

Conclusion: There is no evidence to support the routine inclusion of breathing exercises or mucus clearance techniques in a pulmonary rehabilitation programme. These techniques should be trialled on an individual basis with appropriate evaluation for benefit.

This is a preview of subscription content, log in via an institution.

References

  1. Gosselink R. Breathing techniques in patients with chronic obstructive pulmonary disease (COPD). Chron Respir Dis. 2004;1(3):163–72.

    Article  CAS  PubMed  Google Scholar 

  2. Breslin EH. Breathing retraining in chronic obstructive pulmonary disease. J Cardiopulm Rehabil. 1995;15(1):25–33.

    Article  CAS  PubMed  Google Scholar 

  3. Pulmonary rehabilitation-1999. American Thoracic Society. Am J Respir Crit Care Med. 1999;159(5 Pt 1):1666–82.

    Google Scholar 

  4. Breslin EH. The pattern of respiratory muscle recruitment during pursed-lip breathing. Chest. 1992;101(1):75–8.

    Article  CAS  PubMed  Google Scholar 

  5. Nield MA, Soo Hoo GW, Roper JM, Santiago S. Efficacy of pursed-lips breathing: a breathing pattern retraining strategy for dyspnea reduction. J Cardiopulm Rehabil Prev. 2007;27(4):237–44.

    Article  PubMed  Google Scholar 

  6. Tiep BL, Burns M, Kao D, Madison R, Herrera J. Pursed lips breathing training using ear oximetry. Chest. 1986;90(2):218–21.

    Article  CAS  PubMed  Google Scholar 

  7. Holland AE, Hill CJ, Jones AY, McDonald CF. Breathing exercises for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012;10:CD008250. doi:10.1002/14651858.CD008250.pub2.

    Article  PubMed  Google Scholar 

  8. Lewis LK, Williams MT, Olds T. Short-term effects on outcomes related to the mechanism of intervention and physiological outcomes but insufficient evidence of clinical benefits for breathing control: a systematic review. Aust J Physiother. 2007;53(4):219–27.

    Article  PubMed  Google Scholar 

  9. Cahalin LP, Braga M, Matsuo Y, Hernandez ED. Efficacy of diaphragmatic breathing in persons with chronic obstructive pulmonary disease: a review of the literature. J Cardiopulm Rehabil. 2002;22(1):7–21.

    Article  PubMed  Google Scholar 

  10. Fernandes M, Cukier A, Feltrim MIZ. Efficacy of diaphragmatic breathing in patients with chronic obstructive pulmonary disease. Chron Respir Dis. 2011;8(4):237–44.

    Article  PubMed  Google Scholar 

  11. Roberts SE, Stern M, Schreuder FM, Watson T. The use of pursed lips breathing in stable chronic obstructive pulmonary disease: a systematic review of the evidence. Phys Therapy Rev. 2009;14(4):240–6.

    Article  Google Scholar 

  12. Mueller RE, Petty TL, Filley GF. Ventilation and arterial blood gas changes induced by pursed lips breathing. J Appl Physiol. 1970;28(6):784–9.

    Article  CAS  PubMed  Google Scholar 

  13. Jones AY, Dean E, Chow CC. Comparison of the oxygen cost of breathing exercises and spontaneous breathing in patients with stable chronic obstructive pulmonary disease. Phys Ther. 2003;83(5):424–31.

    PubMed  Google Scholar 

  14. Spahija J, de Marchie M, Grassino A. Effects of imposed pursed-lips breathing on respiratory mechanics and dyspnea at rest and during exercise in COPD. Chest. 2005;128(2):640–50.

    Article  PubMed  Google Scholar 

  15. Bianchi R, Gigliotti F, Romagnoli I, Lanini B, Castellani C, Binazzi B, Stendardi L, Grazzini M, Scano G. Patterns of chest wall kinematics during volitional pursed-lip breathing in COPD at rest. Respir Med. 2007;101(7):1412–8.

    Article  PubMed  Google Scholar 

  16. Visser FJ, Ramlal S, Dekhuijzen PN, Heijdra YF. Pursed-lips breathing improves inspiratory capacity in chronic obstructive pulmonary disease. Respiration. 2011;81(5):372–8.

    Article  PubMed  Google Scholar 

  17. Casciari RJ, Fairshter RD, Harrison A, Morrison JT, Blackburn C, Wilson AF. Effects of breathing retraining in patients with chronic obstructive pulmonary disease. Chest. 1981;79(4):393–8.

    Article  CAS  PubMed  Google Scholar 

  18. Dolmage TE, Janaudis-Ferreira T, Hill K, Price S, Brooks D, Goldstein RS. Arm elevation and coordinated breathing strategies in patients with COPD. Chest. 2013;144(1):128–35.

    Article  PubMed  Google Scholar 

  19. Collins EG, Langbein WE, Fehr L, O'Connell S, Jelinek C, Hagarty E, Edwards L, Reda D, Tobin MJ, Laghi F. Can ventilation-feedback training augment exercise tolerance in patients with chronic obstructive pulmonary disease? Am J Respir Crit Care Med. 2008;177(8):844–52.

    Article  PubMed  Google Scholar 

  20. van Gestel AJ, Kohler M, Steier J, Teschler S, Russi EW, Teschler H. The effects of controlled breathing during pulmonary rehabilitation in patients with COPD. Respiration. 2012;83(2):115–24.

    Article  PubMed  Google Scholar 

  21. McCarthy B, Casey D, Devane D, Murphy K, Murphy E, Lacasse Y. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2015;2:CD003793. doi:10.1002/14651858.CD003793.pub3.

    Article  Google Scholar 

  22. Blackstock FC, Webster KE, McDonald CF, Hill CJ. Comparable improvements achieved in chronic obstructive pulmonary disease through pulmonary rehabilitation with and without a structured educational intervention: a randomized controlled trial. Respirology. 2014;19(2):193–202.

    Article  PubMed  Google Scholar 

  23. Yamaguti WP, Claudino RC, Neto AP, Chammas MC, Gomes AC, Salge JM, Moriya HT, Cukier A, Carvalho C. Diaphragmatic breathing training program improves abdominal motion during natural breathing in patients with chronic obstructive pulmonary disease: a randomized controlled trial. Arch Phys Med Rehabil. 2012;93(4):571–7.

    Article  PubMed  Google Scholar 

  24. Garrod R, Dallimore K, Cook J, Davies V, Quade K. An evaluation of the acute impact of pursed lips breathing on walking distance in nonspontaneous pursed lips breathing chronic obstructive pulmonary disease patients. Chron Respir Dis. 2005;2(2):67–72.

    Article  CAS  PubMed  Google Scholar 

  25. Bhatt SP, Luqman-Arafath TK, Gupta AK, Mohan A, Stoltzfus JC, Dey T, Nanda S, Guleria R. Volitional pursed lips breathing in patients with stable chronic obstructive pulmonary disease improves exercise capacity. Chron Respir Dis. 2013;10(1):5–10.

    Article  PubMed  Google Scholar 

  26. Faager G, Stahle A, Larsen FF. Influence of spontaneous pursed lips breathing on walking endurance and oxygen saturation in patients with moderate to severe chronic obstructive pulmonary disease. Clin Rehabil. 2008;22(8):675–83.

    Article  CAS  PubMed  Google Scholar 

  27. de Araujo CLP, Karloh M, Dos Reis CM, Palú M, Mayer AF. Pursed-lips breathing reduces dynamic hyperinflation induced by activities of daily living test in patients with chronic obstructive pulmonary disease: A randomized cross-over study. J Rehabil Med. 2016;47(10):957–62.

    Article  Google Scholar 

  28. Cabral LF, D'Elia TDC, Marins DDS, Zin WA, Guimarães FS. Pursed lip breathing improves exercise tolerance in COPD: a randomized crossover study. Eur J Phys Rehabil Med. 2015;51(1):79–88.

    PubMed  Google Scholar 

  29. Roberts SE, Schreuder FM, Watson T, Stern M. Do COPD patients taught pursed lips breathing (PLB) for dyspnoea management continue to use the technique long-term? A mixed methodological study. Physiotherapy. 2016; doi:10.1016/j.physio.2016.05.006.

  30. Rubin BK. Physiology of airway mucus clearance. Respir Care. 2002;47:761–8.

    PubMed  Google Scholar 

  31. Houtmeyers E, Gosselink R, Gayan-Ramirez G, Decramer M. Regulation of mucociliary clearance in health and disease. Eur Respir J. 1999;13:1177–88.

    Article  CAS  PubMed  Google Scholar 

  32. Hess DR. Airway clearance: physiology, pharmacology, techniques, and practice. Respir Care. 2007;52(10):1392–6.

    Google Scholar 

  33. Zach MS. Lung disease in cystic fibrosis—an updated concept. Pediatr Pulmonol. 1990;8(3):188–202.

    Article  CAS  PubMed  Google Scholar 

  34. Hernandez ML, Harris B, Lay JC, Bromberg PA, Diaz-Sanchez D, Devlin RB, Kleeberger SR, Alexis NE, Peden DB. Comparative airway inflammatory response of normal volunteers to ozone and lipopolysaccharide challenge. Inhal Toxicol. 2010;22:648–56.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  35. Rubin BK. Mucus, phlegm, and sputum in cystic fibrosis. Respir Care. 2009;54:726–32. Discussion 732

    Article  PubMed  Google Scholar 

  36. Fahy JV, Dickey BF. Airway mucus function and dysfunction. N Engl J Med. 2010;363:2233–47.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  37. Nelson HP. Postural drainage of the lungs. Br Med J. 1934;2:251–5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  38. Kim CS, Iglesias AJ, Sackner MA. Mucus clearance by two-phase gas-liquid flow mechanism: asymmetric periodic flow model. J Appl Physiol. 1987;62:959–71.

    Article  CAS  PubMed  Google Scholar 

  39. Postiaux G. Chest physical therapy of the distal lung. Mechanical basis of a new paradigm. Rev Mal Respir. 2014;31:552–67.

    Article  CAS  PubMed  Google Scholar 

  40. Martins JA, Dornelas de Andrade A, Britto RR, Lara R, Parreira VF. Effect of slow expiration with glottis opened in lateral posture (ELTGOL) on mucus clearance in stable patients with chronic bronchitis. Respir Care. 2012;57:420–6.

    Article  PubMed  Google Scholar 

  41. Agostini P, Knowles N. Autogenic drainage: the technique, physiological basis and evidence. Physiotherapy. 2007;93:157–63.

    Article  Google Scholar 

  42. Osadnik CR, McDonald CF, Miller BR, Hill CJ, Tarrant B, Steward R, Chao C, Stodden N, Oliveira CC, Gagliardi N, Holland AE. The effect of positive expiratory pressure (PEP) therapy on symptoms, quality of life and incidence of re-exacerbation in patients with acute exacerbations of chronic obstructive pulmonary disease: a multicentre, randomised controlled trial. Thorax. 2014;69:137–43.

    Article  PubMed  Google Scholar 

  43. Volsko TA, DiFiore J, Chatburn RL. Performance comparison of two oscillating positive expiratory pressure devices: Acapella versus Flutter. Respir Care. 2003;48:124–30.

    PubMed  Google Scholar 

  44. Armstrong D. The use of continuous positive airway pressure or non-invasive ventilation as forms of respiratory support in children with cystic fibrosis. Paediatr Respir Rev. 2013;14(1):19–21.

    Article  PubMed  Google Scholar 

  45. Venturelli E, Crisafulli E, DeBiase A, Righi D, Berrighi D, Cavicchioli PP, Vagheggini G, Dabrosca F, Balbi B, Paneroni M, Bianchi L, Vitacca M, Galimberti V, Zaurino M, Schiavoni G, Iattoni A, Ambrosino N, Clini EM. Efficacy of temporary positive expiratory pressure (TPEP) in patients with lung diseases and chronic mucus hypersecretion. The UNIKO(R) project: a multicentre randomized controlled trial. Clin Rehabil. 2013;27:336–46.

    Article  PubMed  Google Scholar 

  46. Snijders D, Fernandez Dominguez B, Calgaro S, Bertozzi I, Escribano Montaner A, Perilongo G, Barbato A. Mucociliary clearance techniques for treating non-cystic fibrosis bronchiectasis: is there evidence? Int J Immunopathol Pharmacol. 2015;28:150–9.

    Article  CAS  PubMed  Google Scholar 

  47. Toussaint M, Guillet MC, Paternotte S, Soudon P, Haan J. Intrapulmonary effects of setting, parameters in portable intrapulmonary percussive ventilation devices. Respir Care. 2012;57:735–42.

    Article  PubMed  Google Scholar 

  48. Garuti G, Verucchi E, Fanelli I, Giovannini M, Winck JC, Lusuardi M. Management of bronchial secretions with Free Aspire in children with cerebral palsy: impact on clinical outcomes and healthcare resources. Ital J Pediatr. 2016;42:7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  49. Bach JR, Goncalves MR, Hon A, Ishikawa Y, De Vito EL, Prado F, Dominguez ME. Changing trends in the management of end-stage neuromuscular respiratory muscle failure. Am J Phys Med Rehabil. 2013;92:267–77.

    Article  PubMed  Google Scholar 

  50. McCool FD. Nonpharmacologic airway clearance therapies. Chest. 2006;129:250S–12.

    Article  PubMed  Google Scholar 

  51. Fink JB. Forced expiratory technique, directed cough, and autogenic drainage. Respir Care. 2007;52:1210–21. discussion1221–3

    PubMed  Google Scholar 

  52. Dwyer TJ, Alison JA, McKeough ZJ, Daviskas E, Bye PTP. Effects of exercise on respiratory flow and sputum properties in patients with cystic fibrosis. Chest. 2011;139:870–7.

    Article  PubMed  Google Scholar 

  53. Rodriguez Hortal MC, Nygren-Bonnier M, Hjelte L. Non-invasive ventilation as airway clearance technique in cystic fibrosis. Physiotherapy. 2016; doi:10.1002/pri.1667.

  54. Osadnik CR, McDonald CF, Holland AE. Advances in airway clearance technologies for chronic obstructive pulmonary disease. Expert Rev Respir Med. 2013;7:673–85.

    Article  CAS  PubMed  Google Scholar 

  55. Chalmers JD, Aliberti S, Blasi F. Management of bronchiectasis in adults. Eur Respir J. 2015;45:1446–62.

    Article  PubMed  Google Scholar 

  56. Warnock L, Gates A. Chest physiotherapy compared to no chest physiotherapy for cystic fibrosis. Cochrane Database Syst Rev. 2015;12:CD001401.

    Google Scholar 

  57. Flume PA. Mogayzel PJ Jr., Robinson KA, Goss CH, Rosenblatt RL, Kuhn RJ, Marshall BC, and the Clinical Practice Guidelines for Pulmonary Therapies Committee*. Cystic Fibrosis Pulmonary Guidelines. Am J Respir Crit Care Med. 2009;180:802–8.

    Article  PubMed  Google Scholar 

  58. Lee AL, Burge AT, Holland AE. Airway clearance techniques for bronchiectasis. Cochrane Database Syst Rev. 2015;11:CD008351.

    Google Scholar 

  59. Sivasothy P, Brown L, Smith IE, Shneerson JM. Effect of manually assisted cough and mechanical insufflation on cough flow of normal subjects, patients with chronic obstructive pulmonary disease (COPD), and patients with respiratory muscle weakness. Thorax. 2001 Jun;56(6):438–44.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  60. Winck JC, Goncalves MR, Lourenço C, Viana P, Almeida J, Bach JR. Effects of mechanical insufflation-exsufflation on respiratory parameters for patients with chronic airway secretion encumbrance. Chest. 2004;126:774–80.

    Article  PubMed  Google Scholar 

  61. Osadnik CR, McDonald CF, Jones AP, Holland AE. Airway clearance techniques for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012;3:CD008328.

    Google Scholar 

  62. Andrews J, Sathe NA, Krishnaswami S, McPheeters ML. Nonpharmacologic airway clearance techniques in hospitalized Patients: a systematic review. Respir Care. 2013;58(12):2160–86.

    Article  PubMed  Google Scholar 

  63. Yang M, Yan Y, Yin X, Wang BY, Wu T, Liu GJ, Dong BR. Chest physiotherapy for pneumonia in adults. Cochrane Database Syst Rev. 2013;2:CD006338.

    Google Scholar 

  64. Tang CY, Taylor NF, Blackstock FC. Chest physiotherapy for patients admitted to hospital with an acute exacerbation of chronic obstructive pulmonary disease (COPD): a systematic review. Physiotherapy. 2010;96:1–13.

    Article  PubMed  Google Scholar 

  65. Stanford G, Parrott H, Bilton D, Agent P. Positive pressure—analysing the effect of the addition of non-invasive ventilation (NIV) to home airway clearance techniques (ACT) in adult cystic fibrosis (CF) patients. Physiother Theory Pract. 2014;31:270–4.

    Article  Google Scholar 

  66. Aquino ES, Shimura F, Santos AS, Goto DM, Coelho CC, de Fuccio MB, Saldiva PHN, Lorenzi-Filho G, Rubin BK, Nakagawa NK. CPAP has no effect on clearance, sputum properties, or expectorated volume in cystic fibrosis. Respir Care. 2012;57:1914–9.

    Article  PubMed  Google Scholar 

  67. Gambazza S, Zuffo S. CPAP in cystic fibrosis: is it time to surrender yet? Respir Care. 2013;58:e116–7.

    Article  PubMed  Google Scholar 

  68. Ireland CJ, Chapman TM, Mathew SF, Herbison GP, Zacharias M. Continuous positive airway pressure (CPAP) during the postoperative period for prevention of postoperative morbidity and mortality following major abdominal surgery. Cochrane Database Syst Rev. 2014;8:CD008930.

    Google Scholar 

  69. Faria DAS, da Silva EMK, Atallah ÁN, Vital FMR. Noninvasive positive pressure ventilation for acute respiratory failure following upper abdominal surgery. Cochrane Database Syst Rev. 2015;10:CD009134.

    Google Scholar 

  70. LoMauro A, D'Angelo MG, Aliverti A. Assessment and management of respiratory function in patients with Duchenne muscular dystrophy: current and emerging options. Ther Clin Risk Manag. 2015;11:1475–88.

    PubMed  PubMed Central  CAS  Google Scholar 

  71. Finder JD, Birnkrant D, Carl J, Farber HJ, Gozal D, Iannaccone ST, Kovesi T, Kravitz RM, Panitch H, Schramm C, Schroth M, Sharma G, Sievers L, Silvestri JM, Sterni L. Respiratory care of the patient with Duchenne muscular dystrophy: ATS consensus statement. Am J Respir Crit Care Med. 2004;170(4):456–65.

    Article  PubMed  Google Scholar 

  72. Rubin BK. Designing clinical trials to evaluate mucus clearance therapy. Respir Care. 2007;52:1348–58. discussion1358–61

    PubMed  Google Scholar 

  73. Ides K, Vissers D, De Backer L, Leemans G, De Backer W. Airway clearance in COPD: need for a breath of fresh air? A systematic review. COPD. 2011;8(3):196–205.

    Article  PubMed  Google Scholar 

  74. Volsko TA. Airway clearance therapy: finding the evidence. Respir Care. 2013;58:1669–78.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Physiotherapy Department, Austin Health, Melbourne, Australia

    Catherine J. Hill

  2. Institute for Breathing and Sleep, Heidelberg, Australia

    Catherine J. Hill

  3. Cardio-Thoracic and Vascular Department, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy

    Marta Lazzeri

  4. ARIR—Associazione Riabilitatori dell’Insufficienza Respiratoria, Pavia, Italy

    Marta Lazzeri & Francesco D’Abrosca

  5. SITRA—Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy

    Francesco D’Abrosca

Authors
  1. Catherine J. Hill
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Marta Lazzeri
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Francesco D’Abrosca
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Catherine J. Hill .

Editor information

Editors and Affiliations

  1. Department of Medical and Surgical Sciences, University of Modena, Azienda Ospedaliero Universitaria di Modena Policlinico, Modena, Italy

    Enrico Clini

  2. Alfred Health and Institute for Breathing and Sleep, La Trobe University, Melbourne, Australia

    Anne E. Holland

  3. State University of Londrina, Londrina, Paraná, Brazil

    Fabio Pitta

  4. Department of Rehabilitation Sciences, KU Leuven, Respiratory Division and Rehabilitation, University Hospital Leuven, Leuven, Belgium

    Thierry Troosters

Rights and permissions

Reprints and permissions

Copyright information

© 2018 Springer International Publishing AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Hill, C.J., Lazzeri, M., D’Abrosca, F. (2018). Breathing Exercises and Mucus Clearance Techniques in Pulmonary Rehabilitation. In: Clini, E., Holland, A., Pitta, F., Troosters, T. (eds) Textbook of Pulmonary Rehabilitation. Springer, Cham. https://doi.org/10.1007/978-3-319-65888-9_16

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-65888-9_16

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-65887-2

  • Online ISBN: 978-3-319-65888-9

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation