Breathing Control: The Complete Guide to Diaphragmatic & Pursed Lip Breathing

Breathing is automatic, but efficient breathing is a skill. In conditions like COPD, Asthma, or Anxiety, the breathing pattern becomes shallow, rapid, and reliant on accessory muscles (neck/shoulders). This guide provides a step-by-step masterclass on the two most critical techniques: Diaphragmatic Breathing (to reduce work) and Pursed Lip Breathing (to keep airways open).

1. Why Retrain Breathing?

Normal breathing is effortless. Pathological breathing is exhausting.

• The Problem (Hyperinflation): In obstructive lung disease, air gets trapped in the lungs. The diaphragm gets pushed flat and cannot descend properly. The patient uses neck muscles to lift the rib cage instead.
• The Solution: Retraining the diaphragm improves ventilation efficiency and reduces the "Work of Breathing" (WOB).

2. Diaphragmatic Breathing (Belly Breathing)

Goal: Restore the diaphragm as the primary muscle of inspiration.

The "Bucket Handle" Analogy:
Imagine a bucket handle (ribs) lifting up. Diaphragmatic breathing ensures the bucket expands outwards and downwards, filling the bottom of the lungs where gas exchange is best.

Step-by-Step Technique:

1. Position: Start in semi-fowler's (sitting reclined) or supine with knees bent (relaxes the abs).
2. Hand Placement: Place one hand on the upper chest and the other on the belly (just below ribs).
3. Inhale: Breathe in slowly through the nose. Visual Cue: "Send the air down to your belly button." Only the belly hand should rise. The chest hand should remain still.
4. Exhale: Breathe out gently through the mouth. The belly hand should sink in.
5. Practice: 5-10 minutes, 3 times a day.

Troubleshooting "Paradoxical Breathing"

Some patients suck their belly in when they inhale (Paradoxical). To fix this:

• Have them "sniff" quickly (sniffing naturally engages the diaphragm).
• Place a small weight (1-2kg sandbag) on the belly for proprioceptive feedback.

3. Pursed Lip Breathing (PLB)

Goal: Relieve shortness of breath (Dyspnea) and prevent airway collapse.

The Physics (Bernoulli Principle):

Exhaling against a narrow opening creates Positive Expiratory Pressure (PEP) inside the airways. This internal pressure acts like a stent, holding the floppy airways open longer so trapped air can escape.

Step-by-Step Technique:

1. Relax: Drop the shoulders. Relax the neck.
2. Inhale: Breathe in through the nose for a count of 2 (e.g., "Smell the roses").
3. Exhale: Pucker lips as if whistling or blowing out a candle. Breathe out slowly and gently for a count of 4 (e.g., "Flicker the candle flame").
4. Ratio: The ratio of Inhalation to Exhalation should be 1:2.

[Image of pursed lip breathing technique diagram]

4. When to use which?

Feature	Diaphragmatic Breathing	Pursed Lip Breathing
Primary Goal	Improve volume & efficiency. Reduce accessory muscle use.	Relieve acute dyspnea (shortness of breath). Empty trapped air.
Best For	Rest, post-op recovery, relaxation, anxiety.	COPD, Emphysema, Asthma attacks, exertion.
Mechanism	Maximizes lung expansion.	Creates back-pressure to keep airways open.
Key Cue	"Belly UP on Inhale"	"Blow out the candle slowly"

5. Paced Breathing (Walking with Breath)

Combining breathing with activity is essential for function.

• Rhythmic Walking: Inhale for 1 step, Exhale for 2 steps. (Adjust to 2:4 if able).
• Stairs: Inhale while standing still. Exhale while climbing 1-2 steps. NEVER hold breath while climbing.
• Lifting: "Blow as you go." Exhale during the effort phase of lifting.

6. Safety & Precautions

⚠️ Avoid Forced Expiration!
Never force the air out during PLB. Forcing engages the abdominals, which increases intrathoracic pressure and can collapse airways faster. Exhalation must be passive.

• Hyperventilation: If the patient feels dizzy or tingling fingers, they are breathing too fast/deep (blowing off too much CO2). Instruct them to pause and breathe normally.

7. Revision Notes for Students

WOB: Work of Breathing. Reduced by Diaphragmatic Breathing.
PEP: Positive Expiratory Pressure. Created by PLB.
I:E Ratio: Normal is 1:2. In COPD, we aim for 1:3 or 1:4 to allow emptying.
Accessory Muscles: Scalenes, SCM, Upper Traps. Overused in lung disease.
Dyspnea Position: Lean forward (Tripod position) to fix the shoulder girdle and allow accessory muscles to act as chest elevators.

8. FAQs

Q1. Can Diaphragmatic breathing be harmful?

In severe COPD with hyperinflation, the diaphragm is already flat and mechanically disadvantaged. Forcing diaphragmatic breathing can sometimes increase the work of breathing and dyspnea (paradoxical effect). If the patient feels worse, switch to PLB and relaxation.

Q2. Why breathe through the nose?

The nose filters, warms, and humidifies the air. It also provides a small amount of resistance which improves lung volume compared to mouth breathing.

Q3. Does PLB increase oxygen levels?

Yes, often. By keeping airways open longer, it improves gas exchange (tidal volume) and can raise SpO2 while lowering Respiratory Rate (RR).

9. 10 Practice MCQs

Q1. What is the correct I:E ratio for Pursed Lip Breathing?

Answer: C) Exhalation should be roughly twice as long as inhalation.

Q2. During Diaphragmatic Breathing, which hand should move?

Answer: B) The belly rises as the diaphragm descends; the chest should remain relatively still.

Q3. Pursed Lip Breathing prevents airway collapse by creating:

Answer: B) The back-pressure splints the airways open.

Q4. If a patient gets dizzy during breathing exercises, they are likely:

Answer: B) Hyperventilation causes hypocapnia (low CO2), leading to dizziness.

Q5. Which position is best to teach Diaphragmatic Breathing initially?

Answer: C) This relaxes the abdominal muscles and allows easier palpation of the diaphragm.

Q6. "Paced Breathing" on stairs involves:

Answer: B) Exhale on effort helps stabilize the core and manage dyspnea.

Q7. Which muscle is considered an "Accessory Muscle" of respiration?

Answer: C) SCM and Scalenes lift the rib cage during respiratory distress.

Q8. Paradoxical breathing is defined as:

Answer: A) This is the opposite of normal mechanics and indicates diaphragm fatigue/weakness.

Q9. What should a patient do if they start coughing during exercises?

Answer: B) The recovery position (Tripod) and controlled breathing help settle the airways.

Q10. Why is "sniffing" a useful cue for the diaphragm?

Answer: B) A sharp sniff is a natural way to recruit the diaphragm if the patient can't "find" the muscle.

References

• Pryor, J. A., & Prasad, S. A. (2008). Physiotherapy for Respiratory and Cardiac Problems. Elsevier.
• American Lung Association. (2023). Breathing Exercises.
• Frownfelter, D., & Dean, E. (2012). Cardiovascular and Pulmonary Physical Therapy. Mosby.