2.1: Assisted Breathing Techniques

Key Points:

1. A thorough auscultation examination will provide a baseline to help determine which techniques to use and to determine effectiveness of the techniques.
2. Assisted Breathing and Coughing Techniques can only be performed with patients who have a stable spine and no rib fractures.

Diaphragmatic Breathing (facilitation of the diaphragm):

Diaphragmatic Breathing (facilitation of the diaphragm)

Explain the purpose and goals of the exercise. Position the patient supine with legs flexed at 45 degrees in a relaxed and well supported fashion. Demonstrate and explain the technique. Place hand or hands at the costophrenic angle. Squeeze down and inward gently during exhalation. Allow the patient to breathe into your hand during inspiration. After several respiratory cycles the therapist will ask the patient if he feels a difference and should try to perform the maneuver independently using his own hand. How can you modify this technique for the individual without upper extremity control?

Inhibition of the diaphragm:

• Supine position: the heel of the therapist’s hand is placed lightly on the patient’s abdomen below the base of the xiphoid process. As the patient exhales the therapist gently allows his hand to follow the diaphragm up and in. When the exhalation is complete, the therapist will keep his hand in this position. At the next exhalation the therapist will move his hand further in and after two or three cycles, the therapist keeps his hand in one position and observes the patient. The patient will unconsciously alter his breathing pattern to use accessory muscles. When this has happened, the therapist will explain what has occurred and ask the patient to try to reproduce the breathing pattern. The therapist will gradually disengage his hand, observing carefully for the maintenance of the new breathing pattern by the patient. If the patient cannot maintain the pattern, the therapist will help by reapplying the pressure until the patient regains control of the pattern.

Inhibition of the diaphragm: Supine Postion

• Prone position: the patient is positioned prone on elbows. This position will effectively compress the excursion of the diaphragm, forcing the patient to utilize accessory muscles. The patient can then practice the preferred breathing pattern as well as incorporating it into other activities such as head and neck movement, reaching and single arm support. Note… this position is much more threatening to the patient than the supine position and should not be attempted as an early training technique. When is it likely you would desire an inhibition of the diaphragm? When would this technique be indicated?

Inhibition of the diaphragm: Prone Position

Upper chest breathing using the pectorals:

The patient is positioned in supine with arms at their sides. The therapist place the heels of her hands close to the sternum and aligns the fingers along the diagonal to the shoulders. As the patient begins to breathe up and into the therapist’s hands the therapist applies a quick manual stretch (down and in toward the sternum) thus facilitating the pectoral muscles and expanding the upper chest.

Upper chest breathing using the pectorals

Counter-rotation assisted breathing:

The patient is placed in a sidelying position. The therapist stands/ kneels behind the patient at a 45 degree angle to the head of the plinth. The cephalic hand is placed along the inferior border of the scapula and caudal hand is placed on the ASIS. As the patient inspires the therapist will assist this movement by pushing the shoulder forward and down while pulling the hip backward and down. At the end of inspiration, the therapist will smoothly and gently move her cephalic hand to the gluteal fossa. As the patient expires the therapist assists this movement by pulling the two hands together. In both assists, the hands move in a counter-rotation or wringing fashion. It is important in performing this technique to apply pressure through the palms instead of fingertips and palms, which can be painful to the patient.

Counter-rotation assisted breathing

Glossopharyngeal breathing:

No diaphragm action is required for this. An excellent technique to teach a patient if he or she requires ventilator assist. If a patient knows how to do this, then there would not be a fear of loss of electricity or power. The patient open his mouth widely and abruptly creates a negative area of pressure which air fills. The patient then closes his lips and “swallows” the air down into the lungs. It looks like a frog gulping air. The patient will report a feeling as though his lungs were about to burst if the technique is being performed correctly. A feeling of nausea and indigestion indicates that air is being sucked into the stomach instead of the lungs. Initial training can be very tiring. In addition to providing an alternative method of breathing if a stimulator or ventilator malfunctions, GPB can also act to

1. increase vital capacity or produce a more effective cough,
2. assist in a longer and stronger phonation, and
3. act as an internal mobilizer for the chest wall.

Problems which interfere with a patient’s ability to perform this activity include an open nasal passage or glottis that allows the air to escape, incorrect shaping of the mouth, uncoordinated backward movement of the tongue and swallowing of air into the stomach.