Breathwork has seen a massive spike in interest in the Western world over the past decade. But what does science have to say about its effectiveness in alleviating psychological maladies? New research published in Scientific Reports helps to summarize the current state of research and provides evidence that breathwork can have beneficial effects on stress and mental health.

Breathwork refers to various practices that involve deliberate control of breathing patterns in order to bring about physical and psychological benefits. There are several different breathing techniques that can be used for breathwork, including slow breathing, rhythmic breathing, and alternate nostril breathing. These techniques are often incorporated into meditative practices.

Preliminary research suggests that controlled breathing can help to reduce anxiety, depression, and stress, and that it can also help to improve overall well-being. This is thought to occur through several mechanisms, including the regulation of the autonomic nervous system, the activation of the parasympathetic nervous system, and the release of endorphins.

Motivated in part by personal experience, the authors behind the new research sought to investigate whether the hype around breathwork was grounded in evidence.

“I was introduced to meditation when I was studying at the University of California, Berkeley — I remember reading ‘The Art of Happiness’ by the Dalai Lama and Howard Cutler,” said lead author Guy William Fincham (@breath_Guy), a doctoral researcher at the University of Sussex School of Psychology, and Brighton and Sussex Medical School.

“I practiced here and there for several years. After moving to China where I met my long-term partner, she had to go back to Italy and I stayed; I was becoming increasingly stressed, anxious (without truly knowing and grasping this) and physically ill. From as early as I can remember, I always lived in the future (constantly planning, etc.) — and deemed this to be the root of my ‘problems’ — so I devoted myself to mindfulness meditation practice.”

Fincham participated in Buddhist meditation retreats in India and Sri Lanka, and was first introduced to the importance of nasal breathing and breathwork in the form of Yogic pranayama. He pursued a master’s degree in psychology with a focus on mindfulness and meditation. Fincham was practicing daily, but still experienced mental and physical health issues and was diagnosed with chronic fatigue syndrome and anxiety disorder.

The researcher discovered Wim Hof breathing technique and found it helpful, then learned about various other breathing techniques and decided to pursue research and teaching in breathwork and its potential impact on mental health. “Simply put, my purpose is to conduct research and teaching, contributing the best I can to bring scientific validity to various modalities involving breathwork, which may (or may not!) help people and improve their lives,” Fincham said.

To this end, Fincham and his colleagues conducted a meta-analysis of randomized-controlled trials (RCTs) on the potential efficacy or effectiveness of breathwork. The total sample included 785 adult participants.

A meta-analysis is a statistical technique that combines the results of multiple studies to determine a summary effect size or overall conclusion. It is used to examine the accumulated evidence from multiple studies on a particular topic or research question. Meta-analyses are useful because they provide a way to synthesize the results of many individual studies, increasing the power and accuracy of the conclusions that can be drawn.

“Breathwork has received an unprecedented surge in public interest and breathing practices may improve mental health,” Fincham told PsyPost. “More accessible approaches are needed to reduce or build resilience to stress worldwide, made even more evident by the COVID-19 pandemic. However, while breathwork has become increasingly popular in the West owing to its possible therapeutic potential, there also remains potential for a mismatch between hype and evidence.”

“Accordingly, we (myself and my supervisors at Sussex Profs Kate Cavanagh and Clara Strauss; research leads at Sussex Mindfulness Centre, and Dr Jesus Montero-Marin, an Oxford Mindfulness Centre senior researcher at the Department of Psychiatry, University of Oxford) examined whether breathwork interventions were associated with lower levels of self‐reported/subjective stress (classed as our primary outcome), anxiety and depression (classed as secondary outcomes) compared to non-breathwork control groups.”

“We searched seven databases (including two trial registers),” Fincham explained. “The primary outcome of subjective stress included 12 RCTs. Most studies were deemed as being at moderate risk of bias. The secondary outcomes of subjective anxiety and depressive symptoms comprised 20 and 18 RCTs, respectively.”

“Meta-analyses yielded significant small‐medium mean effect sizes, meaning breathwork was associated with lower levels of subjective stress, anxiety, and depression than non-breathwork control groups. Thus, our results showed that breathwork may have potential efficacy for improving stress and mental health. However, we urge caution and advocate for nuanced research approaches with low risk‐of‐bias study designs to avoid a miscalibration between hype and evidence.”

“Nonetheless, breathwork could at least be, or form, part of the solution to meeting the need for more accessible therapeutic behavioral approaches regarding improving mental health but, again, more robust, well-designed studies are now needed to ensure such recommendations are grounded in research evidence.”

Fincham was surprised by the type of breathing techniques that were investigated in the studies.

“Examples include coherent/resonant frequency breathing, abdominal/diaphragmatic and pursed lip breathing, along with Sudarshan Kriya Yoga,” he told PsyPost. “Less than half of the studies used practices related to Yoga and pranayama, and there were only six studies with a primary focus on fast-paced breathwork (which requires much more research in order to determine its safety profile).”

“Breathing techniques have emerged worldwide with complex historical roots from various traditions including but certainly not limited to: Hinduism (Yoga and pranayama — where ‘prana’ means ‘vital energy’ or ‘life force’ and ‘ayama’ means ‘regulation’ or ‘control’), Buddhism, Sufism, Shamanism, psychedelic communities, along with scientific/medical researchers, and practitioners. Using the umbrella term ‘breathwork’ seemed most inclusive, without focusing on one tradition in particular, and this rubric appeared most accessible for the core audience of the journal Scientific Reports.”

The researcher was also surprised by the public interest in the meta-analysis. According to Altmetric, a platform that measures research outputs, the paper is in the 99th percentile of all research papers ever tracked. The author received congratulations from Stanford neurobiology professor and popular podcast host Andrew Huberman.

But there is still much to learn about the potential psychological benefits of breathwork and the underlying mechanisms involved. Further research is needed to fully understand the psychological effects of breathwork and to determine its effectiveness for various mental health conditions.

“A key limitation of our meta-analysis was that, given the small sample size (likely due to the relatively recent phenomena of breathwork in the West) paired with moderate risk of bias across included RCTs, the results should be interpreted very cautiously and not extrapolated,” Fincham said. “Breathwork may help some but not others.”

“Meditation received an unprecedented surge in public interest and research over recent decades. We may be at a similar cusp with breathwork and anticipate considerable growth in the field. Given the close ties of breathwork to psychedelic research, this could accelerate growth further. The scientific research community can build on the preliminary evidence provided here and thus, potentially pave the way for effective integration of breathwork into public health.”

“It’s still very early, but we are lucky in the sense that we can try and avoid mistakes previously made by meditation research, and ensure that we start off with robust, well-designed studies early on,” Fincham explained. “While there is a possibility that it could simply be the cognitive-attentional components of both meditation and breathing practices that explain their effects, observation of the breath (i.e., most practices within mindfulness curricula) versus control of the breath (i.e., breathwork) warrants nuanced investigation.”

The study, “Effect of breathwork on stress and mental health: A meta‑analysis of randomised‑controlled trials“, was authored by Guy William Fincham, Clara Strauss, Jesus Montero‑Marin, and Kate Cavanagh.

 

Read more background on Guy Fincham and his research interests below:

“My doctoral research at Sussex explores the effects of breathwork on health and wellbeing. At present, I’m about to launch a RCT funded by a Sylff Research Grant, collaborating with the organisation Othership who make very high production value breathwork practice sessions, and am in the process of designing another study (again working with Othership, and funded by an Alchemist Grant from PsyDAO, a very early-stage decentralised organisation with the goal of funding research at the intersection of psychedelics and mental health), which will involve collaboration with the Psychology and Medical Schools here at Sussex and Prof Elissa Epel at UCSF.

I’m also working with the Brighton and Sussex Medical School who’re exploring the phenomenological, psychedelic and physiological effects of therapeutic breathwork via MRI, ECG and NIRS. This research is being led by psychiatrist Dr Alessandro Colasanti, MD. You can see a sneak peak of this here. Under the guidance of Dr Colasanti, we’re currently writing a physiologically-oriented review on breathwork.

Additionally, I’m a co-investigator on The Breathwork Survey, launched by the Centre for Psychedelic Research at Imperial College London. The principal investigator is Prof Robin Carhart-Harris, and you can find out more about this study through this thread. In late 2022 I travelled to Amsterdam/Haarlem in the Netherlands for ICPR 2022 (Interdisciplinary Conference on Psychedelic Research), and primarily for a workshop the day before on breathwork as this is my research focus (Breathwork as Psychedelic Therapy). I had a profound experience that I could never have imagined nor expected from breathwork (and so much more). I have undergone a personal paradigm shift and have gained an increasingly newfound respect for the therapeutic potential of breathwork as/for psychedelic therapy. The experience was invaluable and has made me view psychedelic breathwork under a new lens, which will benefit my future research and work.

Ultimately, I hope my work can help build a larger evidence-based picture of the psychophysiological effects (and potential efficacy) of breathwork. I wish to pursue a postdoc here at Sussex with collaboration between the Psychology and Medical Schools (as it is emerging as a central hub for this kind of research, along with mindfulness meditation research) and establish a Sussex Breathwork group/lab (and ultimately a centre, like the Sussex Mindfulness Centre) dedicated to breathwork research and practice, focusing on mental and physical health paired with psychedelic outcomes. Funders and donors please reach out if interested!”



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In today’s lifestyle we have lost the understanding of the pivotal role breathing has on our body. Breathing provides oxygen to produce energy and maintain normal metabolism.

Exhaling carbon dioxide helps in maintaining pH levels in the blood. Deep breathing activates the relaxation response and reduces blood pressure and heart beat. This helps in reduction of stress. Proper breathing has shown to boost the immune system by increasing oxygenation, and improving mental health.

Our body controls breathing through a complex interplay between the respiratory centre in the brain and the muscles. The respiratory centre is located in the medulla oblongata and pons regions of the brainstem. It receives input from sensory receptors in the body and regulates the rate and depth of breathing. The respiratory centre receives signals from chemoreceptors in the blood and the brain, which monitor the levels of oxygen, carbon dioxide, and pH in the body. If the levels of these substances change, the respiratory centre adjusts the rate of breathing accordingly. The respiratory centre sends signals to the motor neurons that control the diaphragm and intercostal muscles, which regulate the volume of air in the lungs and the rate of breathing. The process of breathing is regulated by a feedback loop, where the rate and depth of breathing are adjusted based on the body’s need for oxygen and the levels of carbon dioxide and pH in the body.

There are various breathing patterns, each with a unique impact on the body. Some of the most common types include: Diaphragmatic breathing which involves breathing deeply into the diaphragm, expanding the abdomen, and filling the lungs with air. Another is controlled breathing which refers to techniques used to regulate the rate and depth of breathing, such as slow, deep breathing or breath-holding. Whereas mouth breathing refers to breathing through the mouth rather than the nose, and can impact the body’s ability to filter and humidify inhaled air. Shallow breathing involves taking shallow breaths that do not fully expand the lungs, and can be a sign of stress or anxiety. Rapid breathing is when the rate of breathing increases, can be a symptom of a variety of medical conditions, including panic attacks, asthma, and heart problems. It’s interesting to know Clavicular breathing is a type of shallow breathing that involves only the upper chest, and can occur as a result of stress or tension. The most famous Yogic breathing is type of breathing which involves various techniques used in yoga and meditation, including pranayama, which involves controlled breathing to promote physical and mental well-being.

Different activities and situations may require different breathing patterns. Diaphragmatic breathing involves using the diaphragm, a muscle at the bottom of the ribcage, to control the flow of air into the lungs. To practice diaphragmatic breathing, lie down on your back, place one hand on your chest and the other on your belly, and breathe deeply, focusing on moving your belly up and down as you inhale and exhale. Whereas slowing down the rate of breathing and taking deep breaths can help reduce stress and promote relaxation. To practice slow and deep breathing, inhale slowly through your nose and exhale slowly through your mouth, focusing on the sensation of your breath. On the other hand, breathing through the nose can help filter, warm, and moisten the air before it enters the lungs, which can improve lung function and reduce the risk of respiratory infections. Pursed-lip breathing involves exhaling through pursed lips, like you’re blowing out a candle. It can help improve lung function and reduce shortness of breath in individuals with lung conditions such as chronic obstructive pulmonary disease (COPD).

In general, the correct way to breathe is the one in which you feel comfortable and allows you to take deep breaths without strain. If you have a medical condition that affects your breathing, it is important to consult a doctor for specific guidance.

Advantages of proper breathing are many like Improved oxygenation, reduced stress and anxiety, increased energy levels, better posture, improved focus and concentration, reduced symptoms of depression, anxiety disorders, improved digestion, enhanced athletic performance, better sleep quality, boosted immune system, etc.

As we all know, yoga and deep breathing helps calm the nervous system. The breath aspect of yoga is called ‘pranayama’. Pranayama is a Sanskrit word which means "regulation of breath." It is a type of yogic breathing that involves controlled breathing exercises to promote physical and mental well-being.

In pranayama, the focus is on controlling the breath through specific techniques, such as slow and deep breathing, breath-holding, and alternate nostril breathing. These techniques are believed to help regulate the flow of prana, or life force energy, in the body, promoting physical, mental, and emotional balance.

Pranayama is often used in conjunction with yoga postures (asanas) and meditation, as a means of calming the mind and reducing stress. It is believed to have several benefits, including improved respiratory function, increased oxygenation of the body, reduced stress and anxiety, and improved overall well-being. Pranayama should only be practiced under the guidance of a trained instructor, as improper technique can lead to health issues.

We can also improve our breathing patterns by regularly exercising, maintaining moderate weight, avoiding cigarettes and tobacco consumption, avoiding eating large meals, staying hydrated, etc.



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Breathing Techniques

By Aditya Jaykumar Iyer

According to Stress.org, 83% of US workers suffer from work-related stress. About one million Americans miss work each day because of stress. 76% of US workers report that workplace stress affects their personal relationships.

It is no secret then that stress is one the leading causes of Corporate America’s health problems.

Stress is especially detrimental to senior executives and leaders who often have high-pressure jobs, looming deadlines, limited resources, and little time for themselves. In times like these, we habitually resort to shallow breathing, which increases are cortisol levels and makes us feel stressed out.

Luckily, several breathing exercises can help reduce executive stress and avoid burnout.

Organizations have invited me on numerous occasions to conduct breathwork workshops on managing stress, and it’s always fascinating to hear about the relief practitioners feel after just 10-15 minutes of practice.

Breathwork has undoubtedly taken the post-pandemic wellness world by storm due to the numerous scientific benefits associated! 

This article will explore five powerful breathing techniques that regulate the nervous system and reduce stress levels. Read on to discover practical tools to help you amid uncertainty or strain.

Breath of Fire Breathing (Breathing for Energy and Alertness):

Coffee is a popular morning drink for many senior executives.

The coffee bean contains caffeine, a stimulant that can help increase alertness and energy levels. However, coffee can also cause side effects such as jitteriness and anxiety, leading to a crash when the effects wear off.

Too much coffee can lead to fatigue and impaired decision-making, while the absence of coffee can leave you feeling groggy and unfocused. Does that sound familiar?

What if a breathing technique can replace or complement your cup of coffee?

Kapalabhati is a powerful yet simple breathing technique that is said to heal, cleanse, and energize the body. Practicing this technique also helps massage the internal organs and improve lung capacity.

Kapalabhati is an excellent way to energize the body and clear the mind when feeling stressed or overwhelmed. Moreover, it purifies the blood, boosts the immune system, and increases your energy levels within minutes.

It is a great way to start your day or use it as a break during the workday.

  1. Sit with your spine straight and your eyes closed.
  2. Place your hands on your stomach, just below your navel.
  3. Exhale entirely through your nose, then inhale deeply through your nose.
  4. As you exhale, pull your stomach in so your navel is pulled toward your spine.
  5. Repeat this process for 10-15 minutes.

Diaphragmatic Breathing (Breathing for Sleep):

Work-related stress and economic uncertainty can make it difficult to fall asleep. 

This inability to fall asleep can be frustrating and have consequences for the next day.

Often, people turn to sleep pills or medication to help them fall asleep, but these are not sustainable solutions in the long term.

Diaphragmatic breathing, or belly breathing, is a deep breathing exercise to reduce stress, stabilize blood pressure, and calm anxiety levels.

The diaphragm is a large, dome-shaped muscle below the lungs, which contracts when you inhale and relaxes as you exhale. As babies, we intuitively breathe diaphragmatically, but as we get older, we develop a rather unhealthy habit of ‘chest breathing‘, which keeps us in a fight-or-flight state. 

The diaphragmatic breathing technique strengthens your diaphragm and promotes full oxygen exchange. 

It’s easy to learn, and it only takes a few deep breaths to feel the difference

  1. Lie on your back with your knees bent and your feet flat on the floor.
  2. Place one hand on your stomach and the other hand on your chest.
  3. Take a slow deep breath through your nose, counting to 4 as you inhale.
  4. Hold your breath for a count of 4.
  5. Practice slow pursed lip breathing as you exhale and count to 8.
  6. Repeat this process for 10-15 minutes.

Alternative Nostril Breathing (Breathing for Problem Solving and Creativity):

Executive leaders are under constant pressure to find solutions to problems.

Whether it’s coming up with a strategy for dealing with a problematic competitor, figuring out how to streamline operations, or resolving a conflict among team members, problem-solving is essential for success.

Leaders need to be able to think clearly and creatively, and that’s where our next breathwork technique comes in.

Nadi Shodhana, or “alternative nostril breathing,” is an effective yogic breathing technique that can harmonize your nervous system and optimize brain function for enhanced problem-solving.

The key to understanding the efficacy of this technique is knowing about the ‘nasal cycle’. We typically breathe through one nostril more than the other throughout the day.

This nasal switch happens every 90 to 120 minutes and seems to be controlled by the CNS (Central Nervous System).

When the right nostril is more congested, we breathe more through the left nostril, known as left nostril dominance. This phase is associated with the ‘rest and digest’ mode when the body is generally more relaxed, and the heart rate lowered.

On the other hand, when the left nostril is more congested, we breathe more through the right nostril, which is known as right nostril dominance. This phase is associated with the ‘fight or flight’ mode, when the body is more alert and the heart rate is elevated.

What’s fascinating is that when your left nostril is dominant, the EEG activity is more significant in the right hemisphere of your brain and vice versa. In other words, each brain hemisphere controls the opposite side of the body.

Practicing the alternate nostril breathing exercise is believed to balance the brain’s two hemispheres and reduce mental fatigue, which tends to obstruct decision-making.

Here’s a simple way to perform this breathing exercise:

  1. Sit with your spine straight and your eyes closed.
  2. Place one hand on your stomach, just below your navel.
  3. Close off your left nostril with your thumb and inhale deeply through your right nostril.
  4. Pause for a moment, then close off your right nostril with your index finger and exhale slowly through your left nostril.
  5. Now, pause for a moment and inhale fully through your left nostril.
  6. Close off your left nostril with your thumb and exhale slowly through your right nostril.
  7. Repeat this process for 10-15 minutes.

Heart Coherence breathing (Breathing For Accessing Intuition):

Intuition is a powerful tool that can help senior executives make better decisions.

Research shows that intuition plays a vital role in decision-making and can be more effective than rational thinking.

Intuition results from years of experience and learning, allowing executives to process information quickly and develop strategic solutions to complex problems.

Stress and anxiety activate our fight or flight response, which impairs our ability to access our intuitive abilities and make gut-based decisions. 

According to some research, the key to harnessing intuition may lie in achieving Heart Coherence.

What is Heart Coherence

According to the HeartMath institute, Heart Coherence is a physiological state when our body’s systems, breathing, heart rhythms, brain rhythms, and hormonal response are in sync with each other.

This state of harmony, balance, and flow is most conducive to spontaneous, intuitive hits and eureka moments.

Heart coherence breathing is a method that can help you access this physiological state of balance with some practice.

  1. Sit with your spine straight and your eyes closed.
  2. Focus your attention on your heart and think about something or someone you genuinely appreciate.
  3. Imagine your breath flowing in and out of your heart.
  4. Inhale slowly through your nose and count to 5.
  5. Exhale slowly through your mouth and count to 5.
  6. As you exhale, visualize sending positive vibrations from the center of your heart toward those you appreciate.
  7. Repeat this process for 10-15 minutes.

Chanting breath (Breathing for Harmony):

Omkar breath, or humming breath, is a type of yogic breathing exercise that is said to have numerous scientifically proven benefits for the mind and body.

If you’re feeling stressed or burned out in the middle of the day, a few minutes of this breathing exercise will help activate your parasympathetic nervous system and make you feel calm and centered. Avoid practicing this technique while driving or operating heavy machinery because this technique can make you feel tired and relaxed!

Here are a few reasons why this technique is so powerful:

Vagus Nerve Stimulation:

Humming and chanting create a harmonious vibration that stimulates the vagus nerve, the longest cranial nerve in the human body. This nerve runs from the brain to the large intestine and plays a crucial role in activating the rest and digest mode.

Long Exhales:

You activate the sympathetic nervous system when you inhale, and you start the parasympathetic nervous system when you exhale. By exhaling for longer than you inhale, you turn on the parasympathetic nervous system, further amplifying the relaxation response.

Brain stimulation:

Chanting also sends calming signals to the Limbic brain (amygdala, anterior cingulate gyrus, hippocampus, insula, orbitofrontal cortex, parahippocampal gyrus, and thalamus), calming the overactive mind and promoting deep relaxation.

According to one study by researchers at the National Institute of Mental Health and Neurosciences in India, limbic deactivation during Om chanting is very similar to those observed during vagus nerve stimulation in depression and epilepsy.

While more research is certainly warranted, these results point to a potential role for adopting the non-invasive ‘Om’ chanting in clinical practice!

  • Sit with your spine straight and your eyes closed.
  • Place one hand on your stomach, just below your navel, and the other on your chest.
  • Inhale deeply through your nose, focusing on filling your lungs with air.
  • As you exhale, count to 12 and chant the sound of ‘Om’
  • Repeat this process for 10-15 minutes

Wrapping Up

It’s important to remember that not all forms of stress are harmful. Some stress, such as ‘hormetic stress’, your body’s health stress response, can benefit our health and well-being.

It is when we experience chronic stress that it becomes a problem.

If you find yourself struggling with chronic stress as a corporate leader, several breathing techniques can help naturally reduce executive stress and avoid burnout.

The breathing exercises discussed in this article include the breath of fire, diaphragmatic breathing, alternative nostril breathing, heart coherence breathing, and chanting breath. Experiment with these techniques and add a few of them to your self-care tool kit.

Do you have a favorite breathing technique? Let us know in the comments below!

About the Author

Aditya Jaykumar Iyer (AJ) is a certified Breathwork instructor and the host & founder of the My Seven Chakras podcast and blog with over 6.8 million downloads. 

Aditya has spent the last 8 years conducting interviews with over 500 of the foremost wellness experts and has documented his learnings & discoveries on his blog. You can connect with him on Instagram at @mysevenchakras.

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Weekend Doctor Column

Sherrie Schreck, RRT

Pulmonary Rehab

Blanchard Valley Hospital

Is difficulty breathing making it harder to do the things you want to do? Has it become harder to get the mail, do simple cleaning, or get groceries? If you have chronic obstructive pulmonary disease
(COPD), interstitial lung disease, asthma, cystic fibrosis, pulmonary
hypertension, recovering from lung surgery or other breathing-related
problems, pulmonary rehabilitation is a program that can improve your quality of life. For many patients diagnosed with chronic lung conditions, attending pulmonary rehabilitation can be a lifesaver.

What is pulmonary rehabilitation?

Pulmonary rehabilitation is a gradual exercise and education program to help people

with chronic (long-term) lung diseases. It will not cure your lung disease, but you may

notice fewer breathing problems, more strength and improved quality of life.

Your pulmonary rehabilitation may be overseen by respiratory therapists, nurses,

exercise physiologists and physicians. They will help design a personal program for

you. Your program will include an initial assessment with a walk test to monitor oxygen

levels, blood pressure, heart rate, and the distance you are able to walk in six minutes.

During your pulmonary rehab program, you will learn everything you need to know

about your specific chronic lung disease, including symptoms, medications and oxygen.

You will receive education on how to deal with your chronic lung condition, learn exercises to

help you feel better and do more, and you will learn ways to cope mentally and

emotionally with your lung condition.

You will attend supervised exercise classes that include stretching, strength exercises,

and cardiovascular exercise like walking, using a bike or recumbent stepper. Because

of breathing challenges, people with chronic lung disease tend to avoid exercise. The

right amount and type of exercise can help improve your strength, increase energy

levels and help you use oxygen more efficiently.

Where is pulmonary rehabilitation done? How often do I have to go?

Most pulmonary rehabilitation programs will be done at your local hospital or outpatient

health center. Pulmonary rehabilitation is usually two to three times a week for 12

or more weeks. You will need to try to attend every session to get the most out of the

program. It may be hard and take some time, but, it will be worth the benefits in the end.

How does pulmonary rehabilitation work?

Chronic lung disease can cause your muscles to become weak. The muscles involved

in breathing and in moving must be re-strengthened. You will have your own exercise

program designed to improve your strength and endurance.

All pulmonary rehab patients are taught pursed lip breathing to help increase oxygen

levels
and better manage symptoms. You will be taught to check your oxygen
level and take preventative measures to increase your oxygen level
before it gets too low.

How effective is pulmonary rehabilitation?

Pulmonary rehabilitation is effective if you put effort into it. You will get the best results

if you continue to exercise after completing your pulmonary rehabilitation program.

Insurance and Medicare usually pay for some or all of the cost of pulmonary rehab.

Contact your healthcare provider if you have questions or think that pulmonary rehab

might be right for you.

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Fatigue and postexertional malaise associated with long COVID should be treated with titrated structured activity and energy conservation strategies1

To avoid precipitating postexertional malaise, patients should be advised to begin a structured and symptom-guided return to activity program, tailored to their severity of fatigue. The 4 Ps (pacing; prioritizing which activities need to get done on specific days and which activities can be postponed; positioning to modify activities to make them easier to perform [e.g., while sitting]; and planning) is a helpful framework to educate people about how to apply physical, emotional and cognitive energy conservation strategies.1

Guideline-directed use of psychosocial interventions and medications can be used to treat mental health complications of long COVID

Anxiety, depression and posttraumatic stress disorder are among the most common mental health manifestations of long COVID and may be treated according to relevant guidelines in people with these conditions, which are similar to recommendations among people with myalgic encephalitis (ME).2 The use of cognitive behavioural therapy for the treatment of fatigue is controversial and not currently endorsed by the ME Association.2

Breathing exercises, body positioning and pulmonary rehabilitation may improve dyspnea2

In people with mild dyspnea, pursed lip or deep breathing exercises may improve symptoms. Persistent hypoxemia is not a common manifestation of long COVID and may be caused by severe lung disease or organizing pneumonia. Its presence should prompt referral to a respirologist and consideration of pulmonary rehabilitation.2,3

People with sleep disturbances should receive counselling on sleep hygiene, relaxation techniques and stimulus control2

Sleep disturbances may be a result of their SARS-CoV-2 infection or the negative effects of the pandemic.2 They can be managed using cognitive behavioural therapy or 1 of the following medications currently available in Canada: eszopiclone, zolpidem or doxepin.4

Specific guidelines exist for the treatment of palpitations and tachycardia with particular causes

Current recommendations for the treatment of inappropriate sinus tachycardia and postural orthostatic tachycardia syndrome include behavioural modifications, oral fluids, salt, compression stockings, β-blockers, ivabradine and midodrine.5

Footnotes

  • Competing interests: Kieran Quinn is a former assistant scientific director of the Ontario COVID-19 Science Advisory Table from Aug. 8, 2022, to Sept. 30, 2022. He is the current assistant scientific director of the Ontario Public Health Emergencies Science Advisory Committee and has received Canadian Institutes of Health Research (CIHR) grants (awarded to his institution) to study the long-term effects of COVID-19. He has served as an advisor for the chief science advisor of the Canada Task Force on Post-COVID-19 Condition. Fahad Razak holds a salary award as the Graham Farquharson knowledge translation fellow from the PSI Foundation and is an employee of Ontario Health. He was also an employee of Public Health Ontario during the writing of this manuscript. Fahad Razak has received grants (outside the current article) to study COVID-19 from the CIHR, Canadian Frailty Network, University of Toronto (including the Department of Medicine, St. Michael’s Hospital and the Sunnybrook Health Sciences Centre), Digital Research Alliance of Canada (Data Champions Pilot Project) and Royal College of Physicians and Surgeons of Canada. Angela Cheung has received CIHR grants (awarded to her institution) for CANCOV (platform observational study of COVID-19 in Canada) and RECLAIM (adaptive platform randomized controlled trials for long COVID interventions). MediciNova is providing a study drug and placebo for the RECLAIM trial, a multicentre study across Canada. Angela Cheung has served as an advisor for the Ontario COVID-19 Science Advisory Table, Public Health Agency of Canada, Canadian Agency for Drugs and Technologies in Health, COVID-19 Immunity Task Force and chief science advisor of the Canada Task Force on Post-COVID-19 Condition. No other competing interests were declared.

  • This article has been peer reviewed.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: creativecommons.org/licenses/by-nc-nd/4.0/

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The granulomatous disease tuberculosis (TB) is brought on by the bacteria Mycobacterium tuberculosis. Skeletal TB is involved in 10-35% of extra-pulmonary reported cases worldwide, with the most common kind being tuberculous spondylitis (Pott's disease). Depending upon the extent of spinal engagement, the clinical presentation may include back pain, discomfort, neurological abnormalities, as well as other clinical signs like temperature, malaise, and loss of weight. The multidisciplinary therapeutic care of Pott's illness is centered on a particular medicinal therapy, on-demand surgery, and a customized rehabilitation regimen. A 20-year-old female was diagnosed with Pott’s disease following investigations in Acharya Vinoba Bhave Rural Hospital (AVBRH), Sawangi (Meghe), Wardha, India. A tailored physiotherapy (PT) program was started and continued for six weeks, after which improvement in the mobility of the spine, pain relief, increased respiratory function, improved sensory function, and overall improvement in functional independence was markedly seen in the patient. The protocol included mobility, strengthening of lower limbs and core musculature, breathing, and postural correction exercises. Sensory re-education was done. Thus rehabilitation showed a great improvement in the patient and helped ease the patient's discomfort.

Introduction

In impoverished or emerging nations, tuberculosis (TB) of the spine, also known as Pott's disease, affects 3 to 4% of tuberculous circumstances and 15% of extrapulmonary tuberculous conditions [1]. It is regarded as severe due to the great occurrence of neurological ailments and the impact of bone degradation, all the more so because the consequences are localized to the upper lumbar spine and/or lower thoracic spine in approximately 80% of patients [2]. It is commonly accepted that foci of bacilli trapped in the bone during the initial mycobacteremia of prime infection are the root of tuberculous osteomyelitis and arthritis. The principal focus (area) may be in the kidney or other viscera, or it may be active or dormant, visible or latent, in the lungs or in the mediastinum's lymph glands. Alternate routes for tuberculous bacilli to reach the spine include lymphatic outflow to the para-aortic lymph nodes or Batson's paravertebral venous plexus [3]. Early detection is crucial for preventing neurological sequelae and preventing the infection from spreading further. A particular medical intervention, on-demand operation, and a precise rehabilitative schedule form the basis of Pott's multidisciplinary therapeutic care.

The most prevalent and fatal type of TB infection is TB of the spine, often termed Pott's disease [4]. The spread of TB strains that have become resistant to particular treatments, hunger, drunkenness, insufficient TB control methods, filth, and increased travel appear to be factors in the increase in TB prevalence globally [3]. The gradual clinical picture that commonly precedes this pathology's appearance can lead to a hindered diagnosis. This infers the breakdown of the vertebrae, occasionally occurring kyphoses, as well as the spinal alignment issues it may cause [5]. The most frequent complications of TB of the spine include spinal deformity and paraplegia/quadriplegia. Kyphosis is often the result of TB of the dorsal spine, whereas lordosis reversal first occurs in the cervical and lumbar spines before kyphosis. Adults' kyphosis keeps getting worse when they receive conservative treatment and even after surgical treatment. The diaphragm is forced into the chest cavity and the rib borders move closer to the iliac crest, further worsening the breathing ability. Patients with severe thoracic kyphosis caused by TB may experience respiratory failure within a few years [6]. Spinal canal stenosis and deformity are caused by lacking diagnosis and treatment. Typically, thoracic TB of the spine involves the vertebral body and is localized there. The edges of the vertebrae, especially the anterior part of the vertebrae, are where tuberculous infection typically first manifests itself [7]. Over 70% of individuals having spinal TB develop a paraspinal abscess, which frequently occurs in concordance with epidural extension [8].

Limb weakness, gibbus, tenderness, and a palpable bump are the primary issues that occur. Patients who are in the active stage express fatigue, show weight loss, appetite loss, nocturnal sweats, and an increase in body temperature in the evening. The spine seems to have a regional kyphotic deformity which is sore to touch and rigid and uncomfortable to move. In order to treat patients with TB spine, goal-oriented medical as well as physiotherapy management is required. For Pott's disease, decompressive surgery followed by anti-TB chemotherapy is still the best treatment option. Medical management along with planned physiotherapy rehabilitation helps in easing the symptoms of the sick individual, timely recovery, and improved quality of life. The case of a 20-year-old woman who was recently diagnosed with Pott's disease is presented here. The patient experienced sensory loss in the lower extremity and low back pain. The patient was thoroughly assessed and a six-week physiotherapy program was formulated.

Case Presentation

A 20-year-old female from the Gondia district's Magardoh hamlet visited the Acharya Vinoba Bhave Rural Hospital (AVBRH), Sawangi (Meghe), Wardha, India with the chief complaints of diffused low back pain that had been plaguing her for the last two years and had crept up on her slowly at first. Additionally, the patient also reported a loss of sensation in the front and back of the distal lower limb. The patient gave a negative history of any other comorbidities. The patient had already been referred to a few private hospitals where she underwent a few investigations which revealed the presence of an abscess in the pre- and paravertebral space of the lower spine. After magnetic resonance imaging (MRI) and biopsy were carried out, the patient was diagnosed with TB of the spine L4-L5 and L5-S1. The patient was prescribed anti-TB medications and physiotherapy.

On observation

The patient was seen in a supine position with upper limbs by the side and lower limbs extended. An abscess was seen on the lower spine region.

On palpation

Grade 3 tenderness (patient winces and withdraws the affected part) was present on the lower lumbar region of the back. On examination range of motion (ROM) and manual muscle testing were taken (Tables 1 and 2).

Joint Movement Active (Right/Left) Passive (Right/Left)
Hip Flexion 0-55/0-60 0-60/0-65
  Extension 55-5/60-5 60-0/65-0
  Abduction 0-20/0-20 0-30/0-30
  Adduction 0-10/0-10 0-15/0-15
  External rotation 0-15/0-15 0-20/0-20
  Internal rotation 0-12/0-15 0-20/0-20
Knee Flexion 0-110/0-110 0-120/0-120
  Extension 110-0/110-0 120-0/120-0
Ankle Plantarflexion 0-15/0-15 0-15/0-20
  Dorsiflexion 0-10/0-10 0-15/0-15
Lumbar spine Flexion 0-25 0-30
  Extension 0-10 0-20
  Lateral flexion 0-20/0-20 0-25/0-25
  Side rotation 0-20/0-20 0-25/0-25
Muscle Set Right Left
Hip flexors 2/5 2/5
Hip extensors 3/5 3/3
Knee flexors 3/5 3/5
Knee extensors 3/5 3/5
Ankle plantar flexors 4/5 4/5
Ankle dorsiflexors 4/5 4/5

Sensory examination

The assessment was done using American Spinal Injury Association (ASIA) impairment scale. All the motor functions were intact. There was a sensory deficit in the L5 and S1 segments with both pinprick and light touch impaired. Loss of sensation over the lateral and posterior calf and dorsum of the foot was noted.

Intervention

The main goal of physical therapy is to minimize the symptoms. The primary goal is to improve respiratory function, relieve back pain, increase muscle strength, increase ROM, improve sensory function, improve quality of life and prevent secondary complications.

Before initiating the treatment, it is essential to educate the patient about her condition, its complications, the prognosis, and the benefits physical therapy will have in easing her symptoms, relieving pain, and early recovery.

Strengthening exercises included isometrics initially, followed by resistive exercises first by manual resistance later using weights and mechanical resistance with 10-20 repetitions. Low back pain was managed with the application of transcutaneous electrical nerve stimulation (TENS) and moist heat. ROM exercises (both active and passive) up to full range were given to improve mobility. Mobility exercises for the trunk were given with proper assistance. Breathing exercises included pursed lip breathing and thoracic expansion exercises with five and ten repetitions respectively twice a day. Sensory re-education was done once a day. Postural correction techniques were taught. Aerobic exercise training was started in the fourth week using a static cycle and treadmill (Table 3).

Phase Goal Intervention
Day 1-week 1 I) To promote muscular endurance. Isometric exercises of the upper and lower back, glutei muscles, hamstring, and quadriceps. Static abdominals with the back press were performed.
  II) To improve breathing. Breathing exercises included pursed lip breathing and thoracic expansion exercises with an inspiratory hold of 5 seconds.
  III) To increase ROM. Active ROM exercises to all joints of the upper and lower limbs. Heel slides, SLR, and dynamic quads were performed 10 times twice a day along with ankle-toe movements.
  IV) To relieve pain and spasm. Application of heat pack before exercise therapy was done. Post-treatment 10 mins of cryotherapy using an ice pack. TENS was applied for lower limbs.
  V) Postural correction. The patient was taught to sit upright. Shoulder shrugs, scapular retraction, and cat and camel exercises were given.
Week 2-4 I) To maintain muscle strength. Isokinetic movements were given in the second week. It progressed to resistive exercises using manual resistance initially and later using weight cuffs of 0.5 kg for both upper and lower limbs. In the fourth week, the load was increased to 2kgs for both extremities.
  II) To improve breathing and increase functional capacity. Pursed lip and thoracic expansion exercises were continued with increased respiratory hold.
  III) To increase and maintain ROM. Active ROM exercises of all joints were continued. Exercises of week 1 with increased reps. Trunk bending exercises forward, backward, and sideways were started. Ambulation up to 100 meters was allowed.
  IV) To improve ambulation. Ambulation was done under supervision. The patient was made to walk in the parallel bar to correct posture and gait pattern.
  V) To increase and maintain sensory function. Sensory re-education was done. Different textured fabrics were used to stimulate sensory receptors. 
  VI) To relieve low back pain. Application of TENS to the lower back region along with moist heat to relieve pain and spasm.
Week 4-6 I) To increase and maintain muscle. strength. Resistive exercises using weight cuffs of 2kg for upper and lower limbs. A head lift with the back press, abdominal curl-ups, diagonal curl-ups, and cat and camel position was performed.
  II) To improve breathing and increase aerobic capacity. Pursed lip and thoracic expansion exercises were continued. Aerobic exercise training using a treadmill, stationary bicycle, stretching, running, and jogging was advised for at least 30-40 mins per day.
  III) To maintain ROM. Active ROM exercises of all joints. Trunk bending exercises forward, backward, and sideways were continued. Front lunges, side lunges, and yoga pose for back stretching like cobra pose, extended child’s pose, pigeon’s pose, and reverse plank pose were performed. Ambulation up to 200 meters and more by six weeks was encouraged. Staircase climbing was performed under supervision.
  IV) To improve functional capacity and endurance. Aerobic exercises using a treadmill, static cycle with continuous monitoring of vitals. Fast walking, jogging, and running to be incorporated in daily life.

Discussion

One of the most debilitating effects of extra-pulmonary TB is Pott’s disease, often known as spinal TB [9]. Spondylitis brought on by TB is a rare condition that develops and progresses gradually [10]. Pott's disease is an ailment of the intervertebral discs between two consecutive vertebrae. Any system or tissue within the human body might get infected with TB when it starts in the lung. The spinal column is the extra pulmonary site that is most frequently affected [11].

The patient was sent to the physiotherapy department in the aforementioned case with the primary complaints of low back discomfort, sensory deficiency, and weakness in the lower limbs. On the complete assessment of the patient, a six-week rehabilitation protocol was made. The treatment included ROM exercises, pain reduction modalities, postural correction exercises, breathing exercises, and strengthening exercises along with sensory re-education. The effects of these exercises were remarkably seen post-treatment.

Rakesh Krishna Kovela and others conducted a study on the effectiveness of physiotherapy on the functions of lower limbs in a patient with Pott’s disease. The treatment plan included the application of TENS, breathing exercises, sensory re-education, and mobility exercises which by the end of the session showed marked improvement in the patient [10]. Another study by Zaoui and others on patients with Pott’s spine over a span of eight years also showed significant enhancement in the health of the patients. The rehabilitation protocol included initial immobilization of the affected spinal segment with the help of a corset, followed by mobility exercises, sensory integration, thoracic mobility exercises, ambulation, and ergonomic advice [2].

This case report shows the effects of vigorous physical therapy. The patient was able to function independently owing to an improvement in joint mobility and muscular strength. TENS stimulation and moist heat therapy were applied to alleviate low back pain and muscular spasms. Respiratory function was significantly improved post-exercise. The overall endurance and functional capacity of the patient showed notable improvement.

Conclusions

A planned and goal-oriented physiotherapy regimen along with medications leads to early recovery and easing of symptoms of patients with Pott’s disease. Thus we conclude that the management specially designed for the patient was beneficial in increasing the mobility, stability, functional independence, and endurance of the patient thus improving the quality of life.



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Introduction

Shortness of breath is a feeling of difficulty or discomfort while breathing. It can range from mild to severe and is often associated with feelings of chest tightness, wheezing, coughing, or gasping for air. While there are many potential causes, shortness of breath is usually caused by physical exertion, allergies and asthma, cardiovascular problems, respiratory infections, stress and anxiety, smoking, and air pollution. Fortunately, there are many natural remedies and relaxation techniques that can be used to alleviate symptoms and improve lung capacity.

 Causes of Shortness of Breath
Causes of Shortness of Breath

Causes of Shortness of Breath

Physical exertion is one of the most common causes of shortness of breath. When the body is working harder than usual, the heart rate increases and more oxygen is needed to keep up with the demand. This can cause a person to become out of breath and feel the need to take deep breaths in order to catch their breath.

Allergies and asthma can also cause shortness of breath. Allergens such as dust, mold, pollen, pet dander, and smoke can irritate the airways and cause inflammation and narrowing, resulting in difficulty breathing. Asthma is a condition in which the lungs react strongly to certain triggers, such as exercise, cold air, or allergens, and can cause shortness of breath.

Cardiovascular problems, such as congestive heart failure, can also cause shortness of breath. In this condition, the heart is unable to pump enough blood to meet the body’s needs, resulting in fluid buildup in the lungs, which can make breathing difficult.

Respiratory infections, such as pneumonia, can also cause shortness of breath. Pneumonia is an infection of the lungs caused by bacteria, viruses, or fungi that can lead to inflammation and fluid buildup in the lungs, making it difficult to breathe.

Stress and anxiety can also cause shortness of breath. When a person is feeling anxious or stressed, they tend to take shallow breaths, which can lead to a feeling of not getting enough air.

Smoking is another cause of shortness of breath. Smoking damages the lungs and makes it harder for them to take in oxygen, resulting in difficulty breathing.

Air pollution can also cause shortness of breath. Pollutants in the air, such as smog, can irritate the lungs and make it harder to breathe.

 Natural Remedies for Relief
Natural Remedies for Relief

Natural Remedies for Relief

There are many natural remedies that can help alleviate the symptoms of shortness of breath. Herbal teas, such as chamomile and peppermint, can help relax the airways and reduce inflammation. Essential oils, such as eucalyptus and lavender, can also be used to reduce inflammation and open the airways. Steam inhalation can help loosen mucus and clear the airways. Proper hydration is also important to help thin mucus and prevent dehydration, which can worsen shortness of breath. Nutritional supplements, such as omega-3 fatty acids, can also help reduce inflammation and improve lung function.

Relaxation Techniques to Reduce Anxiety

Stress and anxiety can worsen the symptoms of shortness of breath, so it is important to learn relaxation techniques to help reduce these feelings. Meditation is a great way to relax the mind and body and can help relieve tension and reduce anxiety. Progressive relaxation is a technique that involves tensing and relaxing different muscle groups in sequence to help reduce stress. Guided imagery is a technique in which a person imagines peaceful scenes to help relax the mind and body. Yoga is also a great way to relax the mind and body and can help reduce anxiety and improve breathing.

 Simple Breathing Exercises to Strengthen Lung Capacity
Simple Breathing Exercises to Strengthen Lung Capacity

Simple Breathing Exercises to Strengthen Lung Capacity

Breathing exercises can help strengthen the lungs and improve oxygen intake, which can help reduce shortness of breath. Diaphragmatic breathing is a technique that involves taking slow, deep breaths through the nose and exhaling slowly through pursed lips. Pursed-lip breathing is another technique that involves taking slow, deep breaths through the nose and exhaling slowly through pursed lips. Intercostal breathing involves taking slow, deep breaths and focusing on filling the lungs with air, rather than just the chest.

Seeking Medical Intervention for Severe Shortness of Breath

If shortness of breath is severe or does not go away with natural remedies, it is important to seek medical help. A doctor can diagnose the underlying cause of the shortness of breath and recommend treatments to help alleviate symptoms and improve lung function. Treatment options may include medications, such as bronchodilators and corticosteroids, or lifestyle changes, such as quitting smoking or avoiding triggers. Follow-up care is also important to monitor progress and ensure that the treatment plan is working.

Conclusion

Shortness of breath can be caused by many different factors, including physical exertion, allergies and asthma, cardiovascular problems, respiratory infections, stress and anxiety, smoking, and air pollution. Fortunately, there are many natural remedies and relaxation techniques that can be used to alleviate symptoms and improve lung capacity. If shortness of breath is severe or does not go away with natural remedies, it is important to seek medical help. Finally, remember to stay hydrated, practice deep breathing exercises, and try to avoid triggers that can worsen shortness of breath.

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By Sherrie Schreck, RRT
Pulmonary Rehab, Blanchard Valley Hospital

Is difficulty breathing making it harder to do the things you want to do? Has it become harder to get the mail, do simple cleaning, or get groceries? If you have chronic obstructive pulmonary disease (COPD), interstitial lung disease, asthma, cystic fibrosis, pulmonary hypertension, recovering from lung surgery or other breathing-related problems, pulmonary rehabilitation is a program that can improve your quality of life. For many patients diagnosed with chronic lung conditions, attending pulmonary rehabilitation can be a lifesaver.

What is pulmonary rehabilitation?

Pulmonary rehabilitation is a gradual exercise and education program to help people with chronic (long-term) lung diseases. It will not cure your lung disease, but you may notice fewer breathing problems, more strength and improved quality of life. Your pulmonary rehabilitation may be overseen by respiratory therapists, nurses, exercise physiologists and physicians. They will help design a personal program for you. Your program will include an initial assessment with a walk test to monitor oxygen levels, blood pressure, heart rate, and the distance you are able to walk in six minutes.

During your pulmonary rehab program, you will learn everything you need to know about your specific chronic lung disease, including symptoms, medications and oxygen. You will receive education on how to deal with your chronic lung condition, learn exercises to help you feel better and do more, and you will learn ways to cope mentally and emotionally with your lung condition.

You will attend supervised exercise classes that include stretching, strength exercises, and cardiovascular exercise like walking, using a bike or recumbent stepper. Because of breathing challenges, people with chronic lung disease tend to avoid exercise. The right amount and type of exercise can help improve your strength, increase energy levels and help you use oxygen more efficiently.

Where is pulmonary rehabilitation done? How often do I have to go?

Most pulmonary rehabilitation programs will be done at your local hospital or outpatient health center. Pulmonary rehabilitation is usually two to three times a week for 12 or more weeks. You will need to try to attend every session to get the most out of the program. It may be hard and take some time, but, it will be worth the benefits in the end.

How does pulmonary rehabilitation work?

Chronic lung disease can cause your muscles to become weak. The muscles involved in breathing and in moving must be re-strengthened. You will have your own exercise program designed to improve your strength and endurance.

All pulmonary rehab patients are taught pursed lip breathing to help increase oxygen levels and better manage symptoms. You will be taught to check your oxygen level and take preventative measures to increase your oxygen level before it gets too low.

How effective is pulmonary rehabilitation?

Pulmonary rehabilitation is effective if you put effort into it. You will get the best results if you continue to exercise after completing your pulmonary rehabilitation program. Insurance and Medicare usually pay for some or all of the cost of pulmonary rehab. Contact your healthcare provider if you have questions or think that pulmonary rehab might be right for you.

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Introduction

Breath-holding is the voluntary act of preventing air from entering or leaving your lungs. It takes practice and determination to be able to hold your breath for extended periods of time. With the right training, it is possible to increase your breath-holding time from a few seconds to several minutes. But what are the physiological limits of breath-holding, and how can you safely extend them? This article will explore these questions and provide tips for increasing your breath-holding time.

Exploring the Physiological Limits of Breath Holding

When you hold your breath, your body begins to experience certain physiological changes. The length of time you can hold your breath is determined by several factors, including your age, fitness level, and lung capacity. Generally, an untrained person can hold their breath for up to 30 seconds before feeling the need to take a breath. With proper training, this time can be extended to around 3 minutes.

The body’s response to breath-holding is a combination of oxygen deprivation and carbon dioxide buildup. When you hold your breath, oxygen levels in your blood decrease and carbon dioxide builds up in your lungs. This causes a reflex known as the “gasp reflex”, which triggers an urge to breathe after a certain amount of time.

Training for Longer Breath Holding Times

There are several exercises and techniques you can use to increase your breath-holding time. These include strengthening your diaphragm, increasing your lung capacity, and practicing controlled breathing techniques.

Exercises to strengthen your diaphragm and increase your lung capacity include deep breathing, belly breathing, and pursed lip breathing. Deep breathing involves inhaling slowly through your nose and exhaling through your mouth. Belly breathing involves taking slow, deep breaths while focusing on expanding your abdomen. Pursed lip breathing involves inhaling through your nose and exhaling through your mouth with your lips pursed together.

Controlled breathing techniques involve taking slow, steady breaths and gradually extending the duration of each breath. You can also practice progressive relaxation techniques such as muscle tensing and releasing and visualization. These techniques help to reduce stress and improve your ability to control your breathing.

It is important to start slowly and gradually increase your breath-holding time. Start by practicing your breathing exercises for several minutes each day and then work your way up to holding your breath for longer periods of time. Make sure to take breaks between exercises to prevent overexertion.

The Health Benefits of Controlled Breath Holding
The Health Benefits of Controlled Breath Holding

The Health Benefits of Controlled Breath Holding

In addition to improving your breath-holding time, controlled breath-holding has numerous health benefits. It can help to reduce stress and anxiety, improve cardiovascular health, and improve respiratory health. It can also help to boost your energy levels and improve your concentration.

Breath Holding Techniques to Increase Your Lung Capacity
Breath Holding Techniques to Increase Your Lung Capacity

Breath Holding Techniques to Increase Your Lung Capacity

There are several breath-holding techniques you can use to increase your lung capacity. One of the most popular techniques is Pranayama, an ancient Indian practice that focuses on using the breath to create balance and harmony in the body. Another technique is Box Breathing, which involves taking slow, steady breaths and visualizing a box shape as you inhale and exhale. Finally, there is Kapalabhati, a yogic breathing technique that involves rapid, shallow breaths.

Tips for Safely Prolonging Your Breath Holding Time
Tips for Safely Prolonging Your Breath Holding Time

Tips for Safely Prolonging Your Breath Holding Time

When attempting to increase your breath-holding time, it is important to do so safely. Make sure to warm up your body before attempting any breath-holding exercises. Monitor your heart rate and breathing during the exercise, and focus on relaxation techniques such as muscle tensing and releasing or visualization. If you feel any discomfort or dizziness, take a break and resume when you are ready.

Conclusion

Breath-holding is an activity that requires practice and determination to be able to hold your breath for extended periods of time. By understanding the physiological limits of breath-holding and following some simple training tips, you can safely extend your breath-holding time. There are also numerous health benefits associated with controlled breath-holding, such as stress relief, improved cardiovascular health, and improved respiratory health. With the right training and safety precautions, you can increase your breath-holding time and reap the many benefits of this practice.

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Lütfiye Kiliç,1 Seda Tural Önür,2 Aslı Gorek Dilektasli,3 Gaye Ulubay,4 Arif Balcı5

1Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, Pulmonologist, Department of Pulmonary Rehabilitation, University of Health Sciences, Istanbul, Turkey; 2Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, Associate Professor, Department of Chest Diseases, University of Health Sciences, Istanbul, Turkey; 3Uludağ University, Faculty of Medicine, Associate professor, Department of Chest Diseases, Bursa, Turkey; 4Başkent University, Faculty of Medicine, Professor, Department of Chest Diseases, Ankara, Turkey; 5Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, Physiotherapist, Department of Pulmonary Rehabilitation, University of Health Sciences, Istanbul, Turkey

Correspondence: Lütfiye Kiliç, Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey, Tel +90 532 397 7172, Email [email protected]

Purpose: We investigated the effect of pulmonary rehabilitation (PR) on airway resistance in chronic obstructive pulmonary disease (COPD) patients with severe airway obstruction and hyperinflation.
Patients and Methods: This retrospective cohort study was conducted with data from severe COPD cases with those who underwent an 8-week PR program. Main inclusion criteria were having severe airflow obstruction (defined as a forced expiratory volume in one second (FEV1) < 50%) and plethysmographic evaluation findings being compatible with hyperinflation supporting the diagnosis of emphysema (presence of hyperinflation defined as functional residual capacity ratio of residual volume to total lung capacity (RV/TLC) > 120%). Primary outcomes were airway resistance (Raw) and airway conductance (Gaw) which were measured by body plethysmography, and other measurements were performed, including 6-minute walk test (6-MWT), modified Medical Research Council dyspnea scale (mMRC) and COPD assessment test (CAT).
Results: Twenty-six severe and very severe COPD patients (FEV1, 35.0 ± 13.1%; RV/TLC, 163.5 ± 29.4) were included in the analyses, mean age 62.6 ± 5.8 years and 88.5% males. Following rehabilitation, significant improvements in total specific airway resistance percentage (sRawtot%, p = 0.040) and total specific airway conductance percentage (sGawtot%; p = 0.010) were observed. The post-rehabilitation mMRC scores and CAT values were significantly decreased compared to baseline results (p < 0.001 and p < 0.001, respectively). Although there were significant improvements in 6-MWT value (p < 0.001), exercise desaturation (ΔSaO2, p = 0.026), the changes in measured lung capacity and volume values were not significant.
Conclusion: We concluded that PR may have a positive effect on airway resistance and airway conductance in COPD patients with severe airflow obstruction.

Keywords: airway resistance, body plethysmography, airflow limitation, emphysema, lung mechanics

Introduction

Chronic obstructive pulmonary disease (COPD) is characterized by airflow limitation caused by a combination of many factors,1 including increased airway resistance, impaired airway-parenchymal tethering due to emphysema, and lumen narrowing due to mucus occlusion and bronchoconstriction.2–5 Among the conditions referred to as COPD, patients with emphysema have highest airway resistance.6 In patients with emphysema, peripheral airway resistance may be increased by four to 40-fold.7

Although activity limitation in COPD is multifactorial (reduced cardiac function, hypoperfusion of the working muscle, limb muscle dysfunction and impaired neural regulation),8 therapies aimed at partially reversing pulmonary hyperinflation represent the first step in improving dyspnea and exercise capacity.

Various pharmacological and non-pharmacological interventions have been shown to reduce hyperinflation and delay the onset of airflow restriction in patients with COPD.4 For instance, bronchodilators reduce expiratory airflow resistance by increasing the diameter of the airways, emptying of peripheral airways with trapped air is facilitated, thus reducing hyperinflation and improving breathing mechanics.9 Previous studies showed that inhaled long-acting bronchodilators (LABA/LAMA combination) have been proven to be able to reduce hyperinflation and therefore to improve dyspnea and tolerance to physical activity.10 Inhaled low-dose short-acting β-agonists (SABAs) have been demonstrated to reduce lung hyperinflation despite no change in forced expiratory volume within one second (FEV1) in patients with advanced emphysema.5,11–13

Pulmonary rehabilitation (PR) is the most effective non-pharmacological therapy that has emerged as a standard of care for patients with COPD.14 PR reduces ventilatory requirements and improves breathing efficiency, thereby reducing hyperinflation and improving exertional dyspnea.5 Although there is a limited data to draw a firm conclusion as to the mechanism by which this PR effect occurs, it may be attributable to the multifactorial effects of the rich PR content.15

To date, the benefit of PR in COPD patients has been mostly evaluated by investigating effects on exercise capacity, dyspnea and health-related quality of life.16 Due to variabilities in perceptions and interpretations, assessing benefit based solely on symptoms and clinical response may lead to incomplete or inaccurate outcomes. Moreover, the relationship of improvements in the degree of hyperinflation, which is attributed to the effect of PR on respiratory mechanics in patients with COPD,15 with intra-alveolar pressure and airway conductance has not been elucidated yet. Previous investigations have shown that body plethysmography can potentially provide additional insights into the respiratory mechanics of COPD patients.17

Body plethysmography is an integrative diagnostic procedure in respiratory medicine for comprehensive pulmonary function testing to evaluate static lung volumes and airway resistance (Raw), as well as specific airway conductance (sGaw).18–20 Raw reflects changes in alveolar pressure over changes in flow, representing true resistance of the airways. In this context, it may be a good parameter for the diagnosis of airflow obstruction.21,22 In contrast, sRaw can be interpreted as the work to be performed to establish this flow rate; Raw is calculated as the ratio of sRaw to FRC;23 sGaw is the inverse of sRaw and therefore reflects the conductance of the airways independent of lung volumes.23 In obstructive lung diseases, the Raw value is higher and the sGaw value is lower than both healthy controls and non-obstructive respiratory diseases.18 Furthermore, some authors have suggested that sGaw is more sensitive to changes in airway resistance than FEV1.24

The use of different functional markers to evaluate the effectiveness of PR in COPD may provide a better understanding of its effects on lung mechanics. Assessment of airway resistance is, therefore, important to characterize respiratory mechanisms that contribute to improved exercise capacity after PR in patients adopting different breathing strategies during exercise. To the best of our knowledge, no previous studies have addressed the effects of PR on airway resistance and specific airway conductance in patients with COPD. Accordingly, the primary aim of this study was to examine the effects of PR on airway resistance in patients with advanced COPD who had clinical and physiological features of emphysema, and secondarily, to assess whether airway resistance tests could be used as a physiological biomarker for PR.

Patients and Methods

Study Design and Patient Selection

This observational study involved a retrospective analysis of COPD patients admitted to the PR outpatient clinic of a tertiary-level training and research hospital, between December 2012 and June 2019. The study protocol was approved by the ethics committee of Yedikule Chest Diseases and Thoracic Surgery Training and Research Hospital (Approval Number: 2020–27; September 17, 2020). Written informed consent was obtained from all participants before PR. This study complied with the principles of the Declaration of Helsinki and Good Clinical Practice guidelines.

Records of 154 COPD patients with predominant pathology to emphysema who had attended an 8-week outpatient PR program were reviewed. The criteria for inclusion into the study for all participants were 1) having completed the 8-week outpatient PR program; 2) having a post-bronchodilator ratio of forced expiratory volume per second to forced vital capacity (FEV1 / FVC) less than 0.7 to qualify for the definition of COPD;25 3) having severe airflow obstruction (defined as a FEV1 less than 50% of the predicted value); 4) presence of hyperinflation defined as functional residual capacity (FRC) ≥120% and/or RV/TLC >120% of the predicted value;26 5) having undergone a body plethysmography test, including measures of lung volumes, airway resistance (Raw) and specific airway conductance (sGaw), and 6) no change in dose or use of bronchodilator treatment, prior to, and throughout the duration of the PR program. Patients were excluded in the presence of 1) patients who only participated in a home-based pulmonary rehabilitation program, even if having severe or very severe COPD; 2) patients whose data is missing from their file; 3) patients who could not complete the eight-week PR program due to various reasons; 4) patients whose COPD treatment was changed for an attack and/or other reason during the PR program; 5) patients whose body plethysmography test measurement was discordant; 6) those who have another chronic obstructive pulmonary disease (chronic bronchitis, asthma, bronchiectasis, etc.) other than emphysema, and 7) significant diseases other than COPD that could contribute to dyspnea and exercise limitation (interstitial lung disease, advanced heart disease, anemia, thyroid dysfunction).

Baseline data included age, sex, body mass index (BMI), smoking status, pulmonary function tests (PFTs), and comorbid diseases. The outcome measures were body plethysmography test, 6-minute walk test (6-MWT), modified Medical Research Council (mMRC) dyspnea scale, and COPD Assessment Test (CAT). Disease classification was made according to the GOLD staging.25

Pulmonary Rehabilitation Program

The comprehensive PR program consisted of 1) education (lung anatomy, physiology and pathophysiology etc.) and self-management aimed at improving disease status; 2) training for controlled breathing techniques (slow and deep breathing, pursed-lip breathing, diaphragmatic breathing, and restructuring of breath); 3) teaching effective use of inhaler medication and management of breathing difficulties, both aimed maximizing bronchodilation; 4) at least twice supervised cycle ergometer or treadmill training session (30 min) per a week, the intensity of which was set at 60–80% of maximal workload based on 6-MWT results; 5) supervised upper and lower limb strengthening exercises and inspiratory/expiratory muscle training; 6) psychiatric and social counseling/assistance, and 7) nutritional management (patient counselling and nutritional therapy). All patients underwent a supervised exercise program at the hospital two days per week, for a total of 8 weeks. A home-based program (3 days per week) was also provided, comprising various exercises during the same period. All patients completed a follow-up form for the exercise program.

Functional and Pulmonary Testing

Exercise tolerance was evaluated with the distance covered during a 6-MWT, according to guidelines put forth by the American Thoracic Society (ATS).27 Before and after the test, oxygen saturation, heart rate, dyspnea, and Borg fatigue scores were recorded, and the distance covered was documented.25,28 Oxygen desaturation was defined according to the Royal College of Physicians’ guidelines as a ≥ 4% reduction between arterial oxygen saturation measured by pulse oximetry pre-test and post-test (ΔSpO2 ≥4%) and post-test SpO2 <90%.29 Patients were introduced to a 10-point Borg category scale.30 Patients were asked to describe their perception of dyspnea before exercise testing and at the end of tests.

Lung function testing was performed according to current ATS/ERS recommendations with a Sensor Medics model 2400 (Yorba Linda, CA, USA).31,32 Static, dynamic lung volumes and total specific airway resistances (sRawtot) were assessed by means of an ultrasonic flow measurement plethysmograph (Ganshorn PowerCube Body+, SCHILLER, Germany). The system automatically derived total specific conductance (sGawtot) from the breathing loops and determined total respiratory resistance (Rawtot).

Perceived levels of effort dyspnea were assessed through the modified medical research council (mMRC) dyspnea scale which performs evaluations with respect to daily activities.33 Patient-reported CAT results were obtained to identify COPD impact on health status (ie, cough, sputum and dyspnea).33

Statistical Analysis

Statistical analysis was performed using the SPSS software for Windows, version 15.0 (IBM, Armonk, NY, USA). Continuous variables were expressed with minimum–maximum (median) values (for non-normally distributed variables) or with mean ± standard deviation values (for normally distributed variables), while categorical variables were depicted with number (absolute frequency) and percentage (relative frequency). When continuous variables in dependent groups met normal distribution, they were examined using the paired samples t-test; otherwise, the Wilcoxon test was utilized. A p value of <0.05 was considered statistically significant.

Results

A total of 26 emphysema patients (88.5% males) with severe airflow limitation (FEV1, mean ± SD, 35.0 ± 13.15%) and static hyperinflation (RV/TLC, mean ± SD, 163.5 ± 29.4%) were included in the study, mean age 62.6 ± 5.8 year. The number of patients with at least one comorbidity was 10 (38%), diabetes mellitus was the most common (others: hypertension, hypercholesterolemia and osteoporosis). The demographic characteristics and baseline values of the patients are shown in Table 1. Following PR, there were significant improvements in total specific airway resistance percentage (sRawtot%, p = 0.040) and total specific airway conductance percentage (sGawtot%, p = 0.010) (Table 2; Figures 1 and 2). Of note, after PR, some limited improvements in plethysmographic respiratory measurement values [pre-PR vs post-PR, % of pred (IC: inspiratory capacity; 49.0 ± 24.6 vs 49.2 ± 20.7; p = 0.970), (FVC: forced vital capacity; 57.8 ± 17.0 vs 60.4 ± 15.8; p = 0.054), (FRC: functional residual capacity; 133.7 ± 37.2% vs 132.0 ± 39.9%; p = 0.788), (ERV: expiratory reserve volume; 80.8 ± 29.2% vs 88.5 ± 36.6%; p = 0.364)] were identified in our group of patients, especially in RV and RV/TLC [pre-PR vs post-PR, % of pred (169.9 ± 51.3 vs 163.8 ± 67.9) and (163.5 ± 29.4 vs 156.0 ± 42.5)], albeit statistical significance was not achieved (p > 0.05).

Table 1 Patient Characteristics

Table 2 Changes in Lung Volumes in Plethysmography Measurements After PR

Figure 1 A graph showing the parameters for which statistically significant differences were observed in patients who has participated in an eight-weeks PR program.

Abbreviations: PR, pulmonary rehabilitation; sRawtot, total specific resistance of airways; sGawtot, total specific conductance of airways; ΔSaO2, delta of haemoglobin O2 saturation; mMRC, modified Medical Research Council; CAT, COPD assessment test.

Figure 2 A Body plethysmography data samples of a 57-year-old male patient with a history of smoking 60 pk/year, who has attended sixteen sessions (8 weeks) of PR program; before attending (A) and after attending (B).

The post-rehabilitation mMRC scores and CAT values were significantly decreased compared to the baseline results (p < 0.001 and p < 0.001, respectively) (Table 2 and Figure 1). We observed significant differences between baseline and post-PR measurements in terms of 6-MWT results, including walking distance (Mean ± SD; 307.7 ± 98.3 meters vs 363.7 ± 105.7 meters; p < 0.001) and delta of haemoglobin O2 saturation (ΔSpO2, difference between rest and maximal exercise values; p = 0.026) (Table 3 and Figure 1). In addition, the post-rehabilitation median change in distance (Mean ± SD, 55.9 ± 64.6 meters) observed in the 6-MWT was above the minimal clinically important difference defined for COPD and other chronic respiratory patients.28 Although an improvement in Borg scores was observed, comparisons did not show significant improvement (p = 0.314) (Table 3).

Table 3 Comparison of 6-MWT Data

Discussion

The main new finding of this study is that PR may have a positive effect on airway resistance and airway conductivity in COPD patients with severe airway resistance. The present study is the first to demonstrate that the Raw and sGaw plethysmography parameters have the potential to assess the effect of PR on COPD.

Previous studies have shown that airway resistance and specific conductance have a valuable and potentially important role in the diagnosis of obstructive diseases.18 In a study including 51 participants with emphysema, the variability and sensitivity of plethysmography and spirometry measurements were compared in order to assess bronchodilation in COPD.17 The findings of this study demonstrated the high sensitivity of plethysmography in the detection of minor physiological effects, which resulted in improved airway conductance. In COPD, both specific conductance and airway resistance are more sensitive for assessing short-acting bronchodilator effects than FEV1.24 Moreover, body plethysmography can be a favorable alternative tool in evaluating the effect of PR, especially in elderly patients with COPD who have difficulty in performing spirometry.34

The significant decrease in plethysmography-determined airway resistance, the significant increase in airway conductance, and improvements in lung volumes may be attributed to the mechanical effects of PR on respiratory function.33 We observed limited improvements in the respiratory functions of our cases, as demonstrated by RV and RV/TLC results; however, comparisons did not demonstrate statistical significance (p > 0.05) which is similar to the literature on this topic.35 The changes in Raw and sGaw were also relatively greater compared to the changes in lung volume, and therefore, these parameters are possibly better for the purpose of detecting significant reductions in airflow restriction following PR interventions.

In our cases, there was a statistically significant improvement in exercise-induced hypoxaemia levels observed in 6-MWT after PR compared to baseline (Table 3 and Figure 1). We speculate that the improvement in desaturation during exercise following PR may be achieved by both the reduction in the effort required to breath and the decrease in the oxygen demand associated with the improvement of the oxygen utilization in peripheral muscles.36 In addition, controlled pursed-lip breathing and deeper and longer breaths to decrease the frequency of hyperventilation can reduce the O2 cost caused by the unit force.37,38 It was thought that the decrease in Raw would improve hypoxemia, as it would increase air conduction and reduce the O2 cost caused by the resistant respiratory workload. The clinical equivalent of this was interpreted as an increase in effort capacity and improvement in dyspnea levels in our cases. Although the patients in this study were under optimal pharmacological treatment and there was minimal change in lung function after rehabilitation, improvements in exertional dyspnea and capacity should be mainly attributed to the effect of rehabilitation. This is important as it demonstrates that even patients with advanced emphysema may experience considerable benefit from PR.

In previous studies, the addition of inspiratory muscle training to a PR program for COPD was reported to contribute to improved outcomes.39,40 However, patients with predominant pathologies such as chronic bronchitis or emphysema were not evaluated separately in these studies, whereas, in emphysematous lungs, the radial traction exerted by the surrounding alveoli to the airway decreases, correlated with the degree of parenchymal destruction.41 Accordingly, the bronchodilation effect of deep and strong inspiration is not proportional to the severity of emphysema, and may even cause bronchoconstriction.42 Therefore, in patients with emphysema, it would be more appropriate to focus on PR interventions that affect the expiratory rather than the inspiratory phase of respiratory mechanics, altering the breathing pattern and reducing air trapping.

The impact of PR on airway resistance-related respiratory mechanics cannot be resolved through this study design, but some assumptions are worth testing. The PR interventions that may lead to improved airflow resistance in emphysema may be summarized as follows: 1) breathing training, particularly pursed-lip breathing and controlled breathing techniques, prevent early airway closing, providing enough time to expel trapped air;37,43 2) deep inspiration is established to increase the production of surfactant, which maintains alveolar and airway stability;44 3) effective inhalation techniques allow inhaled medications to reach higher concentrations in the airways, facilitating stronger bronchodilation effect; 4) effective coughing and expectoration techniques eliminate secretions that cause airway obstruction and increased resistance;45 5) exercise training of leg muscles reduces lactate production and decreases ventilator load.46 A lower ventilation load allows COPD patients to breathe more slowly during exercise, consequently reducing dynamic hyperinflation.15,47 We speculate that airway resistance may be significantly reduced by the cumulative effect of PR interventions.48,49 It is clear that breathing exercises in COPD patients yield complex changes in pulmonary physiology.39,49 Therefore, body plethysmography can be beneficial in assessing the different aspects of these physiological changes.24

Although the expansion of airway diameter achieved by bronchodilator drugs in patients with COPD is smaller than in patients with asthma, the decrease in Raw provides an above-expected resistance reduction in relation to Poiseuille’s law (a reduction correlated with the 4th power of airway diameter).50 In addition, according to our clinical experience, we recommend that severe COPD patients take their short-acting bronchodilator drugs (with a nebulizer if necessary) 15–20 minutes before exercise, thus reducing the level of exercise limitation due to shortness of breath.51,52 Similarly, it would be more appropriate to focus on reducing airway resistance before respiratory muscle exercises with an incentive spirometry device.33 Otherwise, in the patient trying to breathe against the high resistance caused by the narrowed airway, the increased respiratory workload may increase O2 cost and cause more harm than benefit.

There are several limitations to this study. The main limitation is the single-center study design and small sample size. Inclusion of only patients with emphysema was the main reason for the low number of patients, but this was necessary for accurate analysis in this particular population. Another reason that plethysmography tests were expensive and had limited indications (preoperatively or before volume reduction intervention, etc.) in our hospital. We realize that the small size of the group does not allow generalization of results beyond this select group of patients. However, our group represents a fairly homogeneous group of patients with severe COPD and hyperinflation of the lungs, which is an important strength of the study.

In conclusion, our study suggests that the PR is effective in reducing airway resistance in COPD patients with severe hyperinflation. In addition, we believe that Raw and sGaw can be used as physiological biomarkers in the evaluation of PR benefit, especially in a select group of patients with severe airflow obstruction.

Funding

There is no funding to report.

Disclosure

The authors report no conflicts of interest in this study.

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By nature, negative thoughts can easily run wild and take over our lives. Something bad someone has done in the past can go alongside worries about finances, future career moves, or our long-term health. It can be difficult to remove thoughts about the situation when something stressful is going on. You can sleep through the day or get distracted. That’s where the practice of self-soothing can help.

Self-soothing is any relaxing practice to distract ourselves from negative thinking and help us feel better. Examples could be breathing exercisesplaying uplifting music, starting a mindfulness hobby like yoga or connect with others.

One study looked at oxytocin release and self-soothing behaviors. Oxytocin, a natural hormone linked to feelings of well-being and anti-stress, is released in the brain through a range of low-intensity stimulation behaviors such as touching and caressing, but it can also be released through pleasurable situations in general. Self-soothing is the release of feel-good hormones by consciously choosing pleasurable activities.

For more mental health tips, visit how gratitude improves your mental health and tips for dealing with depression during the holidays.

Below are eight ways to practice self-soothing techniques to lift your spirits and disrupt feelings of stress.

8 self-smoothing techniques to start today

The next time you’re feeling stressed or anxious, try one of our favorite self-soothing techniques.

Use your breathing well

Try some breathing techniques to help you focus away from negative thoughts. Deep breathing and others breathing exercises can help us distract ourselves from negative thinking and increase feelings of relaxation. Some calming techniques that use breathing include:

Diaphragmatic Breathing: This exercise helps us use our diaphragm to increase deep breathing. The diaphragm is a muscle below the lungs, and using it to breathe properly is associated with lowering blood pressure and heart rate and improving relaxation, according to the Cleveland Clinic.

Practicing diaphragmatic breathing:

1. Lie flat on your back with your knees bent or supported by a pillow. Also support your head. You can also do this sitting down.

2. Place one hand on your upper chest and the other directly under your ribcage.

3. Breathe in through your nose as deeply as possible. You should feel your abdomen rise or expand, while the hand on your chest should remain fairly still.

4. Exhale through your mouth and exhale completely. Make sure the hand on your chest remains as still as possible.

5. Repeat for as long as it takes to feel relaxed or as long as you have.

Woman does breathing exercises.

Westend61/Getty Images

Square breathing: Another method is square breathing, which relies on counting to focus thoughts and get the relaxing benefits of slow breathing. With this method, you simply exhale completely. Then breathe in slowly through your nose, counting to four. Hold that breath and count to four again. Exhale through your mouth for four counts, then hold your breath again for four counts. Repeat for the duration of the exercise.

Breathe with pursed lips: Another popular breathing technique is pursed lip breathing. This technique makes you have to put in more effort to breathe, thus slowing down your breathing and helping you focus only on your breathing. To perform this technique, start by exhaling completely, then inhale through your nose for two counts. Purse or pucker your lips as if you were going to whistle. Then exhale slowly as you count to four. Repeat for as long as comfortable or necessary.

If you have a chronic or temporary nasal congestion, feel free to breathe through your mouth when the instructions ask you to breathe through your nose.

Practice the 5-4-3-2-1 technique

This is a coping mechanism for anxiety. According to the University of Rochester Medical Center, the method is based on grounding you in the present so you can focus on something other than anxious thoughts. It requires you to recognize things from your immediate environment. Use the following steps to perform the exercise:

5: Acknowledge five items that you can see around you. This can be anything from the floor to a ceiling fan.

4: Recognize four things around you that you can touch, such as your hair or the ground.

3: Recognize three things around you that you can hear, such as air coming through an oven vent or a bird outside.

2: Acknowledge two things you can smell, such as some hand lotion or you can even see what the pillow in your bedroom smells like.

1: Recognize one thing you can taste, such as a lingering food taste from lunch or a mint taste from brushing your teeth.

Use your inner dialogue for self-affirmation

This is also known as positive self-talk. We can easily fall into negative self-talk, which can be anything from beating ourselves up mentally for perceived mistakes to worrying about negative judgments others might have. Positive self-talk redirects these thoughts to a more positive mindset.

Finding a good set of self talk lines is a very personal experience. You will usually need to address specific insecurities or find expressions that resonate with you. Self-talk exercises usually involve subverting negative thoughts that make you feel down. For example, instead of thinking how embarrassed you are, remind yourself that you jumped at the chance and were brave to try.

To start with, some common and common positive Self-Talk phrases are:

“I can do it.”

“I’m good enough.”

“I can try again if I make a mistake.”

“I am doing the best I can.”

“I’m trying my best.”

Try looking for positive Self-Talk phrases and see which ones resonate with you. One or two may jump out at you, and you can try relying on them to see how they make you feel. Try as many as you need to see which sticks. Consider working with a therapist to reduce negative self-talk and work on phrases tailored to your situation.

Change the environment

Sometimes something in our environment can bring us down. It could be as simple as getting less daylight in the winter, so you could look into bulbs that mimic natural sunlight.

Sometimes, exposing ourselves to too much negative media can also turn our overall view of the negative. During the COVID-19 pandemic, a study showed that media exposure to COVID-19 news was associated with anxiety and subjective loneliness. You don’t have to cut off all stressful media completely, but it can be helpful to regulate how much you consume in a week or use tools that manage media attention, such as apps that help you limit your time on social media.

You can also work on changing your immediate environment. Repaint your walls soothing tonesredecorate your home with more uplifting and colorful decor or even plain tidy up your room can make a big difference. Play around to see which decor choices lift your mood.

Create a favorite playlist

Music can help improve our mood. You’ve probably experienced firsthand the joy of rocking out to your favorite music. Make a playlist of all your feel-good favorites.

Don’t forget to expand and try new genres, songs and artists. You may find your new favorite song that always lifts you up. Making a playlist of all new songs can also orient you in the present moment, rather than listening to a song that reminds you of the past.

Hug someone (or yourself)

Woman in white shirt hugging herself against pink background

LightField Studios/Getty Images

Above, we discussed how touch can help you release feel-good hormones. Therefore, try to make physical contact with someone you care about. Give them a hug, or even try to hug yourself.

Hugging yourself may sound strange, but it can relieve pain and improve your mood. To hug yourself, wrap your arms in whatever way feels most comfortable, place your hands on your shoulders or upper arms, and squeeze yourself for as long as you need to. You could give a hard hug if that’s what you need right now, or a softer and more soothing hug.

Try gently stroking your shoulders or forearms to get the sense of touch. You can do this while hugging yourself or not.

Try a mindful hobby

You can also look for a hobby that orients you in the present moment or is related to calming practices. For example, anything that includes deep breathing can help add feelings of relaxation, such as meditation, yoga, qigong, or tai chi. You could also try meditation apps.

Look for other hobbies that can provide a positive mood boost from getting outside, such as hiking, gardening, or biking. These activities can also be mindful if you focus as much as possible on the present moment while doing them.

Write down your feelings

Finally, try to write down your feelings, which can help us deal with anxiety, depression, and anxiety tension, according to the University of Rochester Medical Center. You could try keeping a journal of how you feel and why, and writing down ways to feel better or solve problems.

You can also find many books or articles that help you write from a prompt. These often start as questions that you then answer. They are meant to help you think and often focus on self-growth. For example, some prompts ask you to describe your perfect day, ideal home, or goals for the future. Some prompts even help you continue working social anxiety. Try searching for terrifying diary prompts.

Try some general journaling tips to help you focus on the positive things in your life. A common prompt is “Today I am thankful for…”

The information in this article is for educational and informational purposes only and is not intended as health or medical advice. Always consult a physician or other qualified health care professional if you have any questions about a medical condition or health goals.

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By their nature, negative thoughts can easily run wild and take over our lives. Something nasty someone did in the past can sit right alongside worries about finances, future career moves or our long-term health. It can be difficult to remove thoughts about the situation if something stressful is going on. You might lose sleep or find yourself distracted throughout the day. That's where the practice of self-soothing can help.

Health Tips logo

Self-soothing is any relaxing practice to distract ourselves from negative thinking and help us feel better. Examples might be breathing exercises, playing uplifting music, taking up a mindfulness hobby like yoga or connecting with others.

One study looked at oxytocin release and self-soothing behaviors. Oxytocin, a natural hormone linked to feelings of well-being and anti-stress, gets released in the brain from a series of low-intensity stimulation behaviors such as touch and stroking, but it can also be released by pleasant situations overall. Self-soothing is to release feel-good hormones by consciously choosing pleasant activities.

For more mental health tips, check out how gratitude improves your mental health and tips to manage depression during the holidays.

Below are eight ways to practice self-soothing techniques to lift your spirits and disrupt feelings of stress

8 self-soothing techniques to start using today

Next time you're feeling stressed or anxious, try using one of our favorite self-soothing techniques.

Put your breathing to good use

Try a few breathing techniques to help you focus away from negative thoughts. Deep breathing and other breathing exercises can help us distract ourselves from negative thinking and increase feelings of relaxation. Some calming techniques that use breathing include:

Diaphragmatic breathing: This exercise helps us use our diaphragm to increase deep breathing. The diaphragm is a muscle below the lungs, and using it to breathe properly is associated with reducing blood pressure and heart rate while improving relaxation, according to the Cleveland Clinic.

To practice diaphragmatic breathing:

1. Lay flat on your back with your knees bent or supported by a pillow. Also, have your head supported. You can also do this sitting up. 

2. Put one hand on your upper chest and the other right under your ribcage. 

3. Breathe in through your nose as deeply as you can. You should feel your stomach rise or expand, while the hand on your chest should stay fairly still.

4. Breathe out through your mouth, exhaling completely. Make sure the hand on your chest stays as still as you're able. 

5. Repeat for as long as you feel is necessary to feel relaxed or for however much time you have.

Woman doing breathing exercises.

Westend61/Getty Images

Square breathing: Another method is square breathing, which relies on counting to focus thoughts and get the relaxation benefits of slow breathing. With this method, simply exhale completely. Then slowly inhale through your nose, while counting to four. Hold that breath, counting to four again. Exhale for a count of four through your mouth, and then hold your breath again for a count of four. Repeat for the length of the exercise.

Pursed lip breathing: Another popular breathing technique is pursed lip breathing. This technique makes you have to put more effort into breathing, and thus slows your breathing and helps you focus on just your breath. To perform this technique, start by exhaling all the way and then inhaling for two counts through your nose. Purse or pucker your lips like you're going to whistle. Then slowly exhale while counting to four. Repeat for as long as is comfortable or needed.

If you have chronic or temporary nasal congestion, feel free to breathe through your mouth when the instructions call for breathing through your nose.

Practice the 5-4-3-2-1 technique

This is a coping mechanism for anxiety. According to the University of Rochester Medical Center, the method relies on grounding you in the present so that you can focus on something besides anxious thoughts. It requires you to recognize things from your immediate environment. To perform the exercise, use the following steps:

5: Acknowledge five items you can see around you. This can be anything from the floor to a ceiling fan.

4: Acknowledge four things around you that you are able to touch, such as your hair or the ground.

3: Acknowledge three things around you that you can hear, such as air coming through a furnace vent or a bird outside.

2: Acknowledge two things you can smell, such as some hand lotion or you could even check what the pillow smells like in your bedroom. 

1: Acknowledge one thing you can taste, like lingering food tastes from lunch or a mint taste from brushing your teeth. 

Use your inner dialogue for self-validation

This is also called positive self-talk. We can easily fall into negative self-talk, which can include anything from beating ourselves up mentally for perceived mistakes to worrying about negative judgments others might have. Positive self-talk re-routes these thoughts into a more positive mindset. 

Finding a good set of self-talk lines is a highly personal experience. You'll usually have to address specific insecurities or find phrases that resonate with you. Self-talk practice usually involves subverting negative thoughts that make you feel low. For instance, instead of thinking how embarrassed you are, remind yourself that you took the chance and were brave for trying.

To start, some common and general positive self-talk phrases include:

"I can do it."

"I am good enough."

"I can try again if I make a mistake." 

"I make the best effort I can."

"I'm doing my best." 

Try searching for positive self-talk phrases and see which ones resonate with you. One or two may jump out at you, and you can try relying on them to see how they make you feel. Try as many as you need to see which sticks. Consider working with a therapist to reduce negative self-talk and work on phrases tailored to your situation.

Change the environment

Sometimes something in our environment can bring us down. It might be as simple as getting less daylight during the winter, so you might look into lamps that mimic natural sunlight.

Sometimes if we expose ourselves to too much negative media, that can also turn our general outlook towards the negative. During the COVID-19 pandemic, a study showed that media exposure to COVID-19 news related to anxiety and subjective loneliness levels. You don't need to completely cut off all stressful media, but it might be useful to regulate how much you consume in a week or use tools that manage media exposure, like apps that help you limit time on social media.

You might also work to change your immediate surroundings. Repaint your walls to soothing tones, redesign your home with more uplifting and colorful decor or even just tidying up your room can make a big difference. Play around to see which décor choices elevate your mood.

Create a go-to playlist

Music can help elevate our mood. You have likely experienced the first-hand joy of rocking out to your favorite music. Create a playlist of all your feel-good favorites.

Remember to branch out and try new genres, songs and artists. You might find your new favorite song that never fails to lift your spirits. Creating a playlist of all new songs might also orient you in the present moment, instead of listening to a song that reminds you of the past.

Hug someone (or yourself) 

Woman in a white shirt hugging herself against a pink background

LightFieldStudios/Getty Images

Above, we discussed how touch might help you release feel-good hormones. As such, try to connect physically with someone you care for. Give them a hug, or even try hugging yourself.

Hugging yourself may sound strange, but it can relieve pain and improve your mood. To hug yourself, wrap your arms around you in a way that feels most comfortable, rest your hands on your shoulders or upper arms and squeeze yourself for as long as you need to. You might give a hard hug if that's what you need right now, or a softer and more soothing hug.

Try gently stroking your shoulders or forearms to get the sensation of touch. You can do this while self-hugging or not. 

Try a mindful hobby 

You can also look for a hobby that orients you in the present moment or is associated with soothing practices. For instance, anything that incorporates deep breathing can help add feelings of relaxation, like meditation, yoga, qigong or tai chi. You could also try meditation apps.

Look for other hobbies that can add a positive mood boost by going outside, like walking, gardening or cycling. These activities can be mindful, too, if you focus on the present moment as much as possible while doing them. 

Journal your feelings 

Finally, try writing out your feelings, which can help us cope with anxiety, depression and stress, according to the University of Rochester Medical Center. You might try journaling about how you're feeling and why and write out ways to help yourself feel better or problem-solve.

You can also find many books or articles helping you write from a prompt. These often start as questions that you then answer. They're meant to help you reflect and often focus on self-growth. For instance, some prompts ask you to describe your perfect day, ideal home or goals for the future. Some prompts even help you work through social anxiety. Try searching for anxiety-busting journal prompts.

Try some general journal prompts to help you focus on the positives in your life. One common prompt is "Today, I'm grateful for…" 

The information contained in this article is for educational and informational purposes only and is not intended as health or medical advice. Always consult a physician or other qualified health provider regarding any questions you may have about a medical condition or health objectives.

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Steer clear of harmful situations. “The first thing is to reduce further damage if possible,” says MeiLan Han, MD, a spokesperson for the American Lung Association as well as a professor of medicine and chief of pulmonary and critical care at the University of Michigan. So quit smoking if you smoke, and avoid secondhand smoke and polluted air whenever possible.

Get treatment. A provider will generally start with prescriptions for inhaled therapies such as bronchodilators (including albuterol inhalers) and steroids, which can help open airways, Han says. They can be used as needed or regularly depending on your symptoms. (Those with advanced disease may need oxygen or lung surgery.) But there’s no one-size-fits-all approach, and regular checkups are important.

Manage flare-ups. Being unable to breathe can be “panic-inducing,” Han says. Along with inhalers, a technique called pursed lip breathing can help in nonemergencies by moving more oxygen into your lungs. To do it, breathe in through your nose, then pucker your lips as if you’re going to whistle and blow out, Han explains. See if you can breathe out longer than you inhale, then repeat.

Get into an exercise routine. Physical activity is critical for people with COPD, Han says, and it should be tailored to the amount of exertion you can tolerate. Supervised or monitored pulmonary rehabilitation programs are available in person and online, and can reduce flare-ups and improve your life, says Sarath Raju, MD, who specializes in pulmonary and critical care medicine at Johns Hopkins University in Baltimore. If you can’t participate in a program, walking or using a stationary bike or treadmill to increase your endurance can help, Raju adds.

Maintain a healthy weight. Being either underweight or overweight is linked to COPD complications. Stock up on nutritious foods that are easy to make, like precut fruits or vegetables, the American Lung Association suggests.

Seek support. It’s common to feel depressed or anxious if you have COPD, Han says. If you do, ask your doctor for a mental healthcare referral. Also consider joining a support group for people with COPD, such as the American Lung Association’s Better Breathers Club or COPD360social, an online community managed by the COPD Foundation.

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What is COPD?

“Chronic obstructive pulmonary disease (COPD) is a term used to describe chronic lung diseases, including emphysema and chronic bronchitis, and is characterized by breathlessness. Some people with COPD also experience tiredness and chronic cough with or without mucus,” said Army Maj. (Dr.) Nikhil Huprikar, chief of Pulmonary and Critical Care Medicine Service at Walter Reed National Military Medical Center (WRNMMC).

“COPD makes breathing difficult for the 16 million Americans who have this disease. Millions more people suffer from COPD but have not been diagnosed and are not being treated. Although there is no cure for COPD, it can be treated,” according to the Centers for Disease Control and Prevention (CDC).

To draw greater attention to COPD and educate the public about the disease, November is annually observed as National COPD Awareness Month.

Huprikar, and Army Maj. (Dr.) Arthur Holtzclaw, a pulmonologist and chief of Medicine at WRNMMC, explained symptoms of COPD can vary, but typically include decreased exercise tolerance, cough, and increased sputum production, in addition to breathlessness.

“COPD is usually diagnosed through lung function testing such as spirometry, which measures how well the lungs are working,” Huprikar explained. “A person may have COPD but not notice symptoms until it is in the moderate stage. Therefore, it’s important to ask your doctor about testing for COPD,” the CDC states.

Testing for COPD is especially recommended if a person is a current or former smoker, has been exposed to harmful lung irritants for long periods of time, or has a family history of COPD, Holtzclaw furthered. In many cases, COPD may also be caused by inhaling air pollutants, including tobacco smoking (cigarettes, pipes, cigars, etc.) and second-hand smoke.

Work-related environmental factors, such as fumes, chemicals, and dust have also been linked to COPD.

“Genetics has also played a role in the development of COPD, even if the person has never smoked or been exposed to strong lung irritants in the workplace,” the CDC adds.

There is no cure for COPD, but some treatments can decrease breathlessness and increase a person’s ability to do activities, while other treatments may reduce the risk of exacerbations of the disease, Huprikar explained.

Treatments include inhaled medications called bronchodilators, as well as pulmonary rehabilitation, which can include exercise and oxygen therapy, according to health care providers.

Breathing from the diaphragm is an exercise for COPD. Also called abdominal or belly breathing, the abdomen should rise when you breathe in, and lower as you breathe out when doing diaphragmatic breathing. The diaphragm, the muscle separating the chest cavity from the stomach, is the main muscle for breathing. When the diaphragm tightens, the lungs expand. The diaphragm is designed to do most of the work of breathing. When a person has COPD, the diaphragm doesn’t work as well and muscles in the neck, shoulders, and back are used. These muscles don’t do much to move your air, according to the CDC.

“Training your diaphragm to take over more work of breathing can help,” the CDC adds.

Diaphragmatic breathing is not as easy to do as pursed-lip breathing, so health care providers recommend people get instructions from a respiratory health care professional or physical therapist experienced in teaching it.

For more information about COPD and its treatment, visit the CDC website at www.cdc.gov/copd/features/copd-symptoms-diagnosis-treatment.html.&#13;

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A pulmonary embolism (PE) can be life-threatening because a blockage in the lungs damages them and reduces the blood's ability to receive enough oxygen to support the rest of the body. With rapid treatment, most people affected by a pulmonary embolism can recover.

This article discusses breathing exercises and how to do them if you've recently had a pulmonary embolism.

DjelicS / Getty Images


About 1 in 1,000 people in the United States are diagnosed with a pulmonary embolism annually.

Breathing Exercises

Generally, the diaphragm can easily move oxygen and other gases in and out of the lungs. After a pulmonary embolism, the lungs might have more difficulty completing this task. If practiced regularly, breathing exercises can help make the lungs more efficient.

Two types of breathing exercises that may help include:

  • Pursed lip breathing is intended to reduce the number of breaths taken and to keep airways open a little longer. To practice this exercise, breathe in through the nose and breathe out about twice as long through pursed lips (as if you're using a straw).
  • Belly breathing or diaphragmatic breathing: Start by breathing in through the nose and paying attention to how your belly fills with air. Breathe out through the mouth at least two to three times longer than you inhale. While doing this exercise, keep your shoulders and neck relaxed.

Other Recovery Strategies

Although there is no standard guideline for post-pulmonary embolism rehabilitation, there are best practices to help with recovery. Speak with your healthcare provider about which of the following exercises can help assist you with your overall health outcome:

  • Exercise training can improve motor function and strengthen breathing muscles. Ensure that exercises help both upper extremity function (which helps decrease fatigue) and lower extremity function (which helps increase endurance and improves breathing function).
  • Health education should include preventing pulmonary embolism, understanding your treatment options, and learning healthy habits to improve lung and overall body function.
  • Psychological intervention: A life-threatening medical diagnosis can cause fear, anxiety, sadness, and post-traumatic stress, negatively affecting the healing process. Your healthcare providers should ensure you have resources to assist in regulating emotions, decreasing stress and anxiety, and modulating emotional reactions.
  • Nutritional supplementation: PE can adversely affect nutrition, so speaking with a dietician who can provide a treatment and a recovery-friendly nutrition plan can be helpful.

Monitoring Symptoms

Once a pulmonary embolism is diagnosed, the primary treatment is an anticoagulant; this medication is designed to stop the blood clot from growing and to give the body time to break the clot down naturally. It's typically used for three months or longer after a PE diagnosis. Since the use of anticoagulants requires some monitoring, expect follow-up appointments with your healthcare provider.

Any shortness of breath resulting from a PE typically resolves within a few weeks to months after the initial diagnosis. If shortness of breath remains six months after treatment, it is important to consult a healthcare provider. Further testing might be indicated to determine if the PE scarred the lung or the lung's blood vessels or if other treatments are needed.

Tips After a PE Diagnosis

Additional items your healthcare provider might encourage after a pulmonary embolism diagnosis include:

  • Compression socks help increase pressure in the veins of the legs to prevent blood from pooling and clotting. Increased pressure forces the blood to keep moving, making it harder for a blood clot to form and break off, becoming a pulmonary embolism.
  • Bleeding precautions: It's essential to be aware of anticoagulant interactions that may decrease their effectiveness. Examples of things to avoid while taking anticoagulants include alcohol, over-the-counter (OTC) medications (like aspirin), and certain foods.

Summary

A pulmonary embolism is a blood clot in the lungs that can block blood from being oxygenated to support the body's functions. Once a diagnosis is made and a treatment plan begins, it is helpful to learn breathing exercises to help the lungs regain optimal function.

There are also additional considerations for strength training, nutritional support, psychological care, and health education to assist with a successful recovery after a pulmonary embolism diagnosis.

A Word From Verywell

A life-threatening diagnosis of pulmonary embolism can be frightening and stressful. Understanding the disease condition is important, as is knowing how to regain optimal health and wellness. Collaborating with your healthcare provider is vital to ensure any additional activities or treatments are recommended and safe.

Frequently Asked Questions

  • How long will I be breathless after a pulmonary embolism?

    Feeling short of breath after a pulmonary embolism can often resolve quickly. In 3% to 4% of people affected by a pulmonary embolism, the damage can cause scarring, which can cause shortness of breath for weeks or months. If you're still experiencing shortness of breath six months post-treatment, you must talk to your healthcare provider to determine if additional testing is required.

  • What are the long-term effects of a pulmonary embolism?

    As with other lung conditions, people affected by a pulmonary embolism experience different degrees of respiratory symptoms and impaired motor functions for several weeks or months after the initial diagnosis.

    Current best practices to improve health after a pulmonary embolism include breathing exercises, exercise training, health education, nutrition improvement, and psychological intervention if depression or anxiety is present.

  • How much exercise should you do after a pulmonary embolism?

    Generally, exercise is safe until any pain or difficulty breathing is noted; if this happens, stop exercising immediately and contact your healthcare provider for further guidance. Before starting any exercise regimen, speak with your healthcare provider so they can ensure your lungs and motor function are stable enough.


By Pamela Assid, DNP, RN

Pamela Assid, DNP, RN, is a board-certified nursing specialist with over 25 years of expertise in emergency, pediatric, and leadership roles.

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What is COPD?

“Chronic obstructive pulmonary disease (COPD) is a term used to describe chronic lung diseases, including emphysema and chronic bronchitis, and is characterized by breathlessness. Some people with COPD also experience tiredness and chronic cough with or without mucus,” said Army Maj. (Dr.) Nikhil Huprikar, chief of Pulmonary and Critical Care Medicine Service at Walter Reed National Military Medical Center (WRNMMC).

“COPD makes breathing difficult for the 16 million Americans who have this disease. Millions more people suffer from COPD but have not been diagnosed and are not being treated. Although there is no cure for COPD, it can be treated,” according to the Centers for Disease Control and Prevention (CDC).

To draw greater attention to COPD and educate the public about the disease, November is annually observed as National COPD Awareness Month.

Huprikar, and Army Maj. (Dr.) Arthur Holtzclaw, a pulmonologist and chief of Medicine at WRNMMC, explained symptoms of COPD can vary, but typically include decreased exercise tolerance, cough, and increased sputum production, in addition to breathlessness.

“COPD is usually diagnosed through lung function testing such as spirometry, which measures how well the lungs are working,” Huprikar explained. “A person may have COPD but not notice symptoms until it is in the moderate stage. Therefore, it’s important to ask your doctor about testing for COPD,” the CDC states.

Testing for COPD is especially recommended if a person is a current or former smoker, has been exposed to harmful lung irritants for long periods of time, or has a family history of COPD, Holtzclaw furthered. In many cases, COPD may also be caused by inhaling air pollutants, including tobacco smoking (cigarettes, pipes, cigars, etc.) and second-hand smoke.

Work-related environmental factors, such as fumes, chemicals, and dust have also been linked to COPD.

“Genetics has also played a role in the development of COPD, even if the person has never smoked or been exposed to strong lung irritants in the workplace,” the CDC adds.

There is no cure for COPD, but some treatments can decrease breathlessness and increase a person’s ability to do activities, while other treatments may reduce the risk of exacerbations of the disease, Huprikar explained.

Treatments include inhaled medications called bronchodilators, as well as pulmonary rehabilitation, which can include exercise and oxygen therapy, according to health care providers.

Breathing from the diaphragm is an exercise for COPD. Also called abdominal or belly breathing, the abdomen should rise when you breathe in, and lower as you breathe out when doing diaphragmatic breathing. The diaphragm, the muscle separating the chest cavity from the stomach, is the main muscle for breathing. When the diaphragm tightens, the lungs expand. The diaphragm is designed to do most of the work of breathing. When a person has COPD, the diaphragm doesn’t work as well and muscles in the neck, shoulders, and back are used. These muscles don’t do much to move your air, according to the CDC.

“Training your diaphragm to take over more work of breathing can help,” the CDC adds.

Diaphragmatic breathing is not as easy to do as pursed-lip breathing, so health care providers recommend people get instructions from a respiratory health care professional or physical therapist experienced in teaching it.

For more information about COPD and its treatment, visit the CDC website at www.cdc.gov/copd/features/copd-symptoms-diagnosis-treatment.html.







Date Taken: 11.28.2022
Date Posted: 11.28.2022 12:34
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Nose or mouth?

Breathing is automatic. We breathe in oxygen and breathe out carbon dioxide without having to think about it. But many people tell us we should think about it.

Breathwork includes many different practices like shamanic breathwork, Vivation, Transformational Breath, Holotropic Breathwork, Clarity Breathwork, and Rebirthing. There’s also circular breathing, box breathing, and 4-7-8 breathing.

And then there’s Buteyko breathing. Buteyko claimed it would cure 150 diseases! Joseph Albietz evaluated it for SBM in 2009 and not surprisingly found a lack of evidence.

Each method is supported by those who practice it, and each is supported by testimonials rather than credible evidence. There is no consensus as to which method works best, and there are no controlled studies comparing the outcomes from different methods.

All kinds of benefits are claimed for breathwork.

Proper breathing is said to decrease fatigue, reduce anxiety, reduce symptoms of asthma in children and adolescents, improve stress management, reduce blood pressure, reduce aggressive behavior in adolescent males, and improve migraine symptoms.

Dr. Andrew Weil thinks 4-7-8 breathing can help with reducing anxiety, helping a person get to sleep, managing cravings, and controlling or reducing anger responses.

Alleged potential benefits of deep breathing include:

  • Decreases stress, increases calm
  • Relieves pain
  • Stimulates the lymphatic system (detoxifies the body)
  • Improves immunity
  • Increases energy
  • Lowers blood pressure
  • Improves digestion.

I remember reading about a woman who always cut the end off a roast. When asked why she did it, she said it was because her mother had always done that. When finally prompted to inquire why she did it, her mother explained that it was the only way a large roast would fit into her small roasting pan.

The daughter assumed that her mother did it to somehow make the roast come out better. She was blindly following a practice she didn’t understand, just like those cargo cult natives in the South Seas who built imitation runways in the hope that planes would land and enrich them with valuable cargos.

I know a lot of the breathwork stuff is nonsense, but I started to wonder about the admonition to breathe in through the nose, out through the mouth. In almost every exercise video I looked at, the trainer had students breathe like that, and the exhalation was usually through pursed lips. Being a curious skeptic, I couldn’t help asking WHY. Was that practice based on science or superstition? I looked for evidence.

Everything I could find indicated that breathing through the nose (both in and out) was preferable. The nose filters out dust and allergens. It warms and humidifies the inspired air. Mouth breathing lacks these advantages and can dry out the mouth. A dry mouth may contribute to bad breath, gum inflammation, tooth decay, and other problems.

The American Lung Association says pursed lip exhalation is beneficial for patients with chronic obstructive lung disease (COPD) and asthma.

I consulted Paul Ingraham, an Assistant Editor Emeritus of Science-Based Medicine who now runs Pain Science, a science-based website for pain and musculoskeletal medicine. He is currently looking into common claims about breathing and plans to write an article on the subject. He has already looked at the claim that longer expirations are more sedative. He says, “It seems to have a credible rationale, but the evidence shows no effect.” He suspects that the mouth/nose/pursed lip claims are “a thing that a lot of people have learned to say without really having any idea why.” In other words, a sort of folk wisdom that people assume is based on physiology but that probably isn’t.

Effects of breathing mode on exercise

Can nose breathing improve athletic performance compared to mouth breathing? Two small studies found that it lowered the respiratory rate but increased the heart rate, which could increase cardiovascular stress. They concluded:

…breathing technique doesn’t affect athletic performance, and the mode of breathing during exercise should be decided by the individual.

So is the advice wrong?

I couldn’t find any scientific evidence to support the common advice to breathe “in through the nose, out through the mouth.” Unless you have asthma or COPD, the evidence seems to show that nose breathing is always best. Some people may subjectively find it more satisfying to breathe out through the mouth, but I suspect the advice originated with someone who misinterpreted the physiology and was blindly followed by others just as the cargo cults imitated practices they didn’t understand, and like the woman kept needlessly cutting the ends off her roasts.

Conclusion: Don’t think, just breathe

You don’t need to think about your breathing. It is automatic and effortless. The mantra “in through the nose, out through the mouth” is based on superstition, not science.

  • Harriet Hall, MD also known as The SkepDoc, is a retired family physician who writes about pseudoscience and questionable medical practices. She received her BA and MD from the University of Washington, did her internship in the Air Force (the second female ever to do so),  and was the first female graduate of the Air Force family practice residency at Eglin Air Force Base. During a long career as an Air Force physician, she held various positions from flight surgeon to DBMS (Director of Base Medical Services) and did everything from delivering babies to taking the controls of a B-52. She retired with the rank of Colonel.  In 2008 she published her memoirs, Women Aren't Supposed to Fly.

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Xuejie Fang,1,&ast; Zhengtong Qiao,2,&ast; Xinjuan Yu,3,4,&ast; Rujin Tian,5 Kai Liu,5 Wei Han3

1School of Clinical Medicine, Weifang Medical University, Weifang, People’s Republic of China; 2School of Rehabilitation Medicine, Binzhou Medical University, Yantai, People’s Republic of China; 3Department of Respiratory and Critical Medicine, Respiratory Disease Key Laboratory of Qingdao, University of Health and Rehabilitation Sciences Qingdao Hospital (Qingdao Municipal Hospital), Qingdao, People’s Republic of China; 4Clinical Research Center, University of Health and Rehabilitation Sciences Qingdao Hospital (Qingdao Municipal Hospital), Qingdao, People’s Republic of China; 5Department of Rehabilitation Medicine, University of Health and Rehabilitation Sciences Qingdao Hospital (Qingdao Municipal Hospital), Qingdao, People’s Republic of China

Correspondence: Wei Han, Department of Respiratory and Critical Medicine, Respiratory Disease Key Laboratory of Qingdao, University of Health and Rehabilitation Sciences Qingdao Hospital (Qingdao Municipal Hospital), No. 5 Donghaizhong Road, Qingdao, 266071, People’s Republic of China, Tel +86 532 85937579, Email [email protected] Kai Liu, Department of Rehabilitation Medicine, University of Health and Rehabilitation Sciences Qingdao Hospital (Qingdao Municipal Hospital), No. 5 Donghaizhong Road, Qingdao, 266071, People’s Republic of China, Tel +86 532 85937671, Email [email protected]

Background: Chronic obstructive pulmonary disease (COPD) is a chronic lung disease which feature is progressive airflow obstruction. Singing is a popular and convenient activity that requires people to manage their lung volumes and airflow actively. Despite the well-known benefits of singing to healthy people, the specific effect still remains unclear.
Objective: To investigate the mental and psychological benefits of singing in patients with stable COPD.
Search Methods: We used Preferred Reporting Items for Systematic Reviews and Meta-Analyses Guidelines (PRISMA) on randomized controlled trials (RCTs) including singing exercise as the main intervention in stable COPD. We searched 8 electronic databases, including Web of Science, PubMed, Embase, Cochrane Library, Clinical Trials.gov, and the Physical Therapy Evidence Database (PEDro), CNKI, and Wanfang Database from inception until May 2022. The searching languages was English or Chinese. Data extraction using standardized templates was performed by two independent reviewers. The quality of the studies was assessed using the PEDro scale. Data synthesis was performed with Revman 5.4. The pooled effect sizes are reported by MD and 95% CI.
Results: Five RCTs involving 333 patients with stable COPD were included in this meta-analysis. Singing was regarded as the main intervention in the experimental group. Meta-analysis revealed that singing improves quality of life on Short Form 36 physical component summary (SF-36 PCS) (MD = 12.63, 95% CI: 5.52 to 19.73, P max) (MD = 14.30, 95% CI: 0.87 to 27.73, P = 0.04) in patients with COPD. However, it has limited effects on Short Form 36 mental component summary (SF-36 MCS), lung function, exercise capability, and adverse mental state.
Conclusion: Based on results of the meta-analysis, singing could be used to improve quality of life (SF-36 PCS) and respiratory muscles (PEmax) in patients with COPD.

Introduction

Chronic obstructive pulmonary disease (COPD) is characterized by non-curable, progressive airflow limitation chronic respiratory disease, with high prevalence of disability and mortality. It is thought to be the third leading cause of death worldwide by 2030. In China, about 100 million people suffer from COPD. The overall prevalence among adults over the age of 20 was 8.6% in 2015, an increase of 67% from 2005.1

COPD patients suffered from decreased respiratory function and dyspnea. As a result of the progression of the condition, patients have reduced exercise tolerance, limiting their daily activities and resulting in poor health-related quality of life. Adverse psychological states are also common symptoms, such as depression and anxiety.2

Pulmonary rehabilitation has been suggested as Class A method to improve symptoms in COPD patients by GOLD (the Global Initiative for Chronic Obstructive Lung Disease guidelines) statement.3 However, one study found that COPD patients drop out in pulmonary rehabilitation because the exercise is perceived as time-consuming and slow to take effect.4 Therefore, pulmonary rehabilitation approaches should focus not only on improving symptoms but also on increasing adherence.

Singing is a skillful activity designed to produce a musical sound. As known, this active exercise needs accurate management of respiration, airflow as well as adequate vital capacity, for the reason of increasing vital capacity, reducing residual volume and enhancing respiratory muscles, singing can be used as an adjuvant therapy on COPD.5,6 Meanwhile, singing therapy may potentially improve exercise endurance, quality of life and mental well-being, which is considered as a cost-effective, non-pharmacological, person-centred and community-based intervention.7 However, conclusive evidence on the effects of singing therapy on physiological and psychological function in COPD patients is still lacking.8 A pilot study reported that singing improved lung function and reduced anxiety in COPD patients. Nonetheless, health-related quality of life and exercise tolerance did not change significantly, an outcome attributed to the small sample size and short follow-up period.9 Group singing or singing classes may be a better idea in ameliorating social isolation, reducing anxiety and depression levels, and improving the quality of life for COPD patients.10 A 1-year pilot study, based on a long-term community singing group, showed improvements in exercise capacity and anxiety reduction in COPD patients, but no statistically significant reduction in depression scores.7 Conversely, a randomized community-based trial in China revealed that group singing therapy reduced depressive symptoms and improves the quality of life of patients with stable COPD.11 Several studies illustrated that depression was one of the independent risk factors for COPD, and strongly correlated with COPD clinical function and quality of life.12–14

The benefit of singing to improve symptoms in people with COPD remains uncertainty. One systematic review of singing for COPD had been carried out in 2017.15 However, the conclusions of the review may have been limited by the fact that the sample size of patients was insufficient and patient adherence was neglected. We think adherence should be taken care of to some extent. The small number of patients in previous review is also a significant limitation. In recent years, a large number of new trial results have been published and additional data is available for analysis. We aimed to perform a systematic review and meta-analysis of previous studies to determine the effects of singing in adults with COPD.

Methods

This systematic review is reported according to the PRISMA guidelines.1 The review protocol was registered on PROSPERO (CRD42022297240).

Search Strategy

We searched 8 electronic databases (Web of Science, PubMed, Embase, Cochrane Library, Clinical Trials.gov, PEDro, China national knowledge infrastructure(CNKI), and Wanfang Database) from inception until May 2022. Keywords used as follows: (1) COPD or chronic obstructive pulmonary disease; (2) singing or singing therapy or singing*; (3) music therapy or music training. The reference lists of the identified articles also need to be manually searched to find eligible studies. The full search strategy is given in the Supplementary Material.

Inclusion Criteria and Study Selection

Potentially eligibility studies would be included in this review if they met the inclusion criteria below: (1) Chinese or English language studies, published or under publishing in a peer-reviewed journal; (2) RCTs; (3) study subjects were human beings diagnosed with stable COPD; (4) singing exercise (be executed either separately or as part of a mixed therapy) was used as the main intervention, while compared with or without other interventions; (5) one or more than one outcomes (health-associated quantitative parameters related to symptoms of COPD). Those studies could not meet the above criteria were excluded from this review, for example, COPD with other predominant diagnosis, published abstract only or unpublished data.

Data Extraction

Initially, 2 investigators (XF and ZQ) separately screened all the searched results according to their abstracts and titles, then evaluated the remaining documents with full-text reading, in order to remove irrelevant articles. If they had different opinions on one article, the eligibility would be judged by the third reviewer (RT).

Two reviewers (XY and KL) extracted data separately. A standardized form was used in this process, detail information including: the reference information (author, location, language and year of publication), subjects (sample size and attrition rate, mean age/age range, and course of COPD), intervention (exercise dosage weekly and duration), measuring outcomes (lung function, exercise capacity, quality of life and etc.), adverse event and follow-up evaluation.

Study Quality Assessment for Included Studies Selected

The quality of the study was assessed using the PEDro scale.16 Eleven items were involved as follows: (1) eligible criteria; (2) randomization; (3) allocation concealment; (4) similar baseline; (5) blinding of participants; (6) blinding of instructors; (7) blinding of assessors; (8) more than 85% retention; (9) intention to treat analysis; (10) between-group comparison; (11) point measure and measures of variability. Points are awarded only when a criterion is clearly met and each item is worth one point. Given that patients had to be diagnosed with COPD to be included, the first item of eligibility criteria was moved. Therefore, the scale commonly used to assess 10 aspects of bias.

Statistical Analysis

RevMan 5.4 software was applied to synthesize the quantitative data for each group of participants at baseline and post-intervention, and the pooled effect sizes were reported by MD and 95% CI. The value of I2 was applied to determine the between-study heterogeneity, random-effects model was applied when I2>50%. For all results, P < 0.05 was considered to indicate a statistically significant difference. Sensitivity analysis was performed to achieve high-quality studies. Estimation of the rate weighted by the sample size in each study.

The overall acceptance rate was defined as the total number of eligible participants divided by the number of participants approached to participate in the trial. The completion rate was defined as the total number of participants who completed the trial divided by the number of participants who enrolled in the trial and the drop-out rate as the total number of participants in each treatment arm who dropped out from the study divided by the number of participants who consented to allocation in the study.17

Results

Study Selection

A total of 294 records were identified through electronic and manual database searches. As a result, 116 documents were removed based on the duplicate check and 122 irrelevant articles were excluded after the headline and abstract screening. The remaining 56 articles were further evaluated by full-text reading and any articles that did not meet the inclusion criteria were eliminated. Finally, eligible articles (5 RCTs) were left to do meta-analysis (Figure 1).

Figure 1 PRISMA flowchart of study selection.

Notes: Adapted from Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. Creative Commons Attribution (CC BY 4.0) license.1Abbreviations: PEDro, Physiotherapy Evidence Database; RCT, randomized controlled trial.

Study Characteristics and Methodological Quality

The characteristics of 5 eligible studies5,11,18–20 are listed below (Table 1). The publish year was between 2009 and 2022. The COPD patients ranged in age from 63.51 to 71.70 years. The sample sizes ranged from 24 to 195 across the studies Three studies5,18,20 applied isolated singing exercise to compare with other interventions, and two studies11,19 used integrated interventions including singing exercise and conventional therapy. The severity level was range from mild to very severe. The duration of the singing exercise intervention ranged from 6 weeks to 24 weeks, with frequency ranging from 1 to 2 sessions per week, each lasting 60 to 90 minutes.

Table 1 Summary of Studies Characteristics

Methodological Quality

The methodological quality of the trial was scored according to PEDro scale (Table 2). The scores ranged from 5 to 8. Three studies have reported on assessor blinding. Three studies had allocation concealment. All the studies performed well with randomization.

Table 2 Study Quality Assessment of Eligible Trials

Primary Outcomes

Effects of Singing on Quality of Life

SF-36 and CCQ were used to evaluate the quality of life of the patients, with a lower sum score indicating a better quality of life. SF-36 consists of two components, PCS and MCS. Altogether, there were 2 studies18,19 with a total of 52 patients including SF-36 in the meta-analysis. The finding showed that singing exercise was effective in improving PCS (MD = 12.64, 95% CI: 5.50 to 19.77, P < 0.01) (Figure 2) with COPD patients but less effective in improving MCS (MD = 5.42, 95% CI: −3.90 to 14.74, P = 0.25) (Figure 3). CCQ included in 1 study11 with a total of 56 patients was lower than those in the control group, a significant difference was detected at 6-month in the experimental group (MD=−10.61, 95% CI: −12.25 to −8.97, P < 0.01).

Figure 2 Meta-analysis of experimental and control groups in SF-36 PCS.

Abbreviations: CI, confidence interval; df, degrees of freedom; IV, independent variable; SD, standard deviation; SF-36 PCS, Short Form 36 physical component summary.

Figure 3 Meta-analysis of experimental and control groups in SF-36 MCS.

Abbreviations: CI, confidence interval; df, degrees of freedom; IV, independent variable; SD, standard deviation; SF-36 MCS, Short Form 36 mental component summary.

Secondary Outcomes

Effects of Singing Exercise on Lung Function

Two studies5,20 with a total of 225 patients were eligible for lung function analysis. Compared with the control group, kaasgaard20 emerges that the singing group had a significant effect on FEV1% improvement in COPD patients (MD = 0.70, 95% CI: −0.88 to 2.28, P = 0.38). And Bonilha5 research finds that PEmax of COPD patients in the singing group was significantly higher than that in the control group (MD = 14.30, 95% CI: 0.87 to 27.73, P = 0.04). Significant improvements in inspiratory capacity IC (MD = 0.22, 95% CI: 0.06 to 0.38, P < 0.01) were found during just after a singing exercise, but measurements of after 24 singing classes showed no significant difference from the control group.5

Effects of Singing Exercise on Exercise Capability

Two studies18,19 with a total of 52 patients examined the effects of singing exercise on ISWT, the longer distance, the better exercise capability. The meta-analysis of 2 studies shows that singing exercise was less effective in improving the exercise capability of COPD patients than the control group (MD=−9.26, CI: −43.10 to 24.57, P = 0.59) (Figure 4).

Figure 4 Meta-analysis of experimental and control groups in ISWT.

Abbreviations: CI, confidence interval; df, degrees of freedom; IV, independent variable; SD, standard deviation; ISWT, the incremental shuttle walk test.

Effects of Singing on Anxiety and Depression

Three studies18–20 with a total of 247 patients were eligible for HADS-A analysis. Compared with the control group, singing exercise had less significant effect on anxiety improvement in COPD patients (MD = −0.43, 95% CI: −1.91 to 1.04, P = 0.56) (Figure 5).

Figure 5 Meta-analysis of experimental and control groups in Hads-A.

Abbreviations: CI, confidence interval; df, degrees of freedom; IV, independent variable; SD, standard deviation; HADS-A, the hospital anxiety and depression scale-anxiety.

Four studies11,18–20 with a total of 303 patients were eligible for HADS-D analysis. However, because the heterogeneity between studies is obvious, study of liu11 was excluded through sensitivity analysis. Meta-analysis was performed on the remaining 3 studies18–20 with a total of 247 patients. Compared with the control group, the singing group had less significant effect on depression improvement in COPD patients (MD = −0.38, 95% CI: −0.85 to 0.09, P = 0.12, Figure 6).

Figure 6 Meta-analysis of experimental and control groups in Hads-D.

Abbreviations: CI, confidence interval; df, degrees of freedom; IV, independent variable; SD, standard deviation; HADS-D, the hospital anxiety and depression scale-depression.

Acceptance, Completion and Drop-Out Rates

COPD patients with a total number of 846 were approached. Of these, 145 patients were excluded due to ineligible and other reasons, and 259 patients refused to participate in the trial. A total of 442 participants were enrolled in the studies with intervention and control groups, of whom 234 participants were assigned to the intervention group, and 208 to the control group. Finally, 333 participants completed their sessions. Seventeen participants refused allocation and 92 withdrew before the end of the study. Overall, the unweighted average of acceptance, completion and drop-out rates for all included studies were 50%, 75% and 22% (Table 3), respectively. The drop-out rates of the singing group and control group were 21% and 22% (Figure 7).

Table 3 Acceptance, Completion and Drop-Out Rates

Figure 7 Flowchart showing the numbers of participants from all included studies.

Description of Adverse Events

No adverse events or side effects were reported in any of the included studies. According to the study,5,18,19 participants had a better tolerance for the singing exercise, no severe dyspnea, chest pain, reflux or dizziness occurred, and no participants reported negative effects of singing.

Discussion

Medium and high methodological quality of 5 literatures with a total of 333 patients were included to study the effect of singing on COPD patients. Since there are many subjective scales for COPD trial results, and the quality of included articles should be objectively assessed without being limited by the inevitable risk of bias of the scale, PEDro was chosen. The results showed that singing significantly improved patients’ quality of life and lung function. However, the effect on anxiety, depression and exercise ability was not significant. As an economical and effective COPD rehabilitation program,7,21 singing can improve the endurance of respiratory muscles and strengthen patients’ control of breathing and airflow.22 Singing with deep and slow breathing rhythm is conducive to increasing alveolar ventilation and improving blood oxygen saturation,22–25 and its positive effect on the treatment of COPD is widely recognized.26,27 The purpose of our meta-analysis was to explore the effect of singing on the main symptoms of COPD patients.

With the progress of COPD, the quality of life of patients gradually declines.28,29 Several factors may contribute to poor quality of life in COPD patients including respiratory symptoms, exercise limitations.30 In this meta-analysis, SF-36 and CCQ was used to evaluate the effects of singing on COPD patients, and the results showed that the singing group was significantly better than the control group in terms of quality of life physical component score. Although the mental component score was better than the control group, there was no statistical significance. It has always been believed that the positive effects of singing on COPD patients come from psychological factors,31 which is not completely consistent with the results of meta-analysis. Although singing has been shown to have a limited positive effect on improving quality of life,22,32 insufficient training sessions with the exercise program may limit effectiveness on improving quality of life in COPD patients. Further studies with higher quality and larger sample size are still needed.

Lung function is an indicator of the severity of COPD.33,34 Furthermore, monitoring of lung function is essential. Descriptive analysis was performed mainly because of the different monitoring metrics. Numerous studies have shown that pursed-lips and diaphragmatic breathing can improve lung function in patients.35–38 Singing is mainly characterized by pursed-lips and diaphragmatic breathing. Pursed-lips breathing is widely used in pulmonary rehabilitation programmes in order to impose positive expiratory pressure, with the aim of creating resistance to expiratory flow and preventing early bronchial collapse,39,40 and conscious use of the diaphragm during respiration increases lung capacity.41 Meanwhile, Bonilha’s study proved that singing significantly improved respiratory muscle (PEmax), and respiratory muscle is closely related to the lung function of patients with COPD,40,42 suggesting the effectiveness of singing in improving lung function. Lung function indicators (IC) improved significantly during singing, but there was no significant difference in measured results after the training course. This finding may reflect the occurrence of a transient reduction in the extent of thoracic hyperinflation. But there is insufficient data to draw firm conclusions about the short-term effects of singing in COPD patients.

In people with COPD, reduced motor capacity is common.30 Some researchers believe that limited exercise capacity leads to muscle disuse atrophy,43,44 and that atrophy further leads to decreased exercise capacity, forming a vicious cycle. There have also been studies demonstrating that the acute metabolic demands of singing are comparable to those of walking at a moderately brisk pace, which may be related to the physical improvement of singing in patients. Improvements in exercise capacity are extremely important for COPD patients. Meta analysis showed that singing may not significantly improve the exercise ability of patients compared with the control group. Although there was no significant effect of singing therapy alone, studies have shown that singing training combined with pulmonary rehabilitation generally improved exercise capacity,7 suggesting the effectiveness of the combined intervention. Further studies with higher quality and larger sample size are still needed.

Depression, anxiety and other adverse emotions are common in COPD patients.45–47 The symptoms of depression and anxiety in COPD lead to worse health outcomes, including impaired health-related quality of life and increased mortality risk.47–49 Meta-analysis results showed that there was no statistical significance of improvement in HADS-A and HADS-D in the singing group compared with the control group. Remarkably, many participants reported relief from adverse mental states, especially for patients who were expert at singing, and these perceived improvements were not reflected in objective outcome measures. The insufficient sample size in our study may be the limiting factor in confirming this association.

We perform acceptance, completion, and dropout rates to characterize patient adherence. Some literature has been positive about the adherence of singing training compared to the control group, but dropout rates indicate that the singing group is not significantly better than the control group. The results of group discussion suggest that there may be the following reasons: 1. In order to maintain the uniformity of results, the literature generally does not mention the individuation of music type, and patients’ preference for song type may limit adherence; 2. As an auxiliary pulmonary rehabilitation program, singing training is difficult to take effect in a short time, so that it is not easy to be trusted by patients; 3. The small sample size limits the results. More personalized, large sample size and comprehensive comparison experiments are needed in the future.

Limitation

There are several limitations in this study that need to be addressed. Firstly, different studies have different sample characteristics, exercise protocols and criteria, which leads to heterogeneity among studies and research conclusions was affected.

Secondly, even time-related benefit of singing was noted in this study, but it cannot be confirmed due to insufficient data. Finally, this study focused on the clinical effect of singing training in COPD patients, but the specific mechanism of its action still needs further research.

Conclusion

Based on results of a meta-analysis, singing could be used to improve quality of life (SF-36 PCS) and respiratory muscles (PEmax) in patients with COPD, which suggests that singing was effective in improving the Singing was effective in improving the quality of life related to physical health. At the same time, the lack of reported adverse events and the high trial completion rates suggest that singing is safe and effective. But we did not find better adherence in singing than other interventions.

Supplementary Materials

Supplementary Material for this article is available on-line.

Funding

This research was funded by Qingdao Municipal Hospital Innovative Clinical Technologies Funds (CXJJ-006-04) and Shinan District Science and technology plan project (2022-2-014-YY).

Disclosure

No conflict of interest existed in this study.

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Chronic obstructive lung disease (COPD) has been reported as the third leading cause of death globally. The main risk factor for a significant portion of emphysema patients is tobacco use. Additionally, occupational exposure to wood dust enhances the risk of acquiring respiratory disorders, since the respirable wood dust settles into the bronchioles and alveoli and causes lung irritation which presents symptoms like mucus hypersecretion and breathlessness. A secondary complication, emphysema-induced pneumothorax, in the elderly requires the medical intervention of intercostal drainage (ICD) to allow the leak of air out of the thoracic cavity. In this article, we present a case of a 65-year-old male who visited the respiratory department with complaints of breathlessness, fever, and cough with expectoration for four days. He reports a history of tobacco smoking for 30 years with prior hospitalization seven years ago with similar complaints. The patient was initially diagnosed with pulmonary emphysema, which later progressed to spontaneous pneumothorax. He underwent medical management with ICD, which was successful. Following this, an integrated rehabilitation program using various breathing strategies was established in order to get the patient back to his regular daily activities with minimal signs of exhaustion or dyspnea. This protocol proved to be successful in enhancing the patient's respiratory condition.

Introduction

Emphysema is defined as an abnormal permanent enlargement of the air space distal to the terminal bronchioles, accompanied by degradation of the alveolar walls [1]. Based on the pathologic pattern, emphysema is typically categorized into three categories: centrilobular, panlobular, and paraseptal. The secondary lobule's central airways enlarge with normal distal alveolar ducts and sacs in centrilobular emphysema (CLE), a smoking-related condition that frequently affects the higher lobes [2]. In 2019, 3.23 million people perished since chronic obstructive pulmonary disease (COPD) emerged as the third leading cause of death worldwide. About 90% of fatalities occur due to COPD under the age of 70 years especially in low and middle-income countries [3]. Presenting features of emphysema are cough associated with expectoration, dyspnea, reduced chest expansion, declining lung volumes, etc. [4].

Pneumothorax, which can occur spontaneously or as a result of iatrogenic injury or trauma to the lung or chest wall, is the collapse of the lung when air builds between the parietal and visceral pleura inside the chest. The air is outside the lung but inside the thoracic cavity. Consequently, the lung is under pressure, which increases the risk of its collapse and causes the mediastinum to migrate [5]. The migration of air from the lung into the pleural cavity without trauma is known as a spontaneous pneumothorax (SP). Secondary spontaneous pneumothorax (SSP), as opposed to primary spontaneous pneumothorax (PSP), is the term used to describe an SP in a patient with an underlying chronic lung pathology, such as COPD [6]. Spontaneous pneumothorax shows a bimodal age distribution, with the secondary peak including patients aged ≥50 years The most prevalent underlying condition linked to spontaneous pneumothorax in the aged population is pulmonary emphysema [7].

The clinical features of a pneumothorax are sudden onset of dyspnea and pleuritic chest pain, reduced chest excursion on the affected side, an expanded hemithorax on the affected side, diminished breath sounds, no tactile or vocal fremitus, hyper-resonant percussion, etc. [8]. We provide a case of a patient who had an emphysema-induced pneumothorax and underwent medical care, intercostal drainage (ICD), and collateral physiotherapeutic rehabilitation. Intercostal drainage tube insertion and antibiotic chemotherapy continue to be the main treatments for pneumothorax. In order to collect the fluid, blood, and air and for the underlying lung to expand, intercostal tube drainage is employed. It is inserted into the pleural space through the chest wall and is made of flexible plastic. As a result of the accumulation of air, greater respiratory demands appear in the form of dyspnea, a decrease in chest expansion, and faster breathing. Breathing exercises prescribed by a physical therapist are advised because they help with fluid drainage, maintain chest expansion, and reduce dyspnea. Physiotherapists use a range of strategies to increase ventilation for patients with respiratory diseases. Reduced bronchospasm, clearing of lung secretions, regaining full lung expansion, and optimal functional recovery were the objectives of the treatment [9].

Case Presentation

Patient Information

A 65-year-old male, a carpenter by occupation, visited the respiratory department of tertiary care rural hospital with complaints of breathlessness, fever, and cough associated with expectoration that was mucoid in quality for four days. The patient was prior hospitalized seven years ago in a private hospital in Nagpur, India, due to an acute episode of breathlessness suddenly during work and has been experiencing dyspnea since then. X-ray reports showed hyperinflated lungs bilaterally suggestive of pulmonary emphysema. Previous reports suggest dyspnea of grade I-II on Modified Medical Research Council (MMRC) scale. He has a positive history of dust allergy with seasonal variation, exaggerated during winters. The patient claims consuming tobacco products for 20 years and smoking cigarettes for 30 years. The patient consumed 3-4 cigarettes per day. The patient was admitted to our hospital on August 14, 2022, due to acute exacerbation of dyspnea that was evaluated as grade IV on MMRC. Chest X-ray (posterior-anterior view) investigations showed hyperinflated lungs bilaterally along with hyperlucent lung fields. The patient was diagnosed with ipsilateral left-sided pneumothorax secondary to bilateral centrilobular emphysema. ICD was inserted in the left infra axillary in the fourth intercostal space, the air was drained and underwater seal was placed. After the removal of intercostal drainage, post-operative day four, the patient was further referred to the cardiorespiratory physiotherapy department for the removal of excessive secretions, to reduce dyspnea and improve exercise tolerance.

Clinical findings

Informed consent was taken from the patient, which was done prior to the physical examination after the removal of ICD. On inspection, the patient was found in a sitting position and was cooperative, with orientation to time, place, and person. Pallor was present, and clubbing grade II was observed with a positive Schamroth window test as shown in Figure 1. From the lateral view, barrel-shaped chest was inspected as shown in Figure 2. The use of accessory muscles was present. On palpation, the trachea was deviated to the right side, chest excursion was found to be reduced bilaterally, and tactile vocal fremitus was diminished in the upper and middle zones. Chest expansion findings were 1cm, 1.5cm, and 2cm at axillary, nipple, and xiphisternal levels, respectively. On percussion, hyper-resonant note was present on the left side, mammary region. On auscultation, breath sounds were diminished in the upper and lower zones on the left side of the thorax.

Diagnostic assessment

The patient’s high-resolution CT (HRCT) thorax scan findings revealed ICD with the tip in the left pleural space and a few small areas of fibrotic changes in bilateral lung fields with subsegmental atelectasis. Bilateral lungs appear hyperinflated with centrilobular emphysematous changes, extending superiorly to the ipsilateral axilla, shoulder, and suprascapular region as shown in Figure 3. X-ray findings of the chest revealed hyper lucent lung fields bilaterally, with deviation towards the right side and flattening of the left hemidiaphragm as presented in Figure 4.

Physiotherapy management

Table 1 presents the data of the physiotherapy management strategy that was planned and applied as per the patient's limitations. It enlists the problems faced by the patient, goals, and interventions specific to the problems displayed.

Serial no. Problems faced by the patient Goals Description of interventions
1. Pain at the ICD insertion site To reduce pain 1. TENS: Transcutaneous Electrical Nerve Stimulation was used with the following parameters: Mode: Conventional mode Frequency: 100-150 Hz Duration: 10-15 minutes Site of electrode placement at the site of tube insertion.  2. Splinting technique: The patient was instructed to use a towel pad to support the incision site while coughing, sneezing, laughing etc. 3. Breath stacking exercise (after removal of ICD): The patient was encouraged to breathe in slowly, stacking one breath on top of the other, with five seconds hold; three sessions per day with five repetitions were advised (Mohamed et al., 2021).    
2. Exertional dyspnea To reduce dyspnea while working Ventilatory strategies with activity: The patient was explained to breathe through the nostrils and exhale through pursed lips as in blowing a candle. The breathing pattern was synchronized with the activity. For example, explaining to the patient to take two steps and simultaneously inhale and exhale once while walking.
3. Use of accessory muscles Provide relaxation to muscles Dyspnea relieving position with PLB: The patient was instructed to do bedside sitting, place a pillow over both thighs and was asked to lean on it with elbows extended over the pillow. While doing that, the patient was explained to inhale through the nostrils and exhale through pursed lips (five repetitions). Other positions such as sitting on a chair and leaning on the table in front were taught.  
4. Reduced Chest Expansion To improve chest mobility Chest Mobility exercises with breathing strategies: 3 different exercises were demonstrated to the patient. He was instructed to sit in a chair and perform pectoral stretch with hold and pectoral stretch while performing trunk rotations. The patient was explained to stand and perform side bends avoiding overstretching with pursed lip breathing. The effectiveness of chest wall mobility lies in its ability to increase ventilation on that side of the chest, emphasize the depth of inspiration, and regulate expiration. [9].  
5. Accumulation of secretions Clearance of secretions Active Cycle of Breathing Technique (ACBT): The mechanism of ACBT comprises three exercises- breathing control x3, thoracic expansion exercise x3, forced expiratory exercise consisting of coughing and huffing x2, with breathing control thrice after each exercise. The patient is asked to initiate inhaling and exhaling through nostrils three times, then perform thoracic expansion, with an interval of breathing control, followed by coughing and huffing along with breathing control. This procedure helps the movement of secretions from peripheral to central airways and further to the mouth. Oscillatory positive expiratory pressure (OPEP) device: The patient was given a mechanical hand-held OPEP device, and was told to breathe through it. This device had an inhaling valve and a linear track for the patient to follow. Positive pressure oscillations are caused by a one-way valve opening and closing sporadically during exhale. The patient then coughed and huffed a couple of times. Ten to 20 blows into the device were administered four times per day [10].  
6. Reduced cardiovascular endurance To improve exercise tolerance The patient was provided with a well-monitored graded exercise program that started with bedside limb mobility exercises, involved walking, and stair climbing for 10 minutes three to four times per day and was gradually increased in accordance with the patient's hemodynamic response and rate of perceived exertion. Home Exercise Program (HEP): The physiotherapy protocol was designed for two weeks with six sessions a week in the hospital inpatient set-up. Once improvements in his endurance were seen, he was discharged with a well-explained home program. The patient was provided with a plan of exercises that included deep breathing exercises, pursed lip breathing exercise, brisk walking, and stair climbing with symptoms in check and chest mobility exercises.

Outcome measures

Table 2 lists the results that were utilized to evaluate the patient's progress on the day of referral, on the day of discharge, and on the day of follow-up. The patient was given a set of training regimens to follow at home in order to restore strength and increase endurance, including instructions for self-monitoring vital signs and spotting warning signs. Along with this routine, he was also instructed to practice breathing retraining and cleanliness every day, as well as to use relaxation and dyspnea-relieving techniques as needed. Additionally, he was told to follow up after two weeks and contacted by phone if he had any questions about the medication or his health. Positive rehabilitation outcomes were reported by the patient with great satisfaction.

Outcome First day of referral On the day of discharge At the time of Follow-up
Functional Independence Measure  (FIM)   4 6 7
Six-Minute Walk Distance (6 MWD) 230 m  with rest pause 260 m with rest pause 290 m
St. George Respiratory Questionnaire (SGRQ) 50 30 20

Timeline of all the events

Table 3 presents the duration of all the events such as the date of admission, date of surgery, date of physiotherapy referral, date of discharge, and date of the last follow-up.

Events Dates
Date of Admission August 10, 2022
Date of Surgery August 13, 2022
Date of Physiotherapy Referral August 17, 2022
Date of Discharge August 30, 2022
Date of the last follow-up September 28, 20/22

Discussion

Chronic respiratory diseases impact an individual’s breathing and ventilation capacities negatively. A deadly disease, COPD, leads to functional impairments and secondary complications like pneumothorax, pulmonary hypertension, pneumonia, and chronic atelectasis following emphysema, the most common form of COPD to prevail. This case study describes a case of an elderly male patient who developed pneumothorax secondary to pulmonary emphysema. He underwent ICD insertion following which intensive physiotherapy care was required to improve the oxygenation and ventilation capacities of the lungs. Breathing exercises include diaphragmatic breathing and segmental expansion as well as pursed lip breathing that creates back pressure over the alveoli, hence allowing prolonged perfusion and the development of collateral channels for ventilation. Conclusion derived from a study on two groups of COPD participants using flutter as well as active cycle of breathing technique (ACBT) for two weeks showed drastic results, by increasing mucus clearance and improving the viscoelasticity of lungs. An increase in peak expiratory flow rate (PEFR) and forced expiratory volume/forced vital capacity (FEV1/FVC) was observed simultaneously [11].

Dimitrova’s research developed a pulmonary rehabilitation protocol to assess the severity of symptoms of COPD pre- and post-intervention using indicators such as six-minute walk test and modified medical research council (MMRC) scale. Aerobic exercises such as walking, slow running, cycling, etc., along with breathing exercises, forced exhalation, and coughing manoeuvres caused symptoms to be less pronounced [12]. To clear out the secretions, the patient in this case study was provided with an oscillatory expiratory pressure device, which he was instructed to blow in 10-20 times, four times each day. Chest recovery was faster and reflected a reduction in symptoms of dyspnea as well. By the outcome measures, improvement was seen in the six-minute walk test, indicating improvement in exercise tolerance. As observed in the findings of a study by Sarah et al., in COPD patients, oscillatory expiratory positive pressure (OPEP) medication significantly improved forced vital capacity (FVC), six-minute walk distance (6MWD), and symptoms in sputum-producers. It also became easier to cough up sputum. Additionally, significant improvements in the St. George respiratory questionnaire (SGRQ), forced expiratory volume (FEV1), 6MWD, and ventilation-perfusion deficit (VDP) were seen in half of those who generated sputum [10]. Nutsupa et al. in their study showed that patients underwent light exercise training to become acquainted with breathing regulation while doing activities of daily life after ventilatory feedback and exercise training that demonstrated a positive impact on ventilation [13].

Conclusions

The goal of this study was to plan a management structure for a patient of pneumothorax secondary to emphysema in aspects of pulmonary rehabilitation. Prior to the initiation of physiotherapy management, the patient had reduced oxygen saturation and poor mucus clearance. However, our approach with an integrated and comprehensive rehabilitation regimen showed positive changes in the severity of symptoms of dyspnea, cough, mucus clearance, pulmonary capacities, weakness, and overall quality of life. It is vital for these parameters to resolve in elderly patients so that they can get back to their pre-disease state and spend the rest of the years of their lives in peace and prosperity.



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Anxiety exercises can be especially helpful when you're not ready to see a mental health professional.

These are powerful tools you can use at any time of the day. The brain is the 'control room' of the body, which means it manages all bodily functions as well as your feelings and thoughts. You can learn methods and ideas that can help you get rid of sadness and underlying causes of anxiety by training the brain.

Simply put, anxiety is a more severe form of worry. Anxiety dampens emotional energy and raises anxiety levels, as it turns into a persistent, worst-case scenario and what-if cycle in your head with relentless nagging, doubts, and concerns. As a result, anxiety interferes with your daily life, aspirations, and relationships.

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Anxiety Exercises to Abate Worries

A typical human response to stress is anxiety. However, excessive anxiety can make it difficult to have a happy and healthy life.

Anxiety exercises usually work. as they deal with the body's stress reactions, such as elevated heart rate, rapid breathing, and tense muscles, making the body feel more relaxed. Dealing with anxiety can be challenging, but the following five exercises can help:

1) Grounding Exercises

Grounding is an easy yet powerful anxiety exercise. Take a moment to center yourself, and bring yourself back into the present moment.

Tune into four things around you that you can see, things things you can touch, two things you can smell, and one thing you can taste (you can carry around mint, or gum, to use in this situation). You will distract yourself from the anxiety trying to take over your body.


2) Use Your Muscles

Our muscles can ground us and immediately work as an anxiety exercise. (Image via Pexels/Quang Nguyen)
Our muscles can ground us and immediately work as an anxiety exercise. (Image via Pexels/Quang Nguyen)

Using relaxation exercises can be an effective way to reduce stress and anxiety. Alternate between tensing and relaxing different muscle groups in the body.

Tensing the muscles is a common symptom of anxiety. By learning to immediately relax those muscles, you will programme your body to relax when it feels like tension. When feeling anxious, instantly relax your muscles by doing the following:

  • Sit in a calm and pleasant spot. Focus on your breathing while closing your eyes. Slowly inhale through your nose, and exhale through your mouth.
  • Clench your hands into a fist. Make a fist, and tighten it.
  • For a few seconds, keep your hands clenched. Take note of the tension in your hand.
  • Open your fingers gradually, and pay attention to your feelings. You might feel your hand releasing some stress. Your hand will eventually start to feel lighter and more at ease.
  • Continue tensing and relaxing the hands, legs, shoulders, and feet, as well as other muscle groups throughout the body. You might wish to move up and down your tensed body.

3) Instant Relief Tools

Count some coins as an anxiety exercise. (Image via Pexels/Mart Production)
Count some coins as an anxiety exercise. (Image via Pexels/Mart Production)

Carry loose change or count backward by threes to instantly reduce anxiety. These anxiety exercises help those who're about to have a panic or anxiety attack by forcing the brain to focus on another, overriding activity.

The act of counting at random intervals helps people focus, overriding the anxious thoughts that are trying to creep in. Loose change is a great way to do that.


4) Harness Your Breath

Breathwork can do wonders in supporting our mental, physical, and spiritual well-being.

In therapy, breathwork is sometimes used to improve a wide range of issues, such as anger, anxiety, chronic pain, depression, grief, and trauma. Different examples of breathwork exercises include box breathing, 4-7-8 breathing, alternate nostril breathing, pursed lip breathing, and diaphragmatic breathing.

Developing a good breathwork exercise can be beneficial for those of us that experience anxiety. Anxiety can take our minds millions of miles away into the future, while breathwork can ground us in the present moment.


5) Visualization

Visualizing yourself in a happy place is a powerful anxiety exercise. (Image via Pexels/Caleb Oquendo)
Visualizing yourself in a happy place is a powerful anxiety exercise. (Image via Pexels/Caleb Oquendo)

Have you heard the phrase 'finding your happy place'? Your brain and body might truly become more relaxed if you visualize a peaceful setting.

Sit in a calm, relaxing location when you start to feel anxious. Consider where you would like to unwind. Although it could be anywhere in the world, actual or imagined, it needs to be a scene that makes you feel incredibly safe, content, and tranquil.

Make sure it's simple enough to think about so you can come back to it later on when you're feeling anxious. Consider all the minute details you would discover if you were there. Imagine the environment's aroma, ambience, and sound.


Takeaway

The key idea of anxiety exercises is to find something, be it coloring, doing a crossword puzzle, writing, knitting, or anything else that occupies your hands so that the mind will help keep anxiety at bay.

Living with anxiety doesn't have to feel like a life sentence. Take a proactive role in your mental health treatment, and find techniques that work for you to help manage your anxiety.


Janvi Kapur is a counselor with a Master's degree in applied psychology with a specialization in clinical psychology.


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