RESPIRATORY CARE Paper in Press. Published on August 28, 2018 as DOI: 10.4187/respcare.06319 Effects of Diaphragmatic Breathing With and Without Pursed-Lips Breathing in Subjects With COPD Liliane PS Mendes MSc, Karoline S Moraes MSc, Mariana Hoffman PhD, Danielle SR Vieira PhD, Giane A Ribeiro-Samora PhD, Susan M Lage PhD, Raquel R Britto PhD, and Veroˆnica F Parreira PhD BACKGROUND: Breathing exercises, such as diaphragmatic breathing and pursed-lips breathing, play a role in some individuals with COPD and might be considered for those patients who are unable to exercise. However, in the literature are reports of some adverse effects of diaphragmatic breathing in patients with COPD. Thus, the purpose of this study was to assess the effects of diaphragmatic breathing and diaphragmatic breathing combined with pursed-lips on chest wall kinematics, breathlessness, and chest wall asynchrony in subjects with COPD, and also to assess whether the combination of both exercises reduces the adverse effects of diaphragmatic breathing while maintaining its benefits. METHODS: Seventeen subjects with COPD, mean ؎ SD, 65 ؎ 7y of age, with a history of smoking and clinical stability without hospitalization or symptoms of exacerbation in the past 4 wk, were evaluated. On day 1, participants’ characteristics were col- lected, and they learned diaphragmatic breathing and its combination with pursed-lips breathing. On day 2, the participants were evaluated by optoelectronic plethysmography with the participants in the seated position while performing breathing exercises. RESULTS: Diaphragmatic breathing and diaphragmatic breathing plus pursed-lips breathing promoted a significant increase in chest wall tidal volume and its compartments as well as a reduction in breathing frequency compared with quiet breathing. No significant changes were observed in dyspnea or end-expiratory volume of the chest wall. A significant increase in asynchrony (inspiratory-expiratory phase ratio) was ob- served during diaphragmatic breathing and diaphragmatic breathing plus pursed-lips breathing compared with quiet breathing, with no differences observed between the exercises. CONCLUSIONS: Despite the increase in asynchrony, both breathing exercises were able to improve chest wall volumes without affecting dyspnea. The combination of exercises maintained the benefits but did not reduce the adverse effects of diaphragmatic breathing. Key words: COPD; diaphragmatic breath- ing; pursed-lips; optoelectronic plethysmography; breathing pattern; chest wall motion; asynchrony. [Respir Care 0;0(0):1–•. © 0 Daedalus Enterprises] Introduction cause of morbidity, is an important public health concern, and clinical exacerbations are responsible for recurrent COPD is a treatable disease characterized by chronic hospitalizations and an increase in the related economic air-flow limitation and persistent symptoms, such as dys- health-care costs.1,2 Pulmonary rehabilitation is a key com- pnea, cough, weight loss, and fatigue.1 COPD, as a leading Ms Mendes, Ms Moraes, Dr Hoffman, Dr. Ribeiro-Samora, and Dr Lage Financial support was provided by Coordenac¸a˜o de Aperfeic¸oamento de are affiliatted with Rehabilitation Sciences Program, Universidade Fed- Pessoal de Nível Superior, Fundac¸a˜o de Amparo a Pesquisa de Minas Gerais, eral de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil. Dr Vieira is and Conselho Nacional de Desenvolvimento Científico e Tecnolo´gico. affiliated with Health Science Department, Universidade Federal de Santa Catarina, Ararangua´, Santa Catarina, Brazil. Drs Britto and Parreira are Ms Mendes, Ms Moraes, Dr Hoffman, Dr Vieira, Dr Lage, and Dr Par- affiliated with Department of Physiotherapy, Universidade Federal de reira contributed to the literature search. Ms Moraes and Dr Lage per- Minas Gerais, Belo Horizonte, Minas Gerais, Brazil . formed data collection. Ms Moraes and Dr Parreira contributed to study RESPIRATORY CARE • ●●VOL ● NO ● 1 Copyright (C) 2018 Daedalus Enterprises ePub ahead of print papers have been peer-reviewed, accepted for publication, copy edited and proofread. However, this version may differ from the final published version in the online and print editions of RESPIRATORY CARE RESPIRATORY CARE Paper in Press. Published on August 28, 2018 as DOI: 10.4187/respcare.06319 DIAPHRAGMATIC AND PURSED-LIPS BREATHING ponent of managing COPD and involves exercise training, education and self-management interventions, encourag- QUICK LOOK 3 ing behavioral change, and stimulus to physical activity. Current knowledge Pulmonary rehabilitation has been shown to improve symp- toms, exercise tolerance, and health-related quality of life Breathing exercises, such as diaphragmatic breathing and pursed-lips breathing, play a role in some individ- as well as reduce hospitalizations.2-4 Breathing exercises, such as diaphragmatic breathing and pursed-lips breathing, uals with COPD and might be considered for symptom management and for those patients who are unable to which can be performed separately or in combination,5-9 have a role in managing breathlessness in patients with exercise. Both exercises present benefits for patients COPD and can also be considered for those who are un- with COPD; however, there are reports of some adverse effects of diaphragmatic breathing. able to undertake exercise training.1,7 These techniques aim to reduce dyspnea, improve ventilation and gas ex- What this paper contributes to our knowledge change, optimize chest wall motion, and reduce hyperin- flation.7,10,11 We found that diaphragmatic breathing with and with- Diaphragmatic breathing consists of a smooth and deep out pursed-lips breathing improved chest wall volumes nasal inspiration with anterior displacement of the abdom- and oxygenation, reduced breathing frequency, and pro- inal region, which emphasizes the action of the dia- vided more volume for hematosis without increasing phragm.6,10,12 For patients with COPD, the immediate ben- dyspnea. The addition of pursed-lips breathing to dia- efits of diaphragmatic breathing are an increase in the tidal phragmatic breathing provided greater changes in volume and oxygen saturation, reduction in breathing fre- breathing parameters, especially in relation to time vari- quency, and improvements in ventilation and hemato- ables. Therefore, our work supports the positive acute sis.12,13 Adverse effects include an increase in the asyn- effects of these breathing exercises for patients with chronous and paradoxical movement of the chest wall as COPD. well as increased work of breathing and dyspnea in the subjects with the most severe conditions.6,10,12 Pursed-lips breathing consists of a soft exhalation per- formed for 4 to 6 s against the resistance of partially closed jects with COPD, Jones et al5 reported a significant de- lips and clenched teeth.6,10,14 It is frequently adopted spon- crease in breathing frequency and oxygen consumption taneously and voluntarily by some subjects with COPD to during the combined exercise compared with the sponta- control and relieve dyspnea and can be performed at rest neous breathing. The breathing frequency was significantly or during exercise.14-16 Several studies have shown that the lower during diaphragmatic breathing plus pursed-lips benefits of pursed-lips breathing in subjects with COPD breathing, even in relation to each technique in isolation, include decreased breathing frequency and lung hyperin- although there was no difference in oxygen consumption flation, improvements in the P and oxygen in the blood, among the 3 exercises.5 According to these findings, a CO2 and increased tidal volume and oxygen saturation.6,10,14,17 combination of these techniques seemed to be more effec- However, dyspnea relief remains poorly consistent, be- tive than performing the exercises separately. However, to cause this response is different among subjects.6,10 the best of our knowledge, this was the only study to With regard to the combination of these techniques (di- evaluate the effects of the combination of the techniques aphragmatic breathing plus pursed-lips breathing) in sub- for only these 2 outcomes. Thus, the questions addressed in this study were the following: What are the effects of diaphragmatic breathing plus pursed-lips breathing on chest design. Ms Mendes, Ms Moraes, Dr Hoffman, Dr Ribeiro-Samora, and wall motion, breathing pattern, dyspnea, and chest wall Dr Parreira contributed to data analyses and interpretation. asynchrony in subjects with COPD? Could the combina- tion reduce the adverse effects of diaphragmatic breathing Dr Parreira presented a version of this paper at the European Respiratory while maintaining its benefits? Society Annual Congress, 21st September, 2010, Barcelona, Spain, and American Thoracic Society International Conference, 17th May, 2014, San Diego, California. Methods The authors have disclosed no conflicts of interest. Participants Correspondence: Veroˆnica Franco Parreira, PhD, Department of Physio- therapy, Universidade Federal de Minas Gerais, Avenida Antoˆnio Carlos, This was a quasi-experimental study, developed in an 6627, Pampulha, 31270-901 Belo Horizonte, MG Brazil. E-mail: [email protected]. university research laboratory with participants who met the following inclusion criteria: diagnosis of COPD con- DOI: 10.4187/respcare.06319 firmed by pulmonary function test,1 history of smoking, 2RESPIRATORY CARE • ●●VOL ● NO ● Copyright (C) 2018 Daedalus Enterprises ePub ahead of print papers have been peer-reviewed, accepted for publication,