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• Breathe in, Hold on and breathe out, effective exercise for COPD
  Giuseppe A. Marraro, Claudio Spada
  Published on: 4 October 2019

• Published on: 4 October 2019

  Breathe in, Hold on and breathe out, effective exercise for COPD

  • Giuseppe A. Marraro, Professor of Critical Care Medicine and Anesthesiology Second Aff. Hospital Quanzhou Medical University, China /First Aff. Hospital Wenzhou Medical University, China
  • Other Contributors:
    • Claudio Spada, Adj Prof. Second Aff. Hosp. Quanzhou Medical University, China

  Letter response to the article “Effects of breathing exercises using home-based positive pressure in the expiratory phase in patients with COPD

  Abstract
  Following the publication of the manuscript “Effects of breathing exercises using home-based positive pressure in the expiratory phase in patients with COPD” in Postgraduate Medical Journal written by Lin Q. et al., we describe the rationale and origin of the respiratory technique derived from yoga practice and adapted as breathing exercise for a pulmonary rehabilitation programme strategy for COPD patients. The discussed technique consist of breathing with an expiratory resistive load, is a modified Pranayama yogic breathing practices tailored with focus on the specific need of patient with COPD, that allow the patient to breathe simultaneously through both the nostrils and with exhalation to be completed against a resistance to the free flow of exhaled gases. The described method has also been proven very useful in reopening non-ventilating lung areas for both chronic and acute patients.
  I have read with great interest the manuscript “Effects of breathing exercises using home-based positive pressure in the expiratory phase in patients with COPD” published in Postgraduate Medical Journal written by Lin Q. and collaborators 1. As reported by the authors in the acknowledgment of the paper, I was instrumental to inspire the study while working with the Respiratory and Critical Care Medicine and RICU in the...

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  Letter response to the article “Effects of breathing exercises using home-based positive pressure in the expiratory phase in patients with COPD

  Abstract
  Following the publication of the manuscript “Effects of breathing exercises using home-based positive pressure in the expiratory phase in patients with COPD” in Postgraduate Medical Journal written by Lin Q. et al., we describe the rationale and origin of the respiratory technique derived from yoga practice and adapted as breathing exercise for a pulmonary rehabilitation programme strategy for COPD patients. The discussed technique consist of breathing with an expiratory resistive load, is a modified Pranayama yogic breathing practices tailored with focus on the specific need of patient with COPD, that allow the patient to breathe simultaneously through both the nostrils and with exhalation to be completed against a resistance to the free flow of exhaled gases. The described method has also been proven very useful in reopening non-ventilating lung areas for both chronic and acute patients.
  I have read with great interest the manuscript “Effects of breathing exercises using home-based positive pressure in the expiratory phase in patients with COPD” published in Postgraduate Medical Journal written by Lin Q. and collaborators 1. As reported by the authors in the acknowledgment of the paper, I was instrumental to inspire the study while working with the Respiratory and Critical Care Medicine and RICU in the First Affiliated Hospital of Wenzhou Medical University, China.

  I congratulate the authors, and in particular Dr. Chang Cai who planned and coordinated the study at my suggestion, the reviewers and the editorial staff who prepared and published this interesting article.

  The main merit of the study consists in presenting significant evidence of a helpful method used empirically for a long time to perform breathing exercise in acute and chronic respiratory diseases.

  In this study the method has been used as a rehabilitation exercise to improve ventilation and quality of life of COPD patients, although current available evidence in the literature are low to moderate 2-4.

  The rationale and origin of this respiratory technique derived from Pranayama yoga practice.5 6.

  This technique involves: 1. Inhale through the left nostril to a count of four; 2. Close both nostrils and hold breath to a count of sixteen; 3. Exhale through the right nostril to a count of eight; 4. Inhale through the right nostril to a count of four. 5. Close nostrils and hold breath to a count of sixteen. 6. Exhale through the left nostril to a count of eight.
  This yogic technique has been tailored by us allowing the patient to inhale simultaneously through both nostrils and exhale only through the mouth against a resistance to the free flow of exhaled gases.

  Specifically, the breathing technique involves: 1. Inhale through both nostrils to a count of four; 2. Hold breath to a count of six to ten (according to the patient’s resistance); 3. Exhale through the mouth towards an expiratory resistive valve to a count of eight. The exhalation occurs through a tube that attaches to a water valve (Positive End-Expiratory Pressure – PEEP).

  The rationale of the method can be summarised in three phases, specifically:
  1st Phase: The inspiration for about 4-5 seconds allows the introduction of a typical amount of air (tide volume) for each patient into the lungs. In this phase the inhaled air goes preferentially toward the lung areas with lower resistance and better compliance.

  2nd Phase: At the end of inhalation, the start of the expiratory phase is delayed between 6- 10 sec (in Pranayama practice 16 seconds is suggested). The duration of this apnea must be adapted progressively according to the improvement and patient’s acceptance.

  In this phase the gas present in the lungs is redistributed to the lung areas that need more time to be opened. This allows the recruitment of not ventilating lung areas to steady flow.
  3rd Phase: The exhale is done through a plastic or PVC tube (about 2 cm in diameter and 80 cm in length) whose terminal part is immersed in water. Exhalation must be done progressively to a count of 8 seconds.

  The level of tube immersion can be regulated from 5 to 15 cm H2O according to the lung pathology and the progressive adaptation of the patient to the method. It is generally suggested to increase the immersion level by 2-3 cm every 5-6 days in relation to the patient's tolerance.

  The resistance offered to the free exhalation of the gas from the lungs, controlled by the level of tube immersion, allows small bronchi and terminal bronchioles to stay open longer improving the closure volume. Leaving the terminal bronchioles and the alveoli open longer, on one end promotes the elimination of the sputum, on the other, improves gas exchange.
  It is recommended to perform the manoeuvre 2-4 times a day, no less than 2 times, for the duration of 10-15 min. The technique may present some initial difficulty of adaptation on the part of the patient, for which it requires particular attention on the part of those who teach the method, especially if the patient is not completely cooperative.
  The beneficial and indispensable method of rehabilitation becomes evident and better accepted as soon as the patient begins to improve. Chronic patients usually notice the benefit after the first week of treatment as clearly demonstrated by the study to which I refer, and by themselves tend to increase the duration of respiratory exercise. Generally the acute patient perceives the benefit earlier.

  Reference

  1. Lin Q, Zhuo L, Wu Z, et al. Effects of breathing exercises using home-based positive pressure in the expiratory phase in patients with COPD. Postgrad Med J. 2019;95:476-481.
  doi: 10.1136/postgradmedj-2019-136580. Epub 2019 Jul 22.
  2. Holland AE, Hill CJ, Jones AY, et al. Breathing exercises for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012;10:CD008250.
  doi: 10.1002/14651858.CD008250.pub2
  3. Garvey C, Bayles MP, Hamm LF, et al. Pulmonary Rehabilitation Exercise Prescription in Chronic Obstructive Pulmonary Disease: Review of Selected Guidelines: AN OFFICIAL STATEMENT FROM THE AMERICAN ASSOCIATION OF CARDIOVASCULAR AND PULMONARY REHABILITATION. J Cardiopulm Rehabil Prev. 2016;36:75-83.
  doi: 10.1097/HCR.0000000000000171.
  4. Ubolnuar N, Tantisuwat A, Thaveeratitham P, et al. Effects of Breathing Exercises in Patients With Chronic Obstructive Pulmonary Disease: Systematic Review and Meta-Analysis. Ann Rehabil Med. 2019;43:509-523.
  doi: 10.5535/arm.2019.43.4.509. Epub 2019 Aug 31.
  5. Liu XC, Pan L, Hu Q, et al. Effects of yoga training in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis. J Thorac Dis. 2014;6:795-802.
  doi: 10.3978/j.issn.2072-1439.2014.06.05.
  6. Beutler E, Beltrami FG, Boutellier U, et al. Effect of Regular Yoga Practice on Respiratory Regulation and Exercise Performance. PLoS One. 2016;11(4):e0153159.
  doi: 10.1371/journal.pone.0153159.

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  Conflict of Interest:
  None declared.

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