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Physiotherapy 97 (2011) 345–349

Debate Article

Respiratory physiotherapy: towards a clearer definition of terminology

Anne Bruton a,∗, Rachel Garrod b, Mike Thomas c

a Faculty of Health Sciences, Highfield Campus, University of Southampton, Southampton SO17 1BJ, UKb King’s College Hospital NHS Foundation Trust, London, UK

c Centre of Academic Primary Care, Foresterhill Health Centre, Aberdeen, UK

bstract

Interventions used in clinical practice and research need to be described in sufficient detail to permit accurate replication. Since words andhrases can change their meaning over time, it is important that authors choose their words carefully and define anything which might bembiguous. ‘Breathing exercises’ is a phrase which covers a multitude of therapeutic approaches. Recent randomised controlled trials havestablished the value of teaching patients with asthma to retrain their breathing. However, the descriptions of the breathing interventions areenerally inadequate. This problem stems partly from a degree of confusion surrounding terms such as ‘diaphragmatic breathing’ which has

een variously interpreted. A more structured approach to reporting such interventions is proposed. This approach will help to avoid confusion,nd will permit the transfer of those interventions found to be effective in research trials into routine clinical practice.

2011 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

eywords: Respiratory; Breathing retraining; Terminology

Box 1: Breathing exercises used by physiotherapists.

• Breathing training/retraininga

• Breathing control• Pursed lip breathing• Respiratory muscle training (inspiratory or expi-

ratory)• Thoracic expansion exercises• Diaphragmatic breathing• Abdominal breathing• Deep breathing• Shallow/reduced breathing• Nasal breathing• Shoulder girdle/trunk exercises• Relaxation• Ambulation exercises

ntroduction

Language, like breathing, is dynamic. Interpretations ofords are not fixed in time or in space as words and phrases

an acquire different meanings according to context or geog-aphy, and they can also evolve over time. The language usedo describe non-pharmacological respiratory interventions inhe published literature is diverse, which leads to difficultiesn interpreting findings and comparing research outcomes.his paper presents the problem that readers may encounterhen reading the literature, using the literature related toreathing training as a prime example, and proposes ideasor a way forward to ensure more universal understanding inhis field.

The simple phrase ‘breathing exercises’ has legitimatelyeen used to encompass all of the activities listed in Box 1 .

ach listed activity can itself be interpreted in several ways.

f readers are to be able to translate research findings into

∗ Corresponding author. Tel.: +44 0 2380 595283.E-mail address: ab7@soton.ac.uk (A. Bruton).

a Breathing training/retraining is a complex intervention comprisingultiple components, only some of which involve breathing pattern manip-

lation.

• Use of adjunctive devices (e.g. incentive spirome-try, positive expiratory pressure devices, manual

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031-9406/$ – see front matter © 2011 Chartered Society of Physiotherapy. Publisoi:10.1016/j.physio.2010.12.005

hyperinflation)

linical practice, it is essential for authors to describe exactlyhat intervention they administered in sufficient detail to per-

hed by Elsevier Ltd. All rights reserved.

3 iotherap

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46 A. Bruton et al. / Phys

it replication. Unfortunately, when describing respiratoryanoeuvres, there is not only no consensus among differ-

nt health professions and specialties, but also no consensusithin each individual profession, such as physiotherapy. Tri-

ls of prescribed medicines that do not report details of theoute, dose and timing of the drugs administered would beonsidered incomplete, yet trials involving breathing tech-iques have historically been published that simply describedhe intervention as involving ‘a course of breathing exercises’1]. Although most authors now provide more detail, it istill generally insufficient to allow accurate replication. Thisaper proposes a more structured approach to the reportingf respiratory therapy interventions, using breathing trainings an example.

reathing training

Breathing training (or retraining) for asthma is a specificrea of breathing therapy that, after several years of rela-ive neglect, has seen a considerable resurgence in researchctivity over the last decade. The last Cochrane review inhis area, published in 2004, concluded that more trials wereeeded to confirm the trends for benefit seen in the trialshey had reviewed [2]. Since then, a number of controlledrials involving this intervention have been published (seeable 1) [5,15–18]. These trials have been reviewed else-here in terms of clinical effectiveness [3]. Table 1 providesetails of the randomised controlled trials involving breathingraining that have been published in peer-reviewed journalsince the most recent Cochrane review, with notes on thentervention as described by the authors. The purpose of thisable is to compare the level of detail provided in descriptionsf the interventions. When looking at the table, it is clearrom the number of sections labelled as ‘NS’ (not specified)hat the descriptions of the interventions used in these trialsack sufficient detail to permit replication in clinical prac-ice. Breathing training is a complex intervention generallyomprising multiple components (both respiratory and non-espiratory). Respiratory components involve some form ofreathing pattern manipulation, while non-respiratory com-onents include, for example, nutritional advice, medicationsage advice and psychological support.

The evidence base for the use of breathing training pack-ges is now more convincing as a result of the recent trials inable 1. However, there is a continuing lack of precision in

he descriptions of the breathing techniques used, making itifficult for clinicians and researchers to replicate them withny accuracy. Even well-written reports frequently containnsufficient information about the details of the interventionhey have administered. In the trials reported by Thomas et al.4,5] and Holloway and West [6], the phrase ‘diaphragmatic

reathing’ is used. In reality, in the absence of phrenic nervealfunction, all breathing patterns involve some diaphrag-atic activity, so this phrase (although appearing regularly

n peer-reviewed publications) is not useful. The term is

bTet

y 97 (2011) 345–349

ntended to imply greater emphasis on abdominal and lowerhoracic excursion during inspiration, with reduced emphasisn upper thoracic excursion. In Brazil, the term ‘diaphrag-atic breathing’ refers to slow, deep inspirations that try to

isplace the abdomen more than the rib cage [7,8]. However,n the UK, ‘diaphragmatic breathing’ may be used to refer to areathing technique known as ‘breathing control’ by physio-herapists who use the Active Cycle of Breathing TechniquesACBT). The ACBT comprises thoracic expansion exercises,orced expiratory techniques and periods of breathing control9]. The confusion is partly generational in origin. Pryor andrasad state in a current standard undergraduate textbook forhysiotherapists: ‘Breathing control is normal tidal breathingsing the lower chest with relaxation of the upper chest andhoulders. This used to be known as diaphragmatic breathing’10]. However, in the recent ‘Guidelines for the physiotherapyanagement of the adult, medical spontaneously breathing

atient’, Bott et al. emphasise that breathing control ‘shouldot be confused with diaphragmatic breathing’ [11]. In cur-ent physiotherapy practice, the term ‘breathing control’ isenerally interpreted in line with the Pryor and Prasad defi-ition [10]. However, any medical clinician or scientist couldasily confuse this phrase with ‘control of breathing’, whichas a completely different meaning, related to neural path-ays. Diaphragmatic breathing can thus be interpreted toean ‘slow and deep’ breathing and/or ‘normal rate and tidal

olume’ breathing, depending on when and where you wererained.

reathing pattern manipulation

When delivered clinically, breathing training generallynvolves a ‘package’ of components. The core of theseomponents is breathing pattern manipulation, which canake many forms. The main elements of breathing patternhat may be manipulated are route of breathing, depth ofreathing (volume), rate of breathing, airflow velocity, tim-ng (inspiratory/expiratory phase duration and ratio), rhythmf breathing (within-subject variability of rate, volume andiming) and primary region of movement (upper thoracicxpansion, lower thoracic expansion, abdominal expansion).lthough there is no evidence that altering the latter affects

egional distribution of ventilation, it has been proposed thathe abnormal afferent proprioceptive input associated withn upper thoracic breathing pattern can directly result inncreased perception of respiratory symptoms [12]. Each ofhese breathing pattern components can be altered in a rangef combinations depending on the desired effect. Reduc-ng breathing rate while allowing inspired tidal volume toncrease may result in unchanged minute ventilation. If theim is to reduce overall ventilation, it is therefore insufficiento describe aiming for a ‘slow breathing rate’ of six to eight

reaths per minute without also paying attention to volume.he same slow rate can be achieved using slower inspired andxpired flow velocity without pauses, or rapid flow veloci-ies and prolonged end-inspiratory or end-expiratory pauses.

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Table 1Trials of breathing training for adult asthma published since the most recent Cochrane review (2004).

References Route Rate Depth Flow Region Timing Regularity Breath holds(BH)

Interventionroutine

Interventiondelivery

Home routine

Slader et al. [15] Nasal ‘Slow’ ‘Hypoventilation’ NS NS NS NS BH at FRC Instruction byvideo. TimingNS

By video.‘Instructional’and ‘dailyexercises’

Twice daily(13 minutes persession), plusreliever exercises.Fortnightlyresearcher contact(telephone/face toface). 30 weeks

Meuret et al. [16] NS Slow downto sixbreaths perminute

‘Shallow’ NS Abdominal NS Reducevariability(sighs/deepbreaths)

NS Five 1-hoursessions, onceper week over4 weeks

Face to face.CO2 feedback

Twice daily(17 minutes each)

Stanton et al. [17] Nasal NS Tidal ‘Relaxedinspiration’.‘Passiveexpiration’.‘Active efforttoend-expiratoryreserve’

Abdominal End-expiratorypause

NS BH timerecorded atend inspirationand endexpiration

Initial sessionthen weeklyreview for 4weeks

Face to face Six to eight timesper day(10 minutes each)

Thomas et al. [5] Nasal NS NS NS Diaphragmatic NS ‘Regular’ NS Threesessions, each2 weeks apart.First session60 minuteswith two tofour subjects,then twoindividualsessionslasting 30 to45 minutes

Face to face 10 minutes per day

Holloway et al. [6] Nasal ‘Slow’ NS NS ‘Papworth’.Diaphragmatic

NS ‘Reduction inyawning,sighing’

NS Five60-minuteindividualsessions

Face to face CD/audiotape.Once per day

Cowie et al. [18] Nasal. Useof mouthtaping

‘Pacedbreathing’

NS NS ‘Buteyko’ NS BH at FRC Groupsessions (10 to12 subjects).Fiveconsecutivedays. ‘Seriesof exercises’

Face to face ‘Repeatedly’every day

NS, not specified in text; FRC, functional residual capacity; CO2, carbon dioxide.

348 A. Bruton et al. / Physiotherap

Table 2Breathing pattern components and suggestions for their description.

Component Suggested descriptors

Route Nasal or oral. Method of encouragementRate Target rate in breaths per minuteDepth Shallow, normala, deeper than normal, maximalInspiratory flow Normal, faster than normal, slower than normalExpiratory flow Normal, faster than normal, slower than normalRegion Upper thoracic expansion, lateral thoracic

expansion, abdominal compartment expansionTiming Target inspiratory/expiratory duration and ratio, use

of end-inspiratory/expiratory pausesRegularity

Volume Normal, decreased variability, increased variabilityTiming Normal, decreased variability, increased variabilityRate Normal, decreased variability, increased variability

Breath holds Volume held (FRC, TLC), breaking point (e.g. firstdiscomfort, maximum tolerable), nose holding, atrest/during activity

Repetitions Training sessions – how/who, what, how often, howlong for, in what position?Practice sessions – what, how often, how long for, inwhat position?

Manual assistance Use of therapists’/patients’ hands?Where placed?Use of counterpressure?

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a Normal, normal for each individual; FRC, functional residual capacity;LC, total lung capacity.

nother frequently used term is ‘deep breathing’, whichmplies use of increased volume but generally provides nonformation on rate, flow or the other elements of breathingattern. Additionally, there is usually limited information onhe depth of breathing that is intended, leaving the readero assume it lies somewhere between tidal volume and vitalapacity.

reath holds

One of the common components of breathing trainingackages which has been tested in published randomisedontrolled trials (such as Papworth, physiotherapy, yoga anduteyko) is the use of breath holds or pauses. Breath holdingas multiple theoretical benefits for respiratory physiothera-ists. For example, end-inspiratory breath holds of 3 secondsre used to make use of collateral ventilation in patientsith reduced ventilation or retained secretions. The aim is

o improve distribution of ventilation and allow air to getehind secretions [13]. Other claimed, but unproven, bene-ts of breath holds are to desensitise individuals to carbonioxide, and to assist in reducing respiratory rate [14]. How-ver, even an apparently simple technique such as breatholding contains hidden complexity. Breath holds can benspiratory or expiratory, held at various volumes (such as

aximal inspiration or functional residual capacity), heldor varying durations using different breakpoints, held dur-

ng rest or during activity, and involve nose holding or not.his level of detailed description is not available in published

rials.

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y 97 (2011) 345–349

he way forward

It is time to dispose of the inaccurate term ‘diaphragmaticreathing’ and replace it with something more meaningful.he phrase ‘abdominal compartment expansion’ breathingould reflect the reality of the pattern desired, and has the

dditional bonus of an easy-to-remember acronym (ACE).thers may have better suggestions. However, the phrases

hosen are ultimately less important than the provision ofufficient information by authors to enable readers to have

complete picture of the intervention being applied, and toe able to teach it to their patients. Limited word space is anssue for most journals, but online supplements or appen-ices can usually overcome this problem. In Table 2, theomponents of breathing pattern, with suggestions for theirtructured description, have been outlined. All these compo-ents need to be considered and described comprehensively,sing such headings, if healthcare professionals are to be ableo take the encouraging findings of recent breathing trials forsthma and apply them in routine clinical practice.

thical approval: Not relevant for a debate article.Conflict ofnterest: None declared.

eferences

[1] Saunders KB, White JE. Controlled trial of breathing exercises. BMJ1965;2:680–2.

[2] Holloway E, Ram FS. Breathing exercises for asthma. CochraneDatabase Syst Rev 2004;1:CD001277.

[3] Bruton A, Thomas M. The role of breathing training inasthma management. Curr Opin Allergy Clin Immunol 2011;11:53–7.

[4] Thomas M, McKinley RK, Freeman E, Foy C, Prodger P, Price D.Breathing retraining for dysfunctional breathing in asthma: a ran-domised controlled trial. Thorax 2003;58:110–5.

[5] Thomas M, McKinley RK, Mellor S, Watkin G, Holloway E, ScullionJ, et al. Breathing exercises for asthma: a randomised controlled trial.Thorax 2009;64:55–61.

[6] Holloway EA, West RJ. Integrated breathing and relaxation training (thePapworth method) for adults with asthma in primary care: a randomisedcontrolled trial. Thorax 2007;62:1039–42.

[7] Tomich GM, Franca DC, Diorio AC, Britto RR, Sampaio RF, Par-reira VF. Breathing pattern, thoracoabdominal motion and muscularactivity during three breathing exercises. Braz J Med Biol Res2007;40:1409–17.

[8] Tomich GM, Franca DC, Diniz MT, Britto RR, Sampaio RF, Par-reira VF. Effects of breathing exercises on breathing pattern andthoracoabdominal motion after gastroplasty. J Bras Pneumol 2010;36:197–204.

[9] Webber BA. The Brompton Hospital guide to chest physiotherapy. 5thed. Oxford: Blackwell; 1988.

10] Pryor JA, Prasad SA. Physiotherapy techniques. In: Pryor JA, PrasadSA, editors. Physiotherapy for respiratory and cardiac problems: adultsand paediatrics. 4th ed. Edinburgh: Churchill Livingstone/Elsevier;2009. p. 134–217.

11] Bott J, Blumenthal S, Buxton M, Ellum S, Falconer C, Garrod R,et al. Guidelines for the physiotherapy management of the adult,medical, spontaneously breathing patient. Thorax 2009;64(Suppl. 1):i1–51.

iotherap

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A. Bruton et al. / Phys

12] Howell JB. The hyperventilation syndrome: a syndrome under threat?Thorax 1997;52(Suppl. 3):S30–4.

13] McIlwaine M. Physiotherapy and airway clearance techniquesand devices. Paediatr Respir Rev 2006;7(Suppl. 1):S220–2.

14] Courtney R, Cohen M. Investigating the claims of Konstantin Buteyko,M.D., Ph.D.: the relationship of breath holding time to end tidal CO2

and other proposed measures of dysfunctional breathing. J Altern Com-plement Med 2008;14:115–23.

15] Slader CA, Reddel HK, Spencer LM, Belousova EG, Armour CL,Bosnic-Anticevich SZ, et al. Double blind randomised controlled trial

[

Available online at www.s

y 97 (2011) 345–349 349

of two different breathing techniques in the management of asthma.Thorax 2006;61:651–6.

16] Meuret AE, Ritz T, Wilhelm FH, Roth WT. Targeting pCO(2) in asthma:pilot evaluation of a capnometry-assisted breathing training. Appl Psy-chophysiol Biofeedback 2007;32:99–109.

17] Stanton AE, Vaughn P, Carter R, Bucknall CE. An observational inves-tigation of dysfunctional breathing and breathing control therapy in a

problem asthma clinic. J Asthma 2008;45:758–65.

18] Cowie RL, Conley DP, Underwood MF, Reader PG. A randomisedcontrolled trial of the Buteyko technique as an adjunct to conventionalmanagement of asthma. Respir Med 2008;102:726–32.

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