Diaphragmatic Breathing

Diaphragmatic breath is also known as belly, deep and relaxed breathing, or abdominal breathing. It maximizes the use the main muscle of breathing, diaphragm. This results in slower and deeper breathing. It is an important skill to have in your patient’s toolbox for self-management. It is easy to teach your patients this skill with practice.

Diaphragmatic breathing differs from shallow breathing in that it involves expanding the abdomen, rather than the chest, during the in breathe. When shallow breathing is used, also known as chest or thoracic breathing, very little air is drawn into your lungs. This is usually achieved by using the intercostal muscle and not your diaphragm. Lung expansion that occurs lower in the body is called “deep breathing”. This refers to the observed or felt movement in the abdomen with inhalation. This technique is useful for self-management of chronic pain.

You Can Use Diaphragmatic Breathing in Various Ways

Diaphragmatic breathing

• The person moves from a place where they are passive to a place where they are active; they “do something” about their symptoms
• This course teaches you how to increase calm and relaxation.
• This simple method can be used to calm high-arousal pain and other symptoms, as well as the emotions it elicits.
• It’s very portable
• There is no cost other than the initial investment of your time
• This can be used for managing other stressors in life
• This can be used in difficult procedures like injections, imaging studies, and so on.
• It provides a positive distraction
• Can be used for interrupting negative thought patterns
• Shows that doctors consider non-pharmacologic intervention important for health

Physiological effects

Low breathing is often associated with anxiety, stress, and other psychological problems. This is often due to sympathetic over-arousal. It is commonly known as the “fight or flee response.” Practice diaphragmatic breathing can help to reverse this response and create a calm response that is modulated by the parasympathetic nerve system. It can have a variety of physiological effects.

• Diaphragmatic breathing increases the venous return from the heart. The diaphragm creates negative intrathoracic tension, which causes blood to flow into the thorax by a vacuum effect. This results in an increase of stroke volume. It triggers arterial stretch receptors. This increases parasympathetic activity and decreases sympathetic activity. These changes result in decreased heart rate, and lower total peripheral resistance.
• A rate of 6-10 minutes per minute inhalation causes an increase in the tidal volume, while maintaining optimal minute ventilation. An increase in tidal volume can cause cardiopulmonary baroreceptor stretching, which results in optimal minute ventilation and increased sympathetic outflow.
• The heart rate variability (HRV), a proxy measure for the heart’s sympathetic and parasympathetic balance, is increased by diaphragmatic breathing. Low HRV is a sign of poor prognosis. It can be seen in a number of clinical situations, such as post-MI, ischemic cardiac disease, congestive and diabetic heart failure, and post-MI.

Clinical Research

Hypertension

We are still not able to fully understand the antihypertensive mechanisms that slow, deep breaths have. It is thought that the effects on chemoreceptors as well as baroreceptors, central cardio- and respiratory control centers, the autonomic nerve system, and the central cardiovascular and respiratory control center’s may all play a role. Essential hypertension is believed to be caused by chemoreceptor Hypersensitivity. This causes excessive sympathetic nervous system activity. Specialized neurons in both the peripheral and central vasculature are responsible for the chemoreceptor reflex. They respond to changes of carbon dioxide. Increased carbon dioxide leads to an increase in minute and sympathetic outflow. Conversely, decreased carbon dioxide leads to a decrease of minute ventilation.

Hypothesized, slow deep breathing may have an autonomic balancing effect at the cross-talk centers between cardiovascular and respiratory control centers in central nervous system. Device-assisted slower breathing is the best evidence to manage hypertension. The respiratory system has been extensively studied. It’s a belt that is worn around your thoracic and monitors your respiration rate. The patient’s breathing is monitored by the device, which emits musical tones to speed up their pace. The American Heart Association released a scientific statement on the use of alternative and complementary therapies to manage hypertension in 2013. According to the committee, device-guided breathing can be used to slow down the patient’s breathing. Additional research is needed to establish if this technique will have similar antihypertensive results.

Congestive heart failure (CHF)

Survival in heart failure is directly related to the strength of your inspiratory muscles. Inspiratory muscle endurance and strength decreases can cause a number of problems, such as inefficient ventilation or preferential blood shunting away from the exercising limbs and to respiratory muscles. Patients suffering from CHF are less able to exercise. Patients with CHF may experience decreased exercise tolerance due to impaired inspiratory muscles strength and endurance.

Chronic obstructive and persistent pulmonary disease (COPD).

Patients with COPD are more likely to experience hyperinflation, which causes the diaphragm to be in chronic partial stretch. This mechanical disadvantage results in increased respiratory muscle weakness and breathing work. This mechanical disadvantage causes increased work of breathing and relative muscle weakness.

Asthma

A 2009 systematic review showed that training in diaphragmatic respiration leads to long-term and short-term improvements in health care quality and improved quality of life. A 2009 systematic review showed that diaphragmatic breathing training can result in short and long term improvements in quality of life, health care, and overall health.

Hot flashes

In 2012 there was a study published, a controlled randomized trial that investigated the effectiveness and safety of slow-paced breathing in the management of hot flashes. The intervention group used audio recordings to pace their breathing at six breaths per minutes, while the control group used audio recordings twice per day to pace their breathing at a normal rate at 14 breaths/minute. All groups saw statistically significant reductions in vasomotor symptoms. There was no significant difference between the two groups. There was no difference in the results between the two groups.

However, also in 2012, Carpenter and colleagues published a randomized-controlled trial wherein paced slow breathing showed a clinically significant (50% or greater) reduction in hot flash symptoms in only 38% of the intervention group. The intervention was not more effective than usual care or active control.

Insomnia

[13] Choliz published 1995 results from a randomized controlled trial that found voluntary hypoventilation induced drowsiness and sleep in the treatment groups.

Depression and anxiety

Brown and Gerbarg have presented a neurophysiologic framework for the therapeutic application of yogic breathing to manage stress, anxiety and depression in a series of 2005 papers. Brown and Gerbarg presented a neurophysiologic model to support the therapeutic use yogic breathing as a means of managing stress, anxiety and depression in a series of papers published in 2005. The clinically significant improvements in the Beck Depression Inventory-21 (posttraumatic checklist-17) were found in the breathing groups. In 2012 Katzman, colleagues, published results from a small, nonrandomized study that evaluated a yoga breathing exercise program as a treatment for generalized anxiety disorder in outpatients who are resistant to treatment.

Pain

A 2010 randomized controlled trial showed that slow breathing can reduce the feeling of negative affect and painful stimuli. Women suffering from fibromyalgia were compared with healthy controls. The study participants were exposed to mildly or moderately painful thermal stimuli while breathing at the same rate as her normal, but at half the speed. The pain intensity was lower and the negative affects were less severe in healthy subjects. These effects were not seen in women suffering from fibromyalgia.

A 2005 study on chronic low back pain found that patients were randomly assigned to receive either breath therapy or physical therapy. Patients in both the physical therapy and breath therapy groups saw statistically and clinically significant reductions in pain intensity and self reported overall health. Both treatments performed equally well. The interventions worked equally well.

Oxidative stress

[21] High levels of oxidative stress are a risk factor for developing heart disease. (23) It has been shown that diaphragmatic breath can decrease oxidative stresses. An analysis of data from 16 male competitive cyclists after a 900-calorie meal was conducted in a retrospective cohort study. Half of the subjects engaged in 40 minutes per day of diaphragmatic breathing postprandially, while the other half sat and read a magazine. The diaphragmatic breathing study showed that postprandial blood glucose, insulin, and circulating antioxidants were lower in those who engaged in diaphragmatic breath.

A similar sample of athletes was tested to determine the effects of diaphragmatic breathing upon exercise-induced oxidative stresses. Before and after eight-hours of hard exercise, blood and saliva were collected. Diaphragmatic breathing also showed similar results to those above. Exercise-induced oxidative stresses were reduced. Exercise-induced oxidative stress was reduced in participants who diaphragmatically breathed than in those who read quietly. [24]

Five Steps for Teaching Diaphragmatic Breathing

Step 1: Make a observation

Take a moment to observe the patient’s breathing while they are sitting down. It can be helpful for them to place one of their hands on the abdomen and one on the chest. You could ask them to close their eyes and distract them by doing something else to reduce anxiety.

• Ask them to breath normally as they would in the rest of their lives.
• You should observe the hand movements, especially the movement of the abdomen and the chest.
• Look at their breathing rate to determine if it is fast, slow, or somewhere in-between. Examine whether their breathing patterns are smooth or choppy.

Step 2: Education

The goal pattern can be described using the acronym DASS, which stands for Deep, Abdominal and Slow. Discuss with your patient if the patient’s breathing pattern seems choppy, shallow, or fast.

• The importance and function of the diaphragm as the main muscle for breathing.
• Breathing in relation to the sympathetic and parasympathetic nervous system.
• The provider can demonstrate the patient by using DASS breathing.
• Stress and shallow chest breathing: What it is and how it can affect your health. Doctors can recognize symptoms and conditions that could cause stress and help patients to adjust their breathing.
• The parasympathetic nervous network activates the quieting response by allowing you to exhale slowly.

Step 3: Instruction

Teaching multiple techniques can be useful and help you find what works for you. Patients can start training if there is an examination table. You can practice each technique for just a few minutes to allow patients to get accustomed to it. Note that some people feel more anxious when they focus their attention on their breathing. This is why it’s important to practice the techniques for at least a minute. Here are four easy diaphragmatic breathing methods that you can try.

Technique 1

Simply ask them to place their hand on their stomach and let them try to breathe under it. If they feel that this is too difficult, or they are trying too hard (over-breathing or too forcefully), they can try other techniques or reduce their effort.

Technique 2

This next technique encourages deeper breaths. Begin by having the patient inhale for a count (with each counted amount taking a second), and exhale for a count (3). If you feel it is too fast, you can slow it down to breathe in for “2” and out for the count of 4. You may be able to take a deeper next step by extending your outbreath.

Technique 3

This technique requires that the person inhales normally. When exhaling, it is important to concentrate on getting all the air out of their lungs. Instead of inhaling quickly again, they should pause and wait until their body is ready to inhale again. They should let all sense of effort go.

Technique 4

For some patients, imagery can be very helpful. The patient imagines that there is a small hole at the bottom of their feet for breathing. As they take in, they visualize breathing in through their feet. This is reversed when they exhale, as they visualize breathing out from the bottom of the feet.

Step 4 – Evaluation of techniques and assignation of at-home practice

Many patients will claim that the activities above were difficult or that they felt “different.” This is because they are used to shallow breathing. This is normal. As they become more comfortable with deeper breathing, it will become more natural. Noting: Feeling light-headed can be a sign that you are breathing too hard, or trying to overbreath. This should be avoided. Some techniques may be more effective than others.

• Ask the patient which of these techniques was most effective and easy for them. Or which ones they loved the best. Encourage them practice this technique at their home.
• Practice 5-10 minutes, twice daily, in a comfortable position. Many patients experience sleep disturbances. There are other times when patients have trouble falling asleep, or wake up frequently. The diaphragmatic breathing technique can be helpful in increasing comfort and falling back to sleep.
• You can also ask them to practice throughout the day in a variety positions. This encourages generalization. It’s also helpful for them to practice in times of low stress until they are comfortable with it.

What should I do if all this proves to be too difficult or very taxing on the patient?

Practice at home with the patient, lying on the stomach if possible. Although not all pain patients can lie on their stomachs, many can. However, they will be able to notice their breathing for a few minutes. Lying on your stomach allows you to feel the diaphragm muscles even when you are not trying hard enough. For five minutes, you can focus on the feeling of deeper breathing. After this, they can flip over on their back and remember the sensations when they were lying on their stomach.

Individuals should practice diaphragmatic breathing until they feel the sensations and experience it. This should help them to practice twice daily. Once comfort and familiarity have been gained, another goal is to perform diaphragmatic breaths while sitting up.

Step 5: Follow Up

The integration of these activities requires follow-up. It can be time-consuming for busy clinicians. A team approach can help. Working with other members of the team can help to teach these techniques. These techniques are important, and patients should receive brief attention from their clinicians. Breathing patterns can be very hard to change if they are a habit that has been ingrained for many years. Here are some suggestions for further reading:

• Examine the exercise to see if the patient still understands it. Encourage them to slow down and deepen their abdominal breathing.
• Discuss with them how and when they use it. Discuss when they use it (e.g., when they wake up in the middle of the nights due to pain, financial distress, after difficult conversations, etc.). Encourage and support continued use. Reaffirm the benefits it may provide, even if it is more effective in reducing symptoms than symptoms.
• It is important to discuss how they can use these skills more often in their lives. Ask them to consider other instances where they could use this skill, such as in a doctor’s office, driving the car, and so on.
• Keep in mind the end goal. It is best to breathe slowly and deeply, with minimal effort, unless you are in a situation where sympathetic arousal is really useful (fight or flight response).

Summary

Breathing can be an effective tool to reduce sympathetic arousal. It can have a variety of physiological benefits and clinical benefits.