Five Steps to Teaching Diaphragmatic Breathing
Step 1: Watch!
For a few minutes, observe patients’ breathing while they sit down. You can ask them to place one hand on their abdomen and the other on their chest. You can help reduce performance anxiety by having them close their eyes, or distract them with another activity that allows you to see comfortably.
- Ask them to inhale normally just like they would outside of the clinic.
- Pay attention to the movements of your hands, including whether the upper hand (chest), or the lower hand (abdomen) is moving more.
- Take note of their breathing rate. You can observe if their breathing is slow, fast or somewhere in between.
Step 2: Education
The goal pattern is described by the acronym DASS (Deep, Abdominal Slow, Smooth). Talk to your patient if you notice a pattern in their breathing that is slow, shallow or choppy.
- The importance of diaphragm muscles as the main breathing muscle.
- The relationship between breathing and the parasympathetic and sympathetic nervous systems.
- How diaphragmatic breathing looks (the provider may use DASS breathing for demonstration to the patient).
- How stress can cause shallow chest breathing. Clinicians recognize that pain and its associated issues can be significant stressors, and can affect their breathing patterns.
- It is helpful to take your time while you exhale. This helps activate the parasympathetic nervous systems’ quieting response.
Step 3: Instruction
It can be beneficial to teach several techniques and find the one that works best for each person. Training can be started with patients lying down if an examination table is available. To allow the patient to find the best technique, each technique can be practiced for at least a minute. Note : Some people become more anxious if they concentrate on their breathing.
These are the four most basic diaphragmatic breathing techniques you can try:
Technique 1
Begin by asking them to place one hand on their abdomen and then gently try to inhale under the hand. If they find it too difficult or forceful, they should try other techniques.
Technique 2
This next technique encourages deeper breaths. The patient should be able to breathe in for a count “2”, with each counted number taking one second. If the patient is uncomfortable, slow down the breathing and go in for “3” and then out for “4. Sometimes, the lengthened outbreath can allow for a deeper next breathe.
Technique 3
The individual must inhale normally during this technique. The goal of exhalation is to exhale all air out of the lungs. They then pause, wait for the body to respond, and exhale again. They should allow any feeling of effort to drop.
Technique 4
Some patients may find imagery helpful. The patient imagines a hole in their bottom that allows them to breathe (like a dolphin’s or whale’s). They imagine taking in air through their bottoms and up to their abdomens with each breath. They imagine exhaling through their bottoms, and then reverse the process.
Step 4: Evaluation and assignment of at home practice
Patients will often say that these activities are difficult or feel “different” because they routinely engage in shallow breathing. This is normal and will become easier as they get more used to deep breathing. Feeling lightheaded or unable to focus is an indication that you are trying too hard. You might find that changing techniques is more beneficial.
- Ask your patient which technique worked best for them and which was the easiest. Also, ask them which one they liked the most. Encourage them to practice the technique at home.
- Practice 5-10 minutes, twice daily, in a comfortable position. Patients with chronic pain often have difficulty falling asleep, intermittent awakening, and other sleep disturbances. Additional practice time may help to increase comfort or fall back to sleep.
- Ask them to practice in different positions throughout the day. This is to encourage generalization. You can also ask them to practice under low stress until they get used to it.
If this proves to be too difficult or very taxing, the patient can practice at home, lying down on their stomach if necessary. While not all pain sufferers are able to lie on their stomachs, most can do so for the few moments it takes to be aware of their breathing. People can feel the diaphragm muscle by lying down on their stomachs, even if they are only breathing lightly. You can do this for five minutes and focus on deeper breathing. They can then turn on their backs and recall the sensations they felt when lying on their stomachs.
It is important that the individual feels the sensations and experiences of diaphragmatic breath until they are accustomed to it. Their learning should be supported by twice-daily practice. Once they feel more comfortable and familiar, the next goal is to practice diaphragmatic breathing while standing up.
Step 5: Follow up
It is crucial to follow up on this activity. This can prove difficult for busy clinicians. Using a team approach and working together with other team members who are skilled in teaching these techniques can help. Patients should be given brief attention by a clinician to let them know that these techniques are important and they should continue to use them. Breathing habits can become a strong habit over many years. Change takes time and reinforcement. For further information, consider the following areas:
- To determine if the patient understands the exercise, review it. Ask them to demonstrate deeper, slower abdominal breathing.
- Talk about how and when they use it (e.g. When they are in pain, upset about finances, or when they feel ill. Encourage continued use. Encourage them to continue using it, even if it helps a little or decreases their emotional distress.
- As a final step in training, ask them to think about how they could use these skills more often in their daily lives. Ask them to think of other situations where they might use the skill.
- Keep your eyes on the goal. It is best to breathe slowly and deeply while remaining relaxed.
