ORIGINAL PAPER
Cardiorespiratory and metabolic stresses during repeated pursed-lips breathing in chronic obstructive pulmonary disease
 
More details
Hide details
1
College of Sports Science and Technology, Mahidol University, Nakhonpathom, Thailand
 
2
Department of Physical Therapy, Faculty of Allied Health Sciences, Thammasat University, Pathumthani, Thailand
 
3
Division of Pulmonary and Critical Care Medicine, Faculty of Medicine at Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
 
 
Submission date: 2021-12-21
 
 
Acceptance date: 2022-03-21
 
 
Publication date: 2022-06-21
 
 
Physiother Quart. 2023;31(4):21-27
 
KEYWORDS
TOPICS
ABSTRACT
Introduction:
Pursed-lip breathing (PLB) is a breathing exercise treatment for patients with chronic obstructive pulmonary disease (COPD). The purpose of this study was to investigate the dynamic changes in the cardiorespiratory and metabolic functions during and after repeated volitional PLB and spontaneous breathing (SB) at rest in COPD patients.

Methods:
Sixteen patients with moderate to severe airflow limitation participated in this crossover study in which the subjects in both the groups randomly received 10 repeated cycles of PLB and SB interventions. Cardiorespiratory and metabolic variables were collected at the baseline, throughout the 10 breathing cycles, and after a recovery period of 5 min.

Results:
During PLB, the tidal volume (VT) increased progressively, whereas the breathing frequency (BF) decreased gradually throughout the 10 volitional PLB cycles (p > 0.05). However, minute ventilation (V̇E), oxygen consumption (V̇O2), and carbon dioxide production (V̇CO2) remained unchanged during PLB (p > 0.05). The VT and BF peaks appeared during the 8th and 7th cycles, respectively, and then plateaued until the 10th breathing cycle. The heart rate (HR) while performing PLB slightly increased (p < 0.05) from the 3rd to the 10th cycle compared to SB.

Conclusions:
Despite the clinical benefits of PLB in increasing the inspired volume and slowing the rate of breathing, this maneuver in COPD patients should be prescribed with an awareness of the risk of cardiac stress, especially the effect on the HR, as well as the respiratory limitations with repeated PLB. Practically, this study recommends limiting repeated PLB in COPD patients to seven breathing cycles.

REFERENCES (35)
1.
Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380(9859):2095–2128; doi: 10.1016/s0140-6736(12)61728-0.
 
2.
Levine S, Kaiser L, Leferovich J, Tikunov B. Cellular adaptations in the diaphragm in chronic obstructive pulmonary disease. N Engl J Med. 1997;337(25):1799–1806; doi: 10.1056/NEJM199712183372503.
 
3.
MacNee W. Pathology, pathogenesis, and pathophysiology. BMJ 2006;332:1202–1204; doi: 10.1136/bmj.332.7551.1202.
 
4.
Jones AY, Dean E, Chow CCS. Comparison of the oxygen cost of breathing exercises and spontaneous breathing in patients with stable chronic obstructive pulmonary disease. Phys Ther. 2003;83(5):424–431; doi: 10.1093/ptj/83.5.424.
 
5.
Schols AM, Fredrix EW, Soeters PB, Westerterp KR, Wouters EF. Resting energy expenditure in patients with chronic obstructive pulmonary disease. Am J Clin Nutr. 1991;54(6):983–987; doi: 10.1093/ajcn/54.6.983.
 
6.
Donahoe M, Rogers RM, Wilson DO, BE Pennock. Oxygen consumption of the respiratory muscles in normal and in malnourished patients with chronic obstructive pulmonary disease. Am Rev Respir Dis. 1989;140(2):385–391; doi: 10.1164/ajrccm/140.2.385.
 
7.
O’Donnell DE, Voduc N, Fitzpatrick M, Webb KA. Effect of salmeterol on the ventilatory response to exercise in chronic obstructive pulmonary disease. Eur Respir J. 2004;24(1):86–94; doi: 10.1183/09031936.04.00072703.
 
8.
Nici L, Donner C, Wouters E, Zuwallack R, Ambrosino N, Bourbeau J, et al. American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation. Am J Respir Crit Care Med. 2006;173(12):1390–1413; doi: 10.1164/rccm.200508-1211ST.
 
9.
Visser FJ, Ramlal S, Dekhuijzen PN, Heijdra YF. Pursed-lips breathing improves inspiratory capacity in chronic obstructive pulmonary disease. Respiration. 2011;81(5):372–378; doi: 10.1159/000319036.
 
10.
Rabe KF, Hurd S, Anzueto A, Barnes PJ, Buist SA, Calverley P, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med. 2007;176(6):532–555; doi: 10.1164/rccm.200703-456SO.
 
11.
Aliverti A, Cala SJ, Duranti R, Ferrigno G, Kenyon CM, Pedotti A, et al. Human respiratory muscle actions and control during exercise. J Appl Physiol. 1997;83(4):1256–1269; doi: 10.1152/jappl.1997.83.4.1256.
 
12.
Zhang W, Mehta A. The historical perspective on pursed lip breathing exercises and its role in pulmonary rehabilitation programs. Med Res Arch. 2018;6(8):1–9; doi: MRA/mra/article/view/1825.
 
13.
van der Schans CP, de Jong W, Kort E, Wijkstra PJ, Koëter GH, Postma DS, et al. Mouth pressures during pursed lip breathing. Physiother Theory Pract. 1995;11(1):29–34; doi: 10.3109/09593989509022395.
 
14.
Nespoulet H, Rupp T, Bachasson D, Tamisier R, Wuyam B, Lévy P, et al. Positive expiratory pressure improves oxygenation in healthy subjects exposed to hypoxia. PLoS One. 2013;8(12):e85219; doi: 10.1371/journal.pone.0085219.
 
15.
Zhou L, Cai G, Xu Z, Weng Q, Ye Q, Chen C. High positive end expiratory pressure levels affect hemodynamics in elderly patients with hypertension admitted to the intensive care unit: a prospective cohort study. BMC Pulm Med. 2019;19(1):224; doi: 10.1186/s12890-019-0965-9.
 
16.
Sakhaei S, Sadagheyani HE, Zinalpoor S, Markani AK, Motaarefi H. The impact of pursed-lips breathing maneuver on cardiac, respiratory, and oxygenation parameters in COPD patients. Open Access Maced J Med Sci. 2018;6(10):1851–1856; doi: 10.3889/oamjms.2018.407.
 
17.
Min-Sik Y, Yun-Seob L, Hae-Yong L. Effects of breathing exercises on resting metabolic rate and maximal oxygen uptake. J Phys Ther Sci. 2018;30(9):1173–1175; doi: 10.1589/jpts.30.1173.
 
18.
Mueller RE, Petty TL, Filley GF. Ventilatory and arterial blood gas changes induced by pursed lips breathing. J Appl Physiol. 28(6):784–789; doi: 10.1152/jappl.1970.28.6.784.
 
19.
Ramos E, Vanderlei L, Ramos D, Teixeira L, Pitta F, Ve­loso M. Influence of pursed-lip breathing on heart rate variability and cardiorespiratory parameters in subjects with chronic obstructive pulmonary disease (COPD). Braz J Phys Ther. 2009;13(4):288–293; doi: 10.1590/S1413-35552009005000035.
 
20.
Spahija J, de Marchie M, Grassino A. Effects of imposed pursed-lips breathing on respiratory mechanics and dyspnea at rest and during exercise in COPD. Chest. 2005;128(2):640–650; doi: 10.1378/chest.128.2.640.
 
21.
Vogelmeier CF, Criner GJ, Martinez FJ, Anzueto A, Bar­nes PJ, Bourbeau J, et al. Global strategy for the diagnosis, management, and prevention of chronic obstructive lung disease 2017 report. GOLD executive summary. Am J Respir Crit Care Med. 2017;195(5):557–582; doi: 10.1164/rccm.201701-0218PP.
 
22.
Roberts SE, Stern M, Schreuder FM, Watson T. The use of pursed lips breathing in stable chronic obstructive pulmonary disease: a systematic review of the evidence. Phys Ther Rev.2009;14(4):240–246; doi: 10.1179/174328809x452908.
 
23.
Gordon N, Abbiss CR, Maiorana AJ, Marston KJ, Peiffer JJ. Intrarater reliability and agreement of the physioflow bioimpedance cardiography device during rest, moderate and high-intensity exercise. Kinesiology. 2018;50(1, Suppl. 1):140–149.
 
24.
Parisien-La Salle S, Abel Rivest E, Boucher VG, Lalande-Gauthier M, Morisset J, Manganas H, et al. Effects of pursed lip breathing on exercise capacity and dyspnea in patients with interstitial lung disease: a randomized, crossover study. J Cardiopulm Rehabil Prev. 2019;39(2):112–117; doi: 10.1097/HCR.0000000000000387.
 
25.
Spahija JA, Grassino A. Effects of pursed-lips breathing and expiratory resistive loading in healthy subjects. J Appl Physiol. 1996;80(5):1772–1784; doi: 10.1152/jappl.1996.80.5.1772.
 
26.
Carroll RG. Pulmonary System. Elsevier’s Integrated Physiology. Philadelphia: Mosby Elsevier; 2007.
 
27.
Fregonezi GA, Resqueti VR, Güell Rous R. Pursed lips breathing. Arch Bronconeumol. 2004;40(6):279–282; doi: 10.1016/S1579-2129(06)70099-4.
 
28.
Johnson BD, Reddan WG, Pegelow DF, Seow KC, Dem­p­sey J. Flow limitation and regulation of functional residual capacity during exercise in a physically active aging population. Am Rev Respir Dis. 1991;143(5):960–967; doi: 10.1164/ajrccm/143.5_Pt_1.960.
 
29.
Gandevia B. The spirogram of gross expiratory tracheobronchial collapse in emphysema. Q J Med. 1963;32:23–31; doi: 10.1093/oxfordjournals.qjmed.a066984.
 
30.
Tiep BL, Burns M, Kao D, Madison R, Herrera J. Pursed lips breathing training using ear oximetry. Chest. 1986;90(2):218–221; doi: 10.1378/chest.90.2.218.
 
31.
Kagan I, Zusman O, Bendavid I, Theilla M, Cohen J, Sin­ger P. Validation of carbon dioxide production (VCO2) as a tool to calculate resting energy expenditure (REE) in mechanically ventilated critically ill patients: a retrospective observational study. Crit Care. 2018;22(1):186; doi: 10.1186/s13054-018-2108-8.
 
32.
Loring SH, Garcia-Jacques M, Malhotra A. Pulmonary characteristics in COPD and mechanisms of increased work of breathing. J Appl Physiol. 2009;107(1):309–314; doi: 10.1152/japplphysiol.00008.2009.
 
33.
Zamzam MA, Azab NY, El Wahsh RA, Ragab AZ, Allam EM. Quality of life in COPD patients. Egypt J Chest Dis Tuberc. 2012;61(4):281–289; doi: 10.1016/j.ejcdt.2012.08.012.
 
34.
Rossi RC, Vanderlei FM, Bernardo AF, Souza NM, Goncalves AC, Ramos EM, et al. Effect of pursed-lip breathing in patients with COPD: linear and nonlinear analysis of cardiac autonomic modulation. COPD. 2014;11(1):39–45; doi: 10.3109/15412555.2013.825593.
 
35.
van Gestel AJ, Steier J. Autonomic dysfunction in patients with chronic obstructive pulmonary disease (COPD). J Thorac Dis. 2010;2(4):215–222; doi: 10.3978/j.issn.2072-1439.2010.02.04.5.
 
eISSN:2544-4395
Journals System - logo
Scroll to top