Understanding Breathing Disorders: A "Primer" for Yoga Practitioners

Continued from page 1 of Understanding Breathing Disorders

First Things First: Basic Self-Care Tools

Actively participate in your medical care

Have you avoided or decreased any activities or exercises you once did because of shortness of breath? If yes, talk with your doctor if you should undergo spirometric assessment. Know your numbers such as the FEV1 and FEV/FVC and keep a baseline for future reference. It usually takes many years before the "hidden" disease causes significant impairment to force one's attention. If needed, find a lung doctor with whom you feel comfortable.

If your student has COPD or asthma attacks still continuing, make sure they are under medical care and are medically stabilized before you do any intensive yoga work. Some with asthma have "exercise induced asthma" and they may not yet be aware of it if they have not exercised in the past. Identify asthma "triggers" or anything to which you are sensitive. However, the techniques such as the relaxed breathing, relaxation, gentle stretching and breathing are almost always helpful for both asthma and COPD.

In order to stay motivated and monitor your progress, make a list of your goals for personally meaningful activities and exercises in terms of what you want to accomplish in next three and six months.

Quit smoking

It is no exaggeration that quitting smoking is the most helpful thing people with compromised breathing can do for themselves. Get professional help if you have not been successful on your own. Also take advantage of the websites that have distinguished themselves by being user friendly, accessible, and valid scientific information on how to quit smoking.

Yoga/self-care tip: Calm, peaceful, non-judgmental, relaxed and somewhat detached and passive breath awareness such as the one offered by yoga can be helpful with weakening the nicotine addiction.

Attend a pulmonary rehabilitation program (PRP)

If you qualify for PRP and there is one available in your area, join it. Medicare usually reimburses for 12 weeks of PRP for qualified patients. PRP participants are supposed to receive supervised assessment of their exercise tolerance. You would perhaps wear an EKG and an oximeter while exercising and RT or nurse is present to monitor your heart and lungs. In addition to that you would learn about activity pacing, breathlessness control, nutrition and advice on adjustment of supplemental oxygen during exercise.

Take charge of self-care responsibilities

In order to participate in collaborative care with your physician, one has to be an informed member for one's own "treatment team." It pays to keep current with the latest disease specific information, lung rehabilitation, symptom control, effective exercises and breathing techniques. Several national professional and patient advocacy organizations provide excellent, user friendly, and easy to access information on the Internet.

Yoga/Self-Care Tip: Yoga encourages a strong self-are orientation. Yoga is one of the oldest and most comprehensive self-care system which teaches about breathing, exercise, nutrition, mental and spiritual training and a psycho-emotional discipline which can be beneficial for the lungs an the heart

Control dyspnea

Dyspnea (breathlessness and breathing discomfort) often leads to activity and exercise avoidance. One of the extrapulmonary effects of COPD is "skeletal muscle dysfunction." Inactivity and lack of exercise leads to physical deconditioning and muscle wasting. In turn, physical deconditioning and muscle wasting lead to dyspnea. It becomes a truly vicious cycle which needs to be broken. Anxiety and panic about dyspnea and the resulting feeling of loss of control and depression can make dyspnea worse. Dyspnea is not merely a physical sensory matter it is also associated with psychological component such as anxiety and depression.

It is of utmost importance that people with breathlessness develop the skill of modifying their own dyspnea and not solely rely on the use of emergency bronchodilators. By learning the skills of breath management and control over breathlessness, you are likely to feel more confident and willing to resume activities and exercises. Following skills are important: Pursed-Lip Breathing (PLB), helpful body positions to reduce dyspnea, pacing of breathing and psychological management of dyspnea-related anxiety.

Pursed Lip Breathing (PLB): PLB is clinically reported to improve arterial oxygen saturation (SaO2) and CO2 removal as well as relieving dyspnea. PLB by patients with COPD promotes a slower and deeper breathing pattern both at rest and during exercise, while prolonging expiratory and total breath durations, particularly at rest. But PLB during exercise is capable of relieving dyspnea for some patients but not others.

Whenever you notice the first sign of accelerated breathing or shortness of breath, relax your mind and body and start the PLB. A helpful phrase to remember about PLB is, "Smell the rose and blow out the candle." Smelling the rose with your nose is the inhalation. In order to exhale, purse your lips like you are going to blow out a candle or kiss a baby. However, we need to refine the PLB skill to receive maximum benefits with these guidelines: Exhale slowly, smoothly, evenly and consistently like when the gentle wind blows the light of the candle flickers but does not extinguish. Another helpful imagery is like when you are cooling that hot soup in the spoon you are holding.

When experiencing breathing discomfort, we want to breathe hard and fast to get a relief from but that would be counterproductive. PLB helps because it builds positive air pressure (PAP) in your lungs. You have to fine tune your PLB to determine what works best for you. For some a helpful PAP is soft blowing and for others a little harder pressure. For example, some like to stiffen their lips while pursing them and others find it helpful to keep their pursed lips soft. Whatever you do, maintain a consistent flow of breath and avoid a "see-saw" breath. Furthermore, your exhalation should smoothly transition into inhalation before you feel rushed to breathe in. Slowly and steadily work on making exhalation slightly longer than your inhalation. Continue PLB until you get a relief from dyspnea.

Utilize body positions that help with dyspnea:

Helpful body positions are those that allow chest expansion, help the diaphragm to move easier and minimize the use of accessory breathing muscles especially the neck and shoulder muscles. Slightly leaning the chest forward while sitting or standing and relaxing the neck and shoulders facilitates the movement of the diaphragm while poor body positions such as tensed up shoulders and "forward head" restricts the breath flow.

When experiencing shortness of breath (SOB), do the following:

While standing, rest your hands over your knees, relax, slightly lean forward and do PLB

While sitting, relax, rest your arms on a table (or rest your forehead in your hands), slightly lean your chest forward and do PLB.

Reduce breathing-related anxiety: Anxiety and panicky thoughts, especially related to breathing, are likely to escalate the breathing discomfort.

Breathing related anxiety is one of the reasons why you might avoid some activities or exercise lest the exertion make SOB more severe.

Good news is that the anxiety related to breathing and exertion can be modified. You can learn breathing techniques and anxious thought modifications in order to gain psychological control over your breathing. Be patient and witness progress in your efforts for gaining control over your Dyspnea. Then you begin to feel confident in your ability to control dyspnea at will. By the same token, the anxiety that your breathing will get out of control diminishes. There are Internet sites you can visit for more tips on anxiety and panic related to breathing.

Pacing your breathing with activity/exertion:

Example of poor pacing: Say you begin walking or jogging on a treadmill. You pick up the speed too fast and too soon. As your breathing accelerates you start breathing harder and faster to catch your "running breath." This would only make the SOB worse. Example of good pacing: However, in the same example, when your breathing accelerates, slow down the treadmill speed. Gain control over your breathing and then gradually, in small increments, increase your speed. In this way, you can exercise longer, handle higher speed and still stay within your comfortable zone. Matching between your breathing rate and the level of exertion is called "pacing."

Learning how to pace your breathing and exercise or activity is important because this can help you to more fully access the level of exertion and challenge possible within your capacity.

Use the pacing skill while doing yoga postures, that is, slowly and steadily maintaining your breathing in a comfortable range. Avoid trying to do maximum number of poses in the shortest time would be a poor strategy.

Relaxation and stress management skills

He following joint statement of the American Thoracic Society and Respiratory Society is of interest here: "Patients should be taught to recognize symptoms of stress and be capable of stress-management techniques. Relaxation training can be accomplished through techniques such as muscle relaxation, imagery, or yoga." Furthermore, the joint statement says, "…relaxation training should be integrated into the patient's daily routine, for tackling dyspnea and controlling panic."

Yoga/Self-Care Tips:

1. Yoga has a rich tradition of guided imagery, visualization and mental and physical relaxation.
2. Relaxation of the body and the mind automatically tries to restore the natural diaphragmatic breathing and slows down the breathing rate. Learn to relax the muscles systematically from toes to head and engage the mind in passively allowing the body to become loose and limp. During relaxation pay special attention to relaxing your neck and shoulder muscles. These are accessory breathing muscles and by relaxing them, you may minimize unnecessary recruitment of them for your breathing. While sitting, imagine the shoulders are being pulled back and down and the elbows are lowering towards the seat, allowing the neck to become long and chin down.
3. Practice relaxation in a chair or in the lying position such as in the yoga relaxation pose (Sāvāsana) regularly at least twice a day for 15-20 minutes each time. Adherence to your relaxation schedule can be most rewarding in establishing correct breathing at least for the duration of the relaxation and can also help with your exercise and activity performance.
4. For stress management adopt yoga approach of staying calm and going about the motions of life with a calm, patient and mindful approach. Shun excitement and rushed activity as that can result in rapid breathing and heart racing. Learn the "stress and breath connection"
5. Bear in mind that COPD itself carries significant stress and can cause disease related anxiety, depression and other negative emotional consequences.

Control hyperinflation and dynamic hyperinflation (DH) of the lungs

Airflow limitation in asthma and COPD can result in significant amount of air trapped in the lungs leading to a permanent over inflated lung referred to as, "hyperinflation." Relatively speaking, expiratory limitation plays a larger role in hyperinflation as Hillsman explains "(During inhalation) all the structures in the lung, including the airways, get larger, and therefore air moves into the lung relatively easier on inspiration. Conversely, on breathing out, everything in the lungs, including the airways, gets smaller. Therefore, it is relatively more difficult to get air out of the lung on expiration. As a result, some air is trapped in the lung, causing it to overinflate" The problem is that with trapped air in the lungs, they don't get enough time to empty before the next inhaled breath.

When you experience SOB you instinctively try to breathe faster to relieve the breathing discomfort. But the faster you breathe, less time you have to get air out of your lungs. The more air you get in the lungs, the more inflated the lungs become making it even more difficult to expel the air out. This is the "dynamic" component of the dynamic hyperinflation (DH).

DH over time reduces both inspiratory and expiratory capacities particularly during exercise or any other exertion. "This results in dyspnea and limitation of exercise capacity…It is now thought that hyperinflation develops early in the disease and is the main mechanism for exertional dyspnea." (GOLD 2006 p. 26)

Yoga/Self-Care Tips:

1. "Slowing the breathing and lengthening the exhalation" should be the mantra for hyperinflated lungs and DH. Slower and longer exhalation would allow more effective emptying of the lung.
2. Stay calm! Hillsman says, "Trying to pump air in and out of your lungs as fast and as hard as you can is a basic cognitive reflex (i.e. controlled by a persons thoughts) generated by a persons conscious will…" Remember by becoming anxious and upset, you can accelerate your breathing and make the dyspnea worse. Therefore, psycho-emotional management of breathing is important.
3. Be watchful of DH. If you feel "fullness" in your lungs and/or chest and you are breathing more rapidly than the normal rate, that is above 15 breaths a minute, try to relax and slow down. Slowly begin emptying the lungs of excess air though slow breathing and longer exhalation.

Modify chronic hyperventilation pattern:

For a healthy young adult at rest the normal breathing rate is 12-15 breaths a minute. 18 or more breaths a minute begin to move in the realm of hyperventilation. Compared to healthy people, many people with asthma and COPD demonstrate chronically higher breathing rate at rest and even more rapid breathing during exertion. Some COPD patients have a breathing rate of 20 breaths per minute at rest. Some clinicians, in order to explore the specific symptoms of hyperventilation, administer a "hyperventilation challenge" by asking a patient to breathe deeply and rapidly (20-30 breaths a minute) for 2-3 minutes. Some clinicians during clinical examination asked a person to breathe at the rate of 40-45 breaths a minute to elicit panic attacks.

Chronic hyperventilation has been associated with an extraordinary number of such psychological disorders as the anxiety, panic attacks and depression and physical disorders such as the hypertension, cardiac arrhythmia, migraine, metabolic disorders or arterial blood vessels constriction (Fried pp 41-49). It is impossible to separate when and to what extent, hyperventilation is the cause or effect of these conditions.

All of the hyperventilation is not solely due to the physical-mechanical limitation of the lungs, but the physical stress and psychological-emotional stress plays an important role in it. Fried says, "Hyperventilation is most probably the most common of the so-called stress-related breathing disorders." (Fried p45)

Yoga/Self-Care Tips:

1. Chronic hyperventilation, in parts, is an automatic and habitual pattern of breathing and the pattern can be changed with patient and steady attention and conscious breathing.
2. Develop awareness of the stress-breath connection. Modify the psychological-emotional component of hyperventilation with self-observation. Seek behavioral health consultation if indicated.
3. Gradually, by slowing the breathing and lengthening exhalation bring the rapid breathing rate to the normal breathing rate of 12-15 breaths a minute and then work towards an even lower breathing rate.
4. Look for tips in the Suggestions for Poses Coordinated with Breathing for strength and flexibility of the muscles of respiration.

Perform a wide variety of exercises and activities:

In addition to your yoga practice of postures and breathing techniques, perform a wide variety of exercises for strength and endurance including such exercises as lifting weights, treadmill, cross country, walking, bicycling, rowing etc. Likewise, engage in a wide variety of activities such as stair climbing, vacuum cleaning, taking the trash, combining mall walking and shopping, etc.

Yoga/Self-Care Tips

1. In order to minimize the occurrence of hyperventilation and DH while performing exercises and activities, stay in touch with your breathing at all times, pace exertion level with your breathing and do not exceed the breathing rate for more than 15 breaths a minute. Above all, don't ever get so short of breath that you feel your breathing is out of your control.
2. Gradually cultivate a breathing pattern of 6-breath a minute. Giardino demonstrated that the breathing rate of 6 breaths per minute improved the efficiency of gas exchange in people without known pathology or impairments.
3. Try walking while maintaining 6-breaths a minute rate. In one study, 6-breaths a minute rate was found to improve gas exchange in the lung and increase 6-minute walk distance in people with COPD.
4. For 6 breaths per minute, ideally, a person with COPD should inhale for a count of 4 and exhale for a count of 6.

Join a support group

Support groups can be a tremendous source of information, solution-oriented thinking and mutual support. If there is no support group in your area, join an online support group. One such online group deserves special mention.

Yoga/Self-Care Tips:

Perhaps, millions of people in yoga community are affected by chronic lung diseases either personally or through their students, friends and families. Many yoga practitioners are rehabilitation specialists such as respiratory, physical, occupational and exercise specialists. Yoga community is well aware of the power and joy of sangha (togetherness). Join or initiate a support group in your area for sanghā and sevā (service for others).

Cultivate 24-7 Breath Awareness:

Going about the business of the day, exercises or activities mindlessly until a significant SOB develops. Trying to control the breathing to relieve the breathing discomfort only when the problem becomes acute is a crisis management mentality. It is much better to cultivate a habit of mindful breathing, that is, maintain continuous and ongoing breath awareness and employ breathing technique as soon as you notice the slightest hint of the problem is good for lung health.

Here is another mantra for better lung function, "24-7 Breath Awareness and Breath Management."

Continued, Adaptations and Guidelines for Yoga Practice: How to Make the Poses (āsanās) and Breathing Techniques Work for You

Return to Stress Reduction Tips
Return to Self Care 

Copyright 2007, Mind Publications 
Posted March 2007


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