Respiratory Muscle Training

Jarrod Wilson (Exercise Physiologist – Burnie)

There are a number of conditions that can affect the airways, causing obstruction and difficulty with breathing. The effect on someone’s health can range from a mild disturbance to breathing to life-threatening. Let’s have a look at some of the common conditions that affect the airways and how you can use respiratory muscle training (RMT) to help manage underlying pathology, maintain good respiratory hygiene and prevent health complications.

The Anatomy

Firstly though, without getting too involved, let’s look at the structure of the airways; primarily the nose and nasal cavity, the pharynx, the larynx, the trachea and the bronchi, bronchioles and the alveoli that allow for gas exchange at the lung.

What Happens When we Breathe?

Below is an illustration of what happens when we inhale a breath of air. This is the mechanics of respiration, a process driven by a control centre in the brain.

Breathing Muscles

We use muscles to take air in (inspiratory muscles) and to help exhale air (expiratory muscles).

The inspiratory muscles include the diaphragm, scalenes, sternocleidomastoid, external intercostals.

The expiratory muscles are the internal intercostals, external obliques, internal obliques, rectus abdominis and the transverse abdominis.

The Diaphragm

The diaphragm is the most important inspiratory muscle which is extensively connected throughout the core region of the body.

Strength of the diaphragm contributes to trunk stability, postural control and muscular efficiency. When all the air is out of the lungs, the diaphragm muscle is at its strongest.

When Things Go Wrong

Now that you know how breathing is mechanically driven and controlled in a healthy individual, we will next talk about common pathologies that affect the airways which can make the process of breathing more challenging.

COPD

COPD (Chronic Obstructive Pulmonary Disease) is a collective term for a group of obstructive airway pathologies (namely Chronic Bronchitis, Emphysema).

  1. Emphysema: A permanent dilation of any part of the air spaces distal to the terminal bronchiole with destruction of tissue and the absence of scarring. The key pathological change is the loss of elastic tissue and so elastic recoil, coupled with a decrease in the surface area available for gaseous exchange. The pathological change results in increased work of breathing which increases shortness of breath.
  2. Chronic Bronchitis: A disease of the airways – persistent inflammation of the airways and excessive mucous production. For a true diagnosis, a patient also must present with a cough productive of sputum on most days for three months of the year for at least two successive years. Key pathological changes include: damage to the respiratory endothelium, increased mucous production, chronic inflammation, secondary infection and lumen narrowing. Airway clearance is paramount.
  • The major risk factor for developing COPD is smoking. Childhood asthmatics are also more likely to develop COPD.

COPD Stages

Mild: This is associated with few problems with activities of daily living, and there is shortness of breath on moderate physical exertion.

Moderate: There is more limitation with activities of daily living, an increase in shortness of breath (e.g. breathlessness with walking on flat ground).

Severe: Activities of daily living become severely restricted; there is shortness of breath on minimal physical exertion.

– There is an estimated 2.1 million Australians living with some form of COPD (estimated 4 million by 2050). Many people have COPD without recognising that they have a problem, either believing that it is a normal part of ageing or it simply goes undetected.

– COPD is a lifelong and progressive condition that can greatly affect someone’s quality of life, however with the right lifestyle, exercise and other strategies, symptoms can improve, the disease progression can be slowed and quality of life can improve.

– It is imperative that people with COPD learn how to take care of their respiratory hygiene, prevent infection and other complications.

Colour of Sputum (Phlegm)

As gross as it may appear the colour of your phlegm can tell you a lot about what is happening deeper down the airways and at times can be suggestive of an underlying infection – further examination with lab testing is always recommended so see your GP if you have a change to the phlegm that you produce and cough up. Here is a rough guide as to what the colour of your phlegm may indicate:

– Clear: typically considered normal. Excessive clear sputum production can be abnormal and be present in the following cases: Pulmonary Oedema; viral respiratory tract infection; Chronic Bronchitis or Asthma.

– Yellow: due to the presence of white blood cells – suggestive of chronic inflammation, an allergy or an acute infection. May be present in Acute Bronchitis, Acute Pneumonia, Asthma.

– Green: Indicative of a chronic infection, colour caused by the breakdown of neutrophils (a white blood cell). Green colour may also be seen with chronic non-infectious inflammatory conditions. Green phlegm may be a sign of Pneumonia, a lung abscess, Chronic Bronchitis, Bronchiectasis or Cystic Fibrosis.

– Brown/black: colour due to the breakdown of red blood cells. It can also be a sign that dust has been inhaled. Patients with Chronic Bronchitis (with infection), chronic Pneumonia, TB and Lung cancer may produce phlegm of this colour.

What is RMT?

RMT applies the principles of common resistance training (strength exercises) to the inspiratory muscles. The lungs do not respond to RMT, but instead the muscles used for respiration can improve with strength and function.

Normal respiration does not challenge the inspiratory muscles to deliver performance improvements so specifically targeting these muscles with exercise can help develop control and improve the overall management of COPD.

Why RMT?

RMT is a method of conditioning for the muscles involved with normal breathing and helps to clear the airways (removal of phlegm), essentially interrupting the degenerative process of COPD.

Given people with COPD experience shortness of breath during moderate exercise they often refrain from exercise which leads to physical deconditioning and a deterioration of their respiratory muscles. This causes even more shortness of breath during mild exertion which can quickly lead to a further decline in fitness. This is the process that we now know can be better managed.

RMT is a safe and effective approach to assist quality of life in people with COPD – within the published literature there has been no complications or adverse events from RMT in 40 years of testing.

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ACBT (Active Cycle Breathing Techniques)

The goal of ACBT is to improve respiratory health by increasing self-control of breathing rate, improve the strength of the diaphragm, and increase production of mucus to clear airways and to reduce infection rates. It can also help to decrease anxiety with shortness of breath episodes. Follow these 3 simple steps:

Step 1: Relaxed breathing: hand on tummy – feel rise and fall with inspiration/expiration; shoulders stay relaxed. Breathe ‘in through the nose and out through mouth’. This step is for times when shortness of breath is a concern (e.g. coughing fit or if anxious about shortness of breath), to regain control rate of breathing. Repeat for 5 reps.

Step 2: Deep breathing: still have hand on tummy – focus on filling the tummy with breath in; hold for 3sec and slowly exhale through pursed lips (controlled exhalation).Repeat for 5 reps.

Step 3: The huff: Aim is to mobilise secretions from central bronchi so this step may result in productive cough. Instruct 3/4 breath in and hold, followed by a huff to expel air quickly. Repeat for 2-3reps. If not productive, move back to step 1 and repeat cycle.

For more information on what you can do to improve your health if you have COPD or any breathing difficulties with exercise, get in contact with a Physiotherapist or Exercise Physiologist at Coastal Physiotherapy. For an appointment call our Burnie clinic on 64314586.