Targeted Breathing Exercises for Covid 19 Recovery

Handheld Therapy Devices & Breathing Exercises for Covid 19 Related Breathing Issues

Author: Rachel Powell; RRT,

Note: Any cardiopulmonary rehab plan should be discussed with your physician before initiation, including these exercises. These exercises are meant as an educational guide to discuss with your primary care physician or pulmonologist.

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After contracting the Covid 19 virus, it may become difficult or impossible to take normal sized breaths.

Your chest and ribs are already sore.
You CANNOT stop coughing.
You get EXHAUSTED just trying to breathe or complete normal activities, even using the restroom.

What is happening?

As your immune system fights the Covid 19 virus, inflammation (swelling) of your lung tissue and airways can make it difficult to breathe in, out, or both.

Why?

The fluid and mucus take up space in the lungs and become an obstacle when trying to breathe in and out.

Frequent coughing is exhausting, especially if mucus is not being expelled as a result.

Here is an example.

Have you ever had a blister? Think about this…

Fluid builds up under a blister to protect the skin from friction & irritation.
In the very same way, fluid and mucus builds up inside your lungs from the irritation of the Covid 19 virus.
The lungs do not like the mucus, and it triggers the cough reflex.

The fluid and mucus then take up space in the lungs and are an obstacle when trying to breathe in and out.

Frequent coughing is exhausting, especially if mucus is not being expelled as a result.

Breathing is supported by a special group of muscles; located between your ribs, across your chest, back, and abdomen. When you cannot take a normal sized breath, these muscles do not provide good chest or lung expansion.

Over time, your breaths become smaller and smaller. This causes you to breathe faster to keep up with the body’s increasing oxygen demand. If this pattern continues, the lower portions of your lungs can become collapsed and unable to conduct gas exchange.

This consolidation is called atelectasis and must be reversed as soon as possible to avoid severe lung problems.

What does this all mean?

While you are healing from Covid 19, it is important to keep your respiratory muscles exercised to avoid future problems with lung expansion, like atelectasis. By using Thera-PEP, Vibratory PEP, and Incentive Spirometry devices; you will properly support your breathing and produce an effective cough to remove mucus. This speeds healing and strengthens your respiratory muscles during the recovery process; and allows you to expand your chest and lungs more effectively.

Self-Assessment for Respiratory Handheld devices.

Good day from your friendly respiratory therapist.

Question 1: Is it difficult for you to take a breath in? If NO, go to question 2.

If YES: You might want to consider an incentive spirometer.

Question 2: Is it difficult for you get a breath out? If NO, go to question 3.

If YES: “You might want to consider a Thera-PEP or Flutter Valve.

You should use the flutter valve if you have trouble coughing up secretions.

Question 3: Both breathing in and out are difficult.

If YES: “You might want to consider an incentive spirometer and a Flutter Valve.

You should also use the flutter valve if you have trouble coughing up secretions.

Results

Problem Area

Appropriate Device

Inspiration muscles (trouble breathing in)

Incentive Spirometer

Expiration muscles (trouble breathing out)

Thera-PEP, Flutter Valve

Both (Trouble breathing in and out)

Incentive Spirometer & Thera-PEP

Trouble removing secretions during a cough

Flutter Valve

Use of your Thera-PEP Device

Primary Goal: Strengthen expiratory muscles to combat shortness of breath (dyspnea) and promote

healthy lung expansion

Therapy may be most effective when completed after a MD ordered breathing treatment (Inhaler/Nebulized) Albuterol Sulfate, Ipratropium Bromide.

Cap Plunger Tubing Mouthpiece Resistance dial

This therapy is best performed while in a tall, sitting position with your feet placed flat on the floor. It also can be performed while standing or positioned in bed at a 45-degree angle. These positions allow for optimal chest expansion and recoil during sessions. Lying flat on your back (supine), abdomen (prone), or your sides is not recommended during therapy without the instruction of a respiratory therapist.

Step 1: Look at the resistance dial and turn it slowly clockwise to the number 6.

(Be aware that 1 is the most difficult, and 6 is the easiest.)

Step 2: Hold the mouthpiece in one hand and place it between your lips; creating a seal.
Step 3: Hold the opposite end of the Thera-PEP in your other hand; and view the 2 horizontal black lines on the transparent chamber. Inside is a blue plunger.
Step 4: Inhale slowly (Breathe in). Then exhale slowly (breathe out) into the mouthpiece and watch the plunger rise. Try to keep the plunger between the two black lines for 3 seconds during exhalation. You should feel resistance as you exhale.
Step 5: Repeat the exhalation 5 to 10 times in a sequence. This equals one cycle. Repeat the cycle every hour while awake.

If the exercise seems overly simple, increase the resistance by moving the dial to the next lowest number. Example: from 6 to 5.

If the exercise is overly difficult, decrease the resistance to the next highest number. Example: 5 to 6. If dial is already on the lowest level, exhale more slowly during use.

Note: Performing this therapy may cause begin coughing, producing oral secretions, or have spasms in your accessory muscles (hiccups). These results should be temporary and decrease after multiple sessions of therapy due to muscle conditioning. Take breaks between breaths if it becomes bothersome.

Challenge yourself! Consider these exercises like a workout and transition your body position from a seated to a standing position after several uses. Avoid leaning on the back of the chair or bed during therapy.

Cleaning: Thera-PEP device mouthpiece should be cleaned with an alcohol or disinfecting wipe after use. Please do not share your Thera-PEP device with others to avoid the spread of pathogens.

Use of your Vibratory PEP/ Flutter Valve

Primary Goal: Remove respiratory secretions by producing an effective cough

Secondary Goal: Strengthen expiratory muscles to combat shortness of breath and healthy lung expansion. Therapy should be completed after use of a MD ordered breathing treatment (MDI/nebulized Albuterol Sulfate, Ipratropium Bromide)

mouthpiece valves expiratory filter resistance dial

This therapy is best performed while in a tall, sitting position with your feet placed flat on the floor. It also can be performed while standing or positioned in bed at a 45-degree angle. These positions allow for optimal chest expansion and recoil during sessions. Lying flat on your back (supine), abdomen (prone), or your sides is not recommended during therapy without the instruction of a respiratory therapist.

Step 1: Locate the resistance dial on the back of the device. Turning the dial towards the plus sign will increase the difficulty.
Step 2: Hold the Vibratory PEP device in one hand and place the mouthpiece between your lips; creating a seal.
Step 3: Inhale slowly (Breathe in). Then exhale slowly (breathe out) into the mouthpiece. You should hear the valves turning, which should vibrate your chest wall during use. You should feel resistance as you exhale.

Step 4: Repeat the exhalation 5 to 10 times in a sequence. This equals one cycle. Repeat the cycle every hour while awake.

Step 5: If a cough is not produced after one cycle, complete another cycle immediately with increased resistance.

If the exercise seems overly simple, increase the resistance by moving the dial to towards the plus sign.

If the exercise is overly difficult, decrease the resistance by turning it towards the minus sign. If dial is already on the lowest level, exhale more slowly during use.

Note: Performing this therapy may cause begin coughing, producing oral secretions, or have spasms in your accessory muscles (hiccups). These results should be temporary and decrease after multiple sessions of therapy due to muscle conditioning. Take breaks between breaths if it becomes bothersome.

Challenge yourself! Consider these exercises like a workout and transition your body position from a seated to a standing position after several uses. Avoid leaning on the back of the chair or bed during therapy.

Cleaning: Vibratory PEP mouthpiece should be cleaned with an alcohol or disinfecting wipe after use. Please do not share your Thera-PEP device with others to avoid the spread of pathogens.

Use of your Incentive Spirometry Device

Primary Goal: To strengthen inspiratory muscles to combat shortness of breath and promote healthy lung expansion. Therapy most effective when completed after a breathing treatment (Inhaler/Nebulized) Albuterol Sulfate, Ipratropium Bromide) if prescribed by your primary care physician.

Base Volume Markers Goal Marker Corrugated Tubing Mouthpiece

This therapy is best performed while in a tall, sitting position with your feet placed flat on the floor. It also can be performed while standing or positioned in bed at a 45-degree angle. These positions allow for optimal chest expansion and recoil during sessions. Lying flat on your back (supine), abdomen (prone), or your sides is not recommended during therapy without the instruction of a respiratory therapist.

Step 1: Hold the base in one hand and mouthpiece with the opposite hand.

Step 2: Place the mouthpiece between your lips; creating a seal.

Step 3: Inhale slowly for 3 to 5 seconds (Breathe in) watch the float rise.

Try to keep the yellow ball in the center during the breath.

Step 4: Let the float fall back to zero before the next attempt.

Step 5: Repeat the exhalation 5 to 10 times in a sequence. This equals one cycle. Repeat the cycle every hour while awake.

Step 6: Use the goal mark to identify the average volume of your 10 attempts. Increase your goal daily.

Note: You cannot use this device for exhalation! (breathing out). It will not work.

Note: The goal is NOT to get the highest volume!!! Repetition is the key, and the technique of inhaling slowly will bring the best results for you. Your volumes will increase as you progress and heal.

Consider: An athlete lifting a small weight multiple times will have better strength and flexibility than someone lifting a large weight one time.

Note: Performing this therapy may cause begin coughing, producing oral secretions, or have spasms in your accessory muscles (hiccups). These results should be temporary and decrease after multiple sessions of therapy due to muscle conditioning. Take breaks between breaths if it becomes bothersome.

Challenge yourself! Consider these exercises like a workout and transition your body position from a seated to a standing position after several uses. Avoid leaning on the back of the chair or bed during therapy.

Cleaning: Incentive Spirometer mouthpiece should be cleaned with an alcohol or disinfecting wipes after use. Please do not share your device with others to avoid the spread of pathogens.

Respiratory Breathing Techniques

for Combating Dyspnea from Covid 19.

For patients that have respiratory symptoms from Covid 19; body positioning, pursed lip breathing techniques, abdominal targeted breathing, and directed coughing are essential tools to relieving dyspnea (shortness of breath) during recovery.

Patients may feel that their breathing is controlled if they restrict their movements and remain in bed or seated.

THIS IS NOT RECOMMENDED.

Being stationary may delay your recovery and even cause future health issues!

The goal of Covid 19 respiratory therapy is to get you back to your daily routine without shortness of breath. Restricting movement alone will not make this goal possible.

While your amazing immune system is currently warring like a gladiator against the Covid 19 virus army, your cardiopulmonary system is currently working overtime to keep your organ systems functioning.

Imagine if you will, a truck revving up the engine to speed away from a dangerous situation.

Just as that truck will burn more fuel as it increases speed, your body will consume and require more oxygen to sustain you as it works to fight the Covid 19 virus.

Because your oxygen needs are increased, you may immediately feel lightheaded or short of breath upon standing or moving. You may have been given oxygen to use at home.

Don’t panic.

Consider the following:

You are much less mobile at this moment than before you had Covid 19 symptoms
Your symptoms are causing you to take smaller breaths to avoid coughing or pain
Your need for oxygen may be increased because your immune system is busy fighting the virus. This alone may temporarily increase your heart rate, blood pressure, and breathing rate.

Understand that you may become short of breath as you begin these exercises. This is a scary thought.

But by strengthening your respiratory muscles, you will begin to counteract this problem. Do not let your fear of being winded temporarily stop the goal of improving your breathing for the long term!

Food for thought.

In physical therapy, muscles around the injured area are strengthened and stretched with a series of progressive exercises. This process takes the stress off the injury and allows for added support as while the area heals.

In respiratory therapy, we strengthen the muscle groups around the chest, back, and abdomen with targeted exercises to support the work of breathing. This effort conditions the muscles to work more efficiently, allowing better air movement to the lungs.

Stronger respiratory muscles = reduced work of breathing

Ready to go to work?

Body Positioning for Breathing Exercises

Body positioning is vital for achieving optimal results from your breathing exercises. You may choose the best one for you upon starting the exercises.

Seated: A tall, seated position in a chair or bed with your feet placed flat on the floor (do not lean on the back of the chair!)
Standing: A standing position with your shoulders back and feet apart (no slouching)
Positioned in bed at a 45-degree angle with your legs extended forward
Supine: Lying flat on your back with your legs extended forward
Prone: Lying flat on your chest and abdomen face down with your legs extended.

IMPORTANT!

Prone position can be useful for patients that have difficulty with low oxygen levels, because it allows gravity to promote better blood flow to the lungs and promote better gas exchange.

This is not recommended for patients that have untreated hypertension, nausea, reflux, artificial airways, or IV access ports, tubes, or lines on the chest / abdomen! Doing this can lead to an emergency situation

Pursed Lip Breathing (Type 1)

Pursed lip breathing is a technique used to increase your ability to exhale more completely. Pursed lip is taught to patients for management of COPD (Chronic Obstructive Pulmonary Disease) issues but is also used to manage Covid 19 dyspnea.

Step 1: Inhale slowly through your nose with your mouth closed.
Step 2: Pucker your lips (tighten them as if you are going to whistle)
Step 3: Breathe out (exhale) slowly through your mouth with pursed lips and keep exhaling until most of the breath is gone.

Note: Inhaling takes a much shorter time than exhaling. Be patient with the process, because you are retraining your brain!

Repeat Step 1 Continue the pursed lip breathing for about 1 to 2 minutes at a time.

Pursed Lip Breathing (Type 2: Pulsating Exhalation)

Pursed lip breathing is a technique used to increase your ability to exhale more completely. Pulsating Exhalation is a breathing exercise like Lamaze, used for pregnancy during labor and delivery to prevent hyperventilation (breathing too fast). It is also used to manage Covid 19 dyspnea.

Step 1: Inhale slowly through your nose with your mouth closed.
Step 2: Pucker your lips (tighten them as if you are going to whistle)
Step 3 Breathe out (exhale) slowly through your mouth with pursed lips
Step 4: Pulsate your breath as you exhale (chug like a train), as many times as you need until the breath is gone.

Repeat step 1. Continue the pursed lip breathing for about 1 to 2 minutes at a time.

Abdominal Targeted Breathing with Arm Butterflies

Primary goal: Provide chest, rib cage, and lung expansion by engaging large muscle groups to promote better lung volumes and prevent lower lobe consolidation (atelectasis)

Secondary Goal: Strengthen respiratory muscles to reverse dyspnea at rest and during exertion.

This exercise should be performed while lying on your back (supine) with your arms extended out to your sides (like a letter t) with the palms of your hands flat. Note: Do not perform this exercise if you are nauseated or cannot lie supine without difficulty.

Step 1: Inhale (breathe in) through your nose for 8 seconds and allow your diaphragm to expand. Your abdomen should be visibly expanded.
Step 2: As you inhale, raise your arms in a “C” shape until your hands touch at the fingertips.
Step 3: Hold the breath for 3 seconds and slowly purse your lips as you exhale (breathe out) through your mouth until all the air is gone. (This step may take longer than you anticipate!)
Step 4: As you exhale, lower your arms back to your sides until they are extended out to your sides like a “t”. Your upper chest should be pushed upward upon completion.

Repeat this exercise 5 to 10 times every 2 hours while awake.

Note: You may have involuntary coughing occur during this exercise but attempt to continue if possible.

If the arm butterflies are too difficult, complete only the abdominal breathing portion of the exercise with your arms extended out by your sides. You can always add the arm butterflies after you gain more strength.

Directed Huff Coughing

Although coughing is probably the last thing you wish to do, you need to have the ability to do it for effective mucus and secretion removal from your lungs and airways. Otherwise, the mucus will remain in your chest and continue to irritate the airways; or worse, become infected.

Huff coughing is a technique taught to patients with COPD, Cystic Fibrosis, and other pulmonary issues that require extra effort to remove secretions. It is useful for Covid 19 patient that have difficulty coughing.

Best Body position: Seated: A tall, seated position in a chair or bed with your feet placed flat on the floor.

Step 1: Place a pillow on your lap and hold it loosely with your forearms.
Step 2: Inhale slowly through your nose and mouth
Step 3: Lean forward and breath out (exhale) quickly while making a “Huff” sound in your throat
Step 4: Clutch the pillow to your chest and abdomen to support your respiratory muscles

Repeat steps 1 to 4 until you can cough up any secretions that might be in your airways.

Note: Please call your physician immediately if you cough up blood during this exercise, or if coughing is too painful to continue.

Author: Rachel Powell; Registered Respiratory Therapist, Cardiopulmonary Rehabilitation Certified

Targeted Breathing Exercises for Covid 19 Recovery

Handheld Therapy Devices & Breathing Exercises for Covid 19 Related Breathing Issues

Author: Rachel Powell; RRT,

After contracting the Covid 19 virus, it may become difficult or impossible to take normal sized breaths.

Your chest and ribs are already sore.

You CANNOT stop coughing.

You get EXHAUSTED just trying to breathe or complete normal activities, even using the restroom.

What is happening?

As your immune system fights the Covid 19 virus, inflammation (swelling) of your lung tissue and airways can make it difficult to breathe in, out, or both.

Why?

The fluid and mucus take up space in the lungs and become an obstacle when trying to breathe in and out.

Frequent coughing is exhausting, especially if mucus is not being expelled as a result.

Here is an example.

Have you ever had a blister? Think about this…

Fluid builds up under a blister to protect the skin from friction & irritation.

In the very same way, fluid and mucus builds up inside your lungs from the irritation of the Covid 19 virus.

The lungs do not like the mucus, and it triggers the cough reflex.

The fluid and mucus then take up space in the lungs and are an obstacle when trying to breathe in and out.

Frequent coughing is exhausting, especially if mucus is not being expelled as a result.

Breathing is supported by a special group of muscles; located between your ribs, across your chest, back, and abdomen. When you cannot take a normal sized breath, these muscles do not provide good chest or lung expansion.

Over time, your breaths become smaller and smaller. This causes you to breathe faster to keep up with the body’s increasing oxygen demand. If this pattern continues, the lower portions of your lungs can become collapsed and unable to conduct gas exchange.

This consolidation is called atelectasis and must be reversed as soon as possible to avoid severe lung problems.

What does this all mean?

Self-Assessment for Respiratory Handheld devices.

Good day from your friendly respiratory therapist.

Question 1: Is it difficult for you to take a breath in? If NO, go to question 2.

If YES: You might want to consider an incentive spirometer.

Question 2: Is it difficult for you get a breath out? If NO, go to question 3.

If YES: “You might want to consider a Thera-PEP or Flutter Valve.

You should use the flutter valve if you have trouble coughing up secretions.

Question 3: Both breathing in and out are difficult.

If YES: “You might want to consider an incentive spirometer and a Flutter Valve.

You should also use the flutter valve if you have trouble coughing up secretions.

Problem Area

Appropriate Device

Use of your Thera-PEP Device

Primary Goal: Strengthen expiratory muscles to combat shortness of breath (dyspnea) and promote

healthy lung expansion

Therapy may be most effective when completed after a MD ordered breathing treatment (Inhaler/Nebulized) Albuterol Sulfate, Ipratropium Bromide.

Step 1: Look at the resistance dial and turn it slowly clockwise to the number 6.

(Be aware that 1 is the most difficult, and 6 is the easiest.)

Step 2: Hold the mouthpiece in one hand and place it between your lips; creating a seal.

Step 3: Hold the opposite end of the Thera-PEP in your other hand; and view the 2 horizontal black lines on the transparent chamber. Inside is a blue plunger.

Step 4: Inhale slowly (Breathe in). Then exhale slowly (breathe out) into the mouthpiece and watch the plunger rise. Try to keep the plunger between the two black lines for 3 seconds during exhalation. You should feel resistance as you exhale.

Step 5: Repeat the exhalation 5 to 10 times in a sequence. This equals one cycle. Repeat the cycle every hour while awake.

If the exercise seems overly simple, increase the resistance by moving the dial to the next lowest number. Example: from 6 to 5.

If the exercise is overly difficult, decrease the resistance to the next highest number. Example: 5 to 6. If dial is already on the lowest level, exhale more slowly during use.

Note: Performing this therapy may cause begin coughing, producing oral secretions, or have spasms in your accessory muscles (hiccups). These results should be temporary and decrease after multiple sessions of therapy due to muscle conditioning. Take breaks between breaths if it becomes bothersome.

Challenge yourself! Consider these exercises like a workout and transition your body position from a seated to a standing position after several uses. Avoid leaning on the back of the chair or bed during therapy.

Cleaning: Thera-PEP device mouthpiece should be cleaned with an alcohol or disinfecting wipe after use. Please do not share your Thera-PEP device with others to avoid the spread of pathogens.

Primary Goal: Remove respiratory secretions by producing an effective cough

Secondary Goal: Strengthen expiratory muscles to combat shortness of breath and healthy lung expansion. Therapy should be completed after use of a MD ordered breathing treatment (MDI/nebulized Albuterol Sulfate, Ipratropium Bromide)

Step 1: Locate the resistance dial on the back of the device. Turning the dial towards the plus sign will increase the difficulty.

Step 2: Hold the Vibratory PEP device in one hand and place the mouthpiece between your lips; creating a seal.

Step 3: Inhale slowly (Breathe in). Then exhale slowly (breathe out) into the mouthpiece. You should hear the valves turning, which should vibrate your chest wall during use. You should feel resistance as you exhale.

Step 4: Repeat the exhalation 5 to 10 times in a sequence. This equals one cycle. Repeat the cycle every hour while awake.

Step 5: If a cough is not produced after one cycle, complete another cycle immediately with increased resistance.

If the exercise seems overly simple, increase the resistance by moving the dial to towards the plus sign.

If the exercise is overly difficult, decrease the resistance by turning it towards the minus sign. If dial is already on the lowest level, exhale more slowly during use.

Note: Performing this therapy may cause begin coughing, producing oral secretions, or have spasms in your accessory muscles (hiccups). These results should be temporary and decrease after multiple sessions of therapy due to muscle conditioning. Take breaks between breaths if it becomes bothersome.

Challenge yourself! Consider these exercises like a workout and transition your body position from a seated to a standing position after several uses. Avoid leaning on the back of the chair or bed during therapy.

Cleaning: Vibratory PEP mouthpiece should be cleaned with an alcohol or disinfecting wipe after use. Please do not share your Thera-PEP device with others to avoid the spread of pathogens.

Primary Goal: To strengthen inspiratory muscles to combat shortness of breath and promote healthy lung expansion. Therapy most effective when completed after a breathing treatment (Inhaler/Nebulized) Albuterol Sulfate, Ipratropium Bromide) if prescribed by your primary care physician.

Step 1: Hold the base in one hand and mouthpiece with the opposite hand.

Step 2: Place the mouthpiece between your lips; creating a seal.

Step 3: Inhale slowly for 3 to 5 seconds (Breathe in) watch the float rise.

Try to keep the yellow ball in the center during the breath.

Step 4: Let the float fall back to zero before the next attempt.

Step 5: Repeat the exhalation 5 to 10 times in a sequence. This equals one cycle. Repeat the cycle every hour while awake.

Step 6: Use the goal mark to identify the average volume of your 10 attempts. Increase your goal daily.

For patients that have respiratory symptoms from Covid 19; body positioning, pursed lip breathing techniques, abdominal targeted breathing, and directed coughing are essential tools to relieving dyspnea (shortness of breath) during recovery.

Patients may feel that their breathing is controlled if they restrict their movements and remain in bed or seated.

THIS IS NOT RECOMMENDED.

Being stationary may delay your recovery and even cause future health issues!

The goal of Covid 19 respiratory therapy is to get you back to your daily routine without shortness of breath. Restricting movement alone will not make this goal possible.

Because your oxygen needs are increased, you may immediately feel lightheaded or short of breath upon standing or moving. You may have been given oxygen to use at home.

Don’t panic.

Consider the following:

You are much less mobile at this moment than before you had Covid 19 symptoms

Your symptoms are causing you to take smaller breaths to avoid coughing or pain