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AIM: To develop and validate an evidence-based home pursed lip breathing (PLB) intervention protocol for improving related health outcomes (e.g., dyspnea and exercise capability) in patients with chronic obstructive pulmonary disease (COPD) and to present a detailed intervention development process. METHODS: This home PLB intervention protocol employed phase one of the Medical Research Council (MRC) Framework for Developing and Evaluating Complex Interventions to guide the development process of the PLB intervention. We searched for research evidence on 5 July 2023 from several databases, including PubMed, Embase (via Ovid), Cochrane Library, Google Scholar and China Biology Medicine Disk (CBM). Using the content validity index, a panel of experts assessed the appropriateness of the PLB protocol. RESULTS: We developed the preliminary home PLB intervention protocol on the basis of several underlying rationales, which encompass the extension of expiration time, enhancement of respiratory muscle strength, augmentation of tidal volume and integration of the most reliable research evidence obtained from four systematic reviews, five RCTs, five clinical trials, and 10 recommendations. We structured the PLB intervention with a designated time ratio of inspiration to expiration, set at 1:2. Additionally, this study recommends that the training parameters of the PLB intervention were as follows: three sessions per day, each lasting for 10 min, over 8 weeks. Individualised PLB training intensity adjusted the inhalation component according to each participant's tolerance level while emphasising the exhalation phase to ensure the complete expulsion of air from the lungs. The home PLB intervention protocol established strong content validity through consensus, which was reached among all panel experts. The item-level and scale-level content validity indices (CVIs) reached a maximum score of 1.0, indicating a high level of agreement and credibility in the protocol's content as evaluated by the expert panel. CONCLUSION: An optimal evidence-based home PLB protocol has been adapted and developed to manage health-related outcomes of patients with COPD. The protocol is transparent and fully supported by relevant mechanisms, concrete evidence, recommendations and experts' consensus. IMPLICATIONS FOR PRACTICE: In this study, we consulted patients with COPD about the 'Prepared Conditions Before PLB Practice', to ensure appropriate measures to prevent patients with COPD from potential risks. In addition, patients with COPD also contributed to the PLB exercise frequency distribution.

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BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) commonly experience dyspnea, which may limit activities of daily living. Pursed-lip breathing improves dyspnea for COPD patients; however, access to pursed-lip breathing training is limited. METHODS: The proposed MELodica Orchestra for DYspnea (MELODY) study will be a single-site pilot study to assess the safety, feasibility, and efficacy of a music-based approach to teach pursed-lip breathing. Patients with COPD and moderate-severe dyspnea are randomized to intervention, education-control, or usual care control groups. Intervention patients meet twice weekly for eight weeks for melodica instruction, group music-making, and COPD education. Safety, feasibility, and efficacy is assessed qualitatively and quantitatively. RESULTS: This manuscript describes the rationale and methods of the MELODY pilot project. CONCLUSIONS: If pilot data demonstrate efficacy, then a multi-site randomized control trial will be conducted to evaluate program effectiveness and implementation.

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BACKGROUND: Anxiety-related dyspnea is a compelling symptom among patients with acute heart failure (AHF). Breathing training is a nonpharmacological intervention to relieve dyspnea and anxiety. This study aimed to investigate the effects of breathing training on dyspnea and anxiety among patients with AHF at the emergency department (ED). METHODS: Two-group pre-post intervention study was conducted at the ED of one university hospital in the northeast of Thailand. Data were collected among 96 patients with AHF, which were equally assigned to breathing training (BT) and control groups. The training group received pursed-lip mindfulness breathing training, whereas the control group received usual care (UC). The pursed-lip mindfulness breathing was delivered from the first 40 min of arrival to the 4th hour in the ED. The breathing training consisted of positioning the patients in Fowler's position with the head of the bed elevated at 60 degrees or higher, supporting both arms with pillows, and breathing in through the nose with breathing out via the mouth with pursed lip while counting. Dyspnea and anxiety scores were measured with Dyspnea Visual Analog Scale and Anxiety Visual Analog Scale, respectively. RESULTS: The dyspnea and anxiety scores significantly decreased after four hours in both groups. Dyspnea score decreased from 8.85 (SD 1.220) to 3.63 (SD 1.468) after BT (t = 26.111, p < 0.001) in the experimental group whereas in the control group it decreased from 8.98 (SD 1.194) to 6.94 (SD 1.590) after UC (t = 16.181, p < 0.001). Comparing between the groups, dyspnea score reductions were 5.22 (SD 1.468) in the experimental and 2.04 (SD 1.590) in the control (t = 0.101, p < 0.001). Anxiety score decreased from 9.35 (SD 1.000) to 4.44 (SD 1.219) after BT (t = 25.231, p < 0.001) in the experimental while the scores in the control group decreased from 9.48 (SD 1.072) to 8.15 (SD 1.502) after UC (t = 8.131, p < 0.001). The anxiety score reductions were 4.91 (SD 1.219) and 1.33 (SD 1.502) in the experimental and the control groups, respectively (t = 0. 066, p < 0.001). Both the dyspnea and anxiety scores after the intervention were significantly different between the experimental and control groups. CONCLUSION: Both UC and BT with UC can reduce dyspnea and anxiety in patients admitted to ED with AHF. However, the effect of BT combined with UC was larger comparing to UC only.

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Although an important cause of vocal cord dysfunction (VCD) is psychogenic reaction, VCD may be associated with severe asthma and must be distinguished from the disease. A 30-years-old woman was admitted to our hospital with dyspnea despite treatment for asthma. Inspiratory stridor and expiratory wheezes were noted, and neck and chest computed tomography showed normal airways and lungs. Fractional exhaled nitric oxide levels were also normal. Pulmonary function test with a flow-volume loop curve showed normal expiratory loop with flattening of the inspiratory loop after methacholine inhalation. During the attack, bronchoscopy revealed the vocal cord closing with stridor during the inspiratory phase. Therefore, the patient was diagnosed with VCD. The dyspnea improved with respiratory rehabilitation and pursed-lip breathing. VCD should be considered in the differential diagnosis of intractable severe asthma. In this case, bronchoscopy and bronchial inhalation challenge with methacholine helped in the diagnosis.

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AIM: to compare anulom vilom pranayama (AVP), kapal bhati pranayama (KBP), diaphragmatic breathing exercises (DBE), and pursed-lip breathing (PLB) for breath holding time (BHT) and rating of perceived exertion (RPE). Methods- Participants were assessed for BHT and RPE, before training on any one intervention using online platforms, for one week during lockdown from COVID-19.15 participants in each group total N = 60 at- (α - 0.05), (1- ß - 0.90) & (effect size - 0.55); were analysed. Results - AVP & DBE decreased RPE (p < 0.000). KBP & PLB did not decrease RPE as compared to AVP & DBE (p. > 0.05). DBE increased BHT more than KBP & PLB interventions (p < 0.05), but not more than AVP (p > 0.05). One-way ANOVA of four interventions revealed significant variation for RPE change (p < 0.05), for AVP. Conclusions - AVP reduces RPE maximally during breath-holding, whereas DPE increases BHT more.

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BACKGROUND: Respiratory system, together with the cardiovascular and central nervous system, is responsible for all processes related to oxygenation and hemodynamics and the defect in the functioning of each of these systems, along with ageing, can have mutual effects on their performance and physiological symptoms. The use of Pursed-lips Breathing (PLB) training is an essential part of the treatment of patients with the obstructive pulmonary disease, PLB stimulates the autonomic nervous system and causes relaxation and improvement of physiological parameters. AIM: This study was conducted to evaluate the effect of PLB on cardiac, pulmonary and oxygenation level in patients with Chronic Obstructive Pulmonary Disease (COPD). METHODS: A three-group clinical trial study with experimental and control which was purposefully conducted with the participation of patients with COPD and healthy individuals referring to Madani hospital Khoy, in 2017. The sample size was selected to be 60 subjects. The patients were randomly allocated to two groups of intervention and control with 20 patients, and 20 healthy subjects were assigned to the healthy intervention group. The demographic, anthropometric information form and checklist recording changes in levels of oxygenation, respiration, temperature, heart rate and blood pressure with cardiopulmonary follow up in three stages before, during and after PLB were used for data collection. Data were analysed using descriptive statistics, repeated measure test, ANOVA, and Chi-square. RESULTS: On evaluation within the COPD patient intervention group in Saturation of Peripheral Oxygen (SPO2) index with the mean difference of 2.05 percent, Respiratory Rate(RR)-0.65 minute and Pulse Rate(PR)-1.6 bpm was significant (p ≤ 0.05), and systolic blood pressure index in healthy subjects was increased (3.35 mmHg). CONCLUSION: The results of this study indicated that using effective PLB as an easy, inexpensive, non- invasive and non-pharmacological method is considered as an important factor in improving the status of oxygenation and physiological indicators in patients with COPD and should be considered as an important part of rehabilitation programs for these patients.

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Exercise-induced laryngeal obstruction is a condition that restricts respiration during exercise via inappropriate glottic or supraglottic obstruction. The literature supports behavioral treatment provided by a speech-language pathologist as an effective means of treating exercise-induced laryngeal obstruction. Treatment includes educating the patient, training on relaxation, instruction on paced exercise, and use of various breathing techniques to optimize laryngeal aperture. Intervention for patients with exercise-induced laryngeal obstruction may be delivered by a speech-language pathologist, given their clinical skill of facilitating long-term behavioral change and expertise in the laryngeal mechanism.

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BACKGROUND: Positive expiratory pressure(PEP) breathing modalities are commonly prescribed in obstructive lung diseases, however practical methods of airway pressures(AP) quantification for therapeutic efficacy are lacking. Excessive dynamic airway collapse(EDAC) is characterized by expiratory central airway collapse leading to dyspnea and poor quality of life(QoL), with limited therapeutic options. PURPOSE: To measure AP and exertional dyspnea in EDAC patients during normal breathing and with use of pursed-lip breathing(PLB), nasal PEP device(nPEP), and oral-PEP valve(oPEP) during rest and exercise using an Esophageal Manometer. METHODS: EDAC patients exercised on a bicycle ergometer sequentially using normal breathing, PLB, nPEP, and oPEP for five-minute intervals. AP's were measured by continuous topographic upper airway manometry. Pre- and post-exercise BORG dyspnea scores were recorded and QoL measured with the St. George's respiratory questionnaire(SGRQ-C). The most effective and patient-preferred PEP modality was prescribed for daily activities and SGRQ-C repeated after one week. RESULTS: Three women with symptomatic EDAC participated. Expiratory laryngopharyngeal AP's during exercise with normal breathing, PLB, nPEP and oPEP in patient-1 were 1.7, 14, 4.5, and 7.3 mmHg, in patient-2; 2.3, 8, 8.3, and 12 mmHg, and in patient-3; 1, 15, unobtainable, and 9 mmHg, respectively. Maximal reduction in BORG scores occurred with PLB in patient 1 and with oPEP in patients 2 and 3. After 1 week mean SGRQ-C scores declined by 17-points. CONCLUSIONS: Upper airway manometry directly measures laryngopharyngeal pressures during rest and exercise and can be used to select and optimize PEP breathing techniques to improve respiratory symptoms in EDAC patients.

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[Purpose] The purpose of this study is to examine the effects of inspiratory diaphragm breathing exercise and expiratory pursed-lip breathing exercise on chronic stroke patients' respiratory muscle activation. [Subjects and Methods] All experimental subjects performed exercises five times per week for four weeks. Thirty chronic stroke patients were randomly assign to an experimental group of 15 patients and a control group of 15 patients. The experimental group underwent exercises consisting of basic exercise treatment for 15 minutes and inspiratory diaphragm breathing exercise and expiratory pursed-lip breathing exercise for 15 minutes and the control group underwent exercises consisting of basic exercise treatment for 15 minutes and auto-med exercise for 15 minutes. The activation levels of respiratory muscles were measured before and after the experiment using MP 150WSW to obtain the results of the experiment. [Results] In the present study, when the pulmonary functions of the experimental group and the control group before and after the experiment were compared, whereas the experimental group showed significant differences in all sections. In the verification of intergroup differences between the experimental group and the control group before and after the experiment. [Conclusion] The respiratory rehabilitation exercise is considered to be capable of inducing positive effects on stroke patients' respiratory muscles through diaphragm breathing exercise and lip puckering breathing exercise.

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Objective To test the clinical effects of the expiration control device with mask in the treat-ment of chronic obstructive pulmonary disease. This device developed by the author. Methods A total of 102 pa-tients were treated by the device. Among them ,50 patients received positive end-expiratory pressure and 52 with expiratory flow retard and blocked function. Differences in carbon dioxide partial pressure(PaCO2),oxygen partial pressure(PaO2)and pH of the arterial blood gas analysis were compared ,as well as differences in forced vital ca-pacity(FVC),forced expiratory volume for1 sec(FEV1),tidal volume(VT)of pulmonary function before and af-ter treatment. Results (1) In the positive end-expiratory pressure group ,there were significant differences of FVC,FEV1 and VT before and after treatment(2.95 ± 0.32)L vs(3.22 ± 0.35)L,(1.88 ± 0.17)L vs(2.00 ± 0.15)L,(335.28 ± 43.59)mL vs(364.64 ± 44.28)mL,(P<0.01)differences of PaCO2,PaO2 and pH before and after treatment had statistical significance(50.42 ± 4.77)mmHg vs(48.42 ± 3.76)mmHg,(65.42 ± 4.60)mmHg vs (68.50 ± 4.69)mmHg,(7.35 ± 0.030)vs(7.37 ± 0.037)(P<0.05).(2)In the expiratory flow retard and blocked group,differences of FVC,FEV1andVT before and after treatment had statistical significance(2.93 ± 0.22)L vs (3.10 ± 0.27)L,(1.83 ± 0.14)L vs(1.91 ± 0.16)L,(335.48 ± 44.16)mL vs(362.46 ± 38.66)mL(P<0.05), differences of PaCO2,PaO2 and pH before and after treatment had statistical significance(52.39 ± 3.37)mmHg vs (50.06 ± 3.92)mmHg,(68.05 ± 3.80)mmHg vs(68.99 ± 4.57)mmHg,(7.34 ± 0.035)vs(7.37 ± 0.036)(P<0.05). Conclusion This device can improve the ventilation function in patients with COPD. It is easy to use ,safe and effective,with high clinical application value.

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BACKGROUND: Unidirectional breathing (UB), nose-in mouth-out (NMB) or vice versa, is thought to create PEEP, stabilize small airways, and increase expiratory flow and exhaled tidal volume (VT) in patients with expiratory obstructive disorders. However, the exact mechanism providing the benefits of UB remains unknown. Our hypothesis was that the benefits of UB are achieved mainly through reduction of upper airway dead space. METHODS: Sixteen stable COPD patients requiring oxygen use at home were enrolled in this prospective study at a tertiary health care center. A nasal mask and a mouthpiece were used, each having a removable one-way valve to direct the breathing pattern. Four experimentally defined patterns of spontaneous breathing, NMB, mouth-in nose-out (MNB), nose-in nose-out (NNB), and mouth-in mouth-out (MMB), were compared. Each breathing pattern lasted 5 min followed by a 5-min rest period. A NICO device continuously monitored respiratory parameters. The functional anatomical dead space volume (VD) and expired VT values were determined. Breathing efficiency (BE) was calculated as alveolar VT divided by expired volume. RESULTS: Functional anatomical VD was higher in bidirectional breathing (BB) (overall: 207.4 ± 7.9 mL; MMB: 232.5 ± 72.7 mL; NNB: 182.2 ± 75 mL) compared to UB (overall: 178.1 ± 87.2 mL; NMB: 176.9 ± 91.3 mL; MNB: 179.3 ± 83.2 mL) (P < .001). BE achieved with UB (overall: 76.2 ± 6.5%; NMB: 76.8 ± 6.8%; MNB: 75.6 ± 6.3%) was higher than that with BB (overall: 66.2 ± 0.09%; MMB: 64.3 ± 0.10%; NNB: 68.1 ± 0.08%) (P < .001). The difference in BE between UB and BB was more pronounced with small VT values (UB: 73.8 ± 0.08; BB: 49.4 ± 0.09) than with large VT values (UB: 77.3 ± 0.06; BB: 63.0 ± 0.07) (P < .001). CONCLUSIONS: Our data suggest that a reduction in functional anatomic VD may be the underlying mechanism for the benefits associated with UB in COPD patients. (ClinicalTrials.gov registration NCT00784004.).

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PURPOSE: Most patients with chronic obstructive pulmonary disease (COPD) complain of dyspnea during and following exercise, and the development of intrinsic positive end-expiratory pressure (PEEP) is thought to contribute to lung hyperinflation and dyspnea. Many people with COPD use pursed lip breathing (PLB) in an attempt to produce extrinsic PEEP to reduce lung hyperinflation and dyspnea during and following exertion. We hypothesized that the use of a threshold, extrinsic PEEP device would reduce post-exercise dyspnea in people with COPD. METHODS: A double blind, crossover study was conducted on post-exercise dyspnea in 8 patients with COPD whose exercise tolerance was limited by dyspnea. Subjects performed two identical 6-minute treadmill bouts that led to a Borg dyspnea rating of at least 5/10. Dyspnea, heart rate, and oxygen-hemoglobin saturation (SpO(2)) were recorded at rest, every 2 minutes during exercise and at 2, 5, and 10 minutes post-exercise. Immediately following the exercise bouts, the subjects used either a threshold PEEP device for 6 breaths at 10 cm H(2)O or a Sham device. RESULTS: Heart rate and SpO(2) were not different between treatments any time point before, during, or after exercise. Dyspnea ratings were not different between devices at rest or during exercise, but were lower in the post-exercise period following use of PEEP (p < 0.05). When asked which device, if any, the subjects would prefer to use to relieve post-exercise dyspnea, 7 of 8 chose the PEEP device and one had no preference. CONCLUSIONS: We found that the use of a PEEP device can help reduce postexercise dyspnea in patients with COPD.

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OBJECTIVES: To assess the effects of pursed-lip breathing (PLB) at rest on the behavior of heart rate (HR) and its variability, and on variations in blood pressure (BP), respiratory rate (RR) and pulse oxygen saturation (SpO2) in subjects with chronic obstructive pulmonary disease (COPD). METHODS: Sixteen subjects with COPD (seven in GOLD stage I, three in GOLD stage II and six in GOLD stage III; mean age 64±11 years; mean FEV1 60±25 percent of predicted value) were assessed at rest, in a seated position, under the following conditions: ten minutes of normal breathing without PLB (R1), eight minutes with PLB (R2) and ten minutes of normal breathing once more (R3). HR was recorded, beat-to-beat, by means of a Polar S810 heart monitor. The RMSSD index (root mean square of the difference between successive R-R intervals) was determined. BP, RR and SpO2 were also assessed during the trials. ANOVA for repeated measures followed by the Tukey test and Kruskal-Wallis test were used for data analysis, with a 5 percent significance level. RESULTS: There was a significant increase in the RMSSD index during R2, in comparison with R1. The HR variation between inspiration and expiration was 8.98 bpm, and the variation between HR at rest and HR with PLB was 8.25 bpm. During R2, RR decreased and SpO2 increased significantly in comparison with R1 and R3. BP values did not show significant changes. CONCLUSIONS: The results showed that PLB produced significant changes in HR, RR and SpO2, and did not alter BP in subjects with COPD. Furthermore, analysis of the RMSSD index showed that PLB promoted increased parasympathetic activity in these subjects, thus indicating that this technique influenced the autonomic cardiac modulation.

OBJETIVOS: Avaliar os efeitos da respiração freno-labial (RFL), em repouso, sobre o comportamento da frequência cardíaca (FC) e sua variabilidade e variações na pressão arterial (PA), frequência respiratória (FR) e saturação parcial de oxigênio (SpO2) em pacientes com doença pulmonar obstrutiva crônica (DPOC). MÉTODOS: Dezesseis pacientes com DPOC (7: estágio GOLD I, 3: estágio GOLD II e 6: estágio GOLD III; média de idade=64±11; média de VEF1=60±25 por cento do predito) foram avaliados em repouso, na posição sentada, nas seguintes condições: 10 minutos respirando normalmente sem RFL (R1), 8 minutos com RFL (R2) e 10 minutos respirando novamente normalmente (R3). A FC foi registrada, batimento a batimento, por meio do frequencímetro Polar S810, e o índice RMSSD (raiz quadrada da média das diferenças entre intervalos RR sucessivos) foi determinado. PA, FR e SpO2 foram também avaliados durante o protocolo. ANOVA para medidas repetidas, seguida pelo teste de Tukey e teste de Kruskal-Wallis foram usados para análise dos dados, com nível de significância de 5 por cento. RESULTADOS: Ocorreu aumento significante no índice RMSSD durante R2 em comparação com R1. A variação na FC inspiração/expiração foi de 8,98 bpm, e a variação na FC em repouso/RFL foi de 8,25 bpm. Durante R2, FR diminuiu e SpO2 aumentou significativamente em comparação a R1 e R3. Os valores de PA não apresentaram modificações significativas. CONCLUSÕES: Os resultados mostraram que a RFL produziu modificações significativas na FC, FR e SpO2 e não alterou a PA em pacientes com DPOC. Além disso, a análise do índice RMSSD mostrou que a RFL promoveu aumento da atividade parassimpática nesses pacientes, indicando que essa técnica influencia a modulação autonômica cardíaca.