by Charlotte Wells, Specialist Paediatric Respiratory Physiotherapist, Royal Brompton & Harefield NHS Foundation Trust
You may have seen a physio if you have had a bad back, after an operation or if you injured yourself playing sports……but have you heard of physiotherapy for your breathing?
How we breathe can change during life, particularly in teenagers and children with asthma or anxiety (or both!). How we breathe then changes how breathless we feel and can make asthma symptoms a whole lot worse. How you breathe, or your breathing pattern, can cause chest pain, breathing difficulty, or can make your breathing feel out of control.
While all of these may sound really similar to symptoms of asthma, changes in your breathing pattern are known to be ‘ great mimics’ of asthma (as well as other conditions) and people come to see me after having all sorts of tests for their lungs, hearts and brains that have come back normal.
Changes in breathing patterns have been shown to be linked with worse asthma symptom control, anxiety levels, more unplanned visits to the GP or A&E because the symptoms of breathing pattern changes feel and look like asthma. Physio can help children (and adults) with asthma work out how to tell the difference and help with breathing retraining.
“But surely my body knows how to breathe without help!”
I like to think of our brains as a very fancy computer and the breathing centre in our brain as a particular programme. It is special because most of the time we don’t have to think about breathing – it just happens, just like we don’t have to tell our hearts to beat or our tummy to digest food. It is on autopilot. But if we want to, we can change how we breathe, like when we have to do peak flows or take our inhalers, we can make our breath bigger, smaller, faster and slower.
Sometimes in people with (and without) asthma, their breathing programme changes and gets reprogrammed. It might be after a bad asthma attack, or something happening in our lives. So, the brain tells the body, rather than breathing quietly through our nose and down to our lower ribs, that we should breathe through our mouths to the top of our chests, and this feels normal and natural. BUT breathing like this is actually unhelpful for our bodies and makes our breathing symptoms worse.
Signs of a changed breathing pattern
Some easy ways to start to look for changes in breathing patterns, which might be making your asthma worse are:
|Changed breathing pattern||Good breathing pattern|
|Breathing through your mouth (or combination of nose and mouth)||Nose breather|
|Regular sighing, yawning or deeper breaths||Regular gentle rhythm to breathing|
|Breathing to the top of your chest||Breathing to the bottom of your chest|
|You can hear the breath in or out – faster noisy breathing||Slow silent breathing|
|Breath IN is longer than breath OUT||Breath OUT is longer than breath IN|
|Juddery breaths or breath-holding||Flowing breath where one breath is similar to the next|
|Tummy muscles tight||Tummy muscles relaxed|
You may have one, two or all of the things in the table to work on. However, just work on one thing at a time.
Sit in front of a mirror and place one hand around you (like you are giving yourself a hug) and the other on the top of your chest like this
Set a timer for 2 minutes and watch and feel your breathing (or the breathing of your child or patient). Ask yourself these questions:
- Am I breathing through my nose or mouth?
- Can I hear my breathing? Is it loud, quiet or is it silent?
- Am I breathing to the top of my chest or down to my tummy and lower ribs?
- Is there a gentle rhythm to my breathing? Like waves on a beach with a calm sea or a stormy sea?
- How am I sitting or standing? Are my shoulders round? Is my chin forward? Can I sit up straight with my chin in and shoulders back?
Here is a link to a video I made showing some different types of breathing patterns. Can you recognise any that you might do?
Now that you have answered those questions, you can start working on your breathing. This is what you ‘should’ be doing:
- Breathe through your nose.
You might need to consult your doctor if your nose is blocked and maybe discuss sprays or medicine to help unblock it. Your nose does an important job of cleaning, warming and wetting the air. You’ll notice if you breathe through your mouth it gets really dry or if it is a cold day and you step out the house and take your first breath in through your mouth it will make you cough. Your lungs like clean, warm, wet air and this is the job of your nose. I tend to think that breathing through your mouth is a bit like itching an insect bite or eczema patch – it will make it worse and inflamed.
- Slow your breath to make it as silent as possible.
– Like you are breathing in S L O W M O T I O N. This will help your breath become quieter.
- Breathe down to your GILLS or lower ribs.
If you have ever seen a fish (not battered on a plate), you will know they breathe through their gills. I like to think of our lower ribs as gills, they move in a similar way. Our main breathing muscle is called the DIAPHRAGM (I am not sure why it has such a tricky name and as a dyslexic it is a pain to spell!). When we breathe with our diaphragm, we can draw more air into our lungs, and so get less breathless. The diaphragm is also an endurance muscle, which means it keeps going and going and going and doesn’t get tired. So, when we use our diaphragm to breath it can also help reduce any chest pain you may get that can be caused by other muscles in the neck or top of our chest when they try and do the job of the diaphragm.
- Get with the FLOW.
There should be a gentle regular rhythm with breathing, like waves on a beach and what goes in should come out. There should not be any judders or sharp, quick breaths. Although sighing, yawning or deeper breaths are normal, and we need to do a couple over the day to keep our lungs nice and open – too many can lead to bad changes in our breathing patterns. Test yourself, can you go for 2 minutes without yawning or sighing, if it is hard then it might show us that we need to work on your breathing pattern some more.
Your breath OUT should be longer and slower than the breath IN. When our asthma feels bad our breath tends to lose this rhythm and getting it back is really important. You can listen to some music and time your breath with the beat, breathing in for 3 beats and out for 5.
- POSTURE POSTURE POSTURE.
Totally boring I know BUT your breathing changes your posture and your posture changes your breathing. There is no way to get your breathing perfect if your posture isn’t right. The trick is to think about this little and often; initially it won’t be comfortable to hold a good posture for long as the muscles aren’t used to it. But if you keep correcting yourself though the day eventually it will just become natural.
Posture is a bit like Goldilocks and the three bears
Shoulders and back rounded and chin poking out. It is hard to breathe down to your lower ribs as they are squashed – you will tend to breathe to the top of your chest in this posture.
The back is over-arched, shoulders are up and the tummy is in.
Sometimes you might do this when doing lung function or peak flows – but it doesn’t help get bigger numbers.
Back is straight but keeps its normal curve, shoulders are back and down and the chin is in.
We could draw a line down the body and the ears are in line with shoulders and hips. The lower ribs are free to move and breathe without being squashed.
WARNING: When it comes to practicing improving your breathing pattern it will feel hard, unnatural or weird. Why is this? Remember we spoke about the brain as a fancy computer? When you try to change your breathing, the brain will notice and think AARRHHHGG you are going against my programming, and it won’t like it. It will try to trick you into breathing the old way, by getting you to yawn, sigh or breathe through your mouth. So, you have to think if it feels a bit hard and be aware of your brain trying to trick you – and don’t worry, you are probably doing the right thing! Stick with it; if you practice regularly, then quite quickly you can press the RESET button on your brain’s breathing program and THIS way of breathing will become your new normal.
What about when I run about or exercise?
Sometimes we might be fine when we are resting and relaxing but notice when we start exercising that our breathing is hard to control and we get short of breath REALLY quickly. Having done lots of exercise tests in children with asthma – ALL because of ‘asthma like’ symptoms when they exercised – I have found that it is rarely caused by the breathing tubes tightening. Instead, it is commonly because of HOW they are breathing or their fitness levels. Understandably, if every time you exercise your breathing gets in the way, then this can be uncomfortable, scary and frustrating……so children and teenagers stop exercising as hard and eventually become less fit. There is some really great research that shows us EVERYONE with asthma (however severe) will benefit from exercise BUT we also know that up to 1/3 of people with asthma get ‘asthma like’ symptoms when they exercise. So what do we do? Well, we don’t ignore it.
As a first port of call make sure you or your child has an asthma plan that includes advice on inhaler use prior and/or during exercise. If you or your child gets symptoms EVERY time they exercise, getting in the routine of taking an inhaler (with the spacer) 10-15 min before sport may help. This can be in the changing room before getting changed for PE (by the time everyone is changed and ready in the sports hall or pitch it’s about 10 minutes). However, if it is just when playing outdoors or doing a sport that is really intense, you may only need it before you are about to take part in these sessions.
Asking a physio for help
Referring a child with asthma to a physiotherapy service to help with breathing retraining both at rest and during exercise is a good way to start and may save future tests and investigations. This can be for ALL levels of sport. I see those who struggle to do anything AND those who compete at a national level who only get symptoms when working at their hardest.
We try to help work out whether symptoms are caused by reduced fitness levels (deconditioning), tightening of breathing tubes (asthma), breathing pattern changes or the vocal cords misbehaving on exercise*. We work together with doctors and physiologists to put together the right plan for each child to minimise airway tightening, improve fitness, breathing patterns and reduce unnecessary vocal cord tightening during exercise.
Hopefully, having read this blog, thinking of a physiotherapist who helps with breathing won’t seem like such a strange thing. You may like to reflect and assess your own breathing and make some changes or ask your doctor for help and to see a physio.
Have a good week,
*Another fancy name alert, this can be called either vocal cord dysfunction (VCD) or exercise-induced laryngeal obstruction (EILO)