What is the best approach to manage breathlessness, particularly in patients with chronic respiratory diseases like chronic obstructive pulmonary disease (COPD) or asthma?

Diaphragmatic Breathing and Other Techniques for Managing Breathlessness in Chronic Respiratory Diseases

Diaphragmatic breathing and other breathing techniques are effective non-pharmacological interventions that should be incorporated into the comprehensive management of breathlessness in patients with chronic respiratory diseases like COPD and asthma. 1, 2

First-Line Breathing Techniques

Pursed Lip Breathing (PLB)

• Most effective breathing technique with strongest evidence for immediate relief of breathlessness 1
• Technique:
  • Inhale through nose for several seconds with mouth closed
  • Exhale slowly through pursed lips for 4-6 seconds
  • Maintain relaxed posture with dropped shoulders 1
• Physiological benefits:
  • Reduces respiratory rate and dynamic hyperinflation
  • Improves oxygen saturation and tidal volume
  • Creates positive back-pressure in airways, maintaining airway patency 1
  • Significantly reduces breathlessness based on high-quality systematic reviews 3, 2

Diaphragmatic Breathing

• Focuses on using the diaphragm more efficiently during breathing
• Can improve disease-specific quality of life 3
• Often combined with pursed lip breathing for enhanced effect

Positioning Strategies

• Forward leaning posture improves diaphragmatic function 1
• Can be combined with pursed lip breathing for enhanced effect
• Using a rollator/walker while ambulating allows forward leaning with arm support 1

Comprehensive Breathlessness Management

Pharmacological Management

• Bronchodilators remain the most effective treatment for breathlessness in COPD and can improve exercise tolerance even without measurable bronchodilation 4
• For severe chronic breathlessness that persists despite optimal treatment:
  • Low-dose oral morphine (starting at 10 mg/day) may be considered
  • Can be titrated up to 30 mg/day if needed and tolerated
  • Use with caution in renal impairment (avoid if GFR <30 mL/min) 4

Oxygen Therapy

• Long-term oxygen therapy (LTOT) in patients with chronic hypoxemia has shown:
  • Improved survival (5-year survival improved from 25% to 41% with 15 hours/day)
  • Prevention of pulmonary hypertension progression
  • Improvement in neuropsychological health 4
• Not beneficial for non-hypoxemic patients 4

Pulmonary Rehabilitation

• Essential component for managing breathlessness in chronic respiratory diseases
• Includes:
  • Exercise training to improve functional capacity
  • Breathing retraining techniques
  • Neuro-electrical leg muscle stimulation 4
• Has been shown to be effective in prospective randomized clinical studies 4

Evidence Quality and Implementation

• Recent high-quality systematic review (2024) found breathing techniques consistently improved health-related quality of life in people with COPD and asthma, with effects generally exceeding minimal important difference 2
• Three high-quality systematic reviews support the effectiveness of breathing techniques, particularly pursed lip breathing, for breathlessness relief 3
• No adverse events related to breathing techniques have been reported 2

Practical Implementation

1. Teach pursed lip breathing as first-line technique
2. Add diaphragmatic breathing and forward leaning posture
3. Ensure proper technique through repeated instruction and practice
4. Encourage use during activities of daily living and exercise
5. Combine with optimal pharmacological management of underlying condition
6. Consider pulmonary rehabilitation program referral

Breathing techniques represent a safe, effective, and accessible intervention that should be taught to all patients with chronic respiratory diseases experiencing breathlessness, as they improve both symptoms and quality of life.