Welcome to the BIS (tm) (Biofeedback Incentive System) breathing control and training system Breathing Trainer v1.0. This version is designed mainly for home use. We will introduce you to the Breathing Trainer and it's controls in this module.
It is not necessary to purchase the Breathing Trainer, in order to derive your breathing training. However, the Breathing Trainer will greatly facilitate this process, and permit fine tuning adjustments to your program. The Breathing Trainer is demonstrated, and may be purchased at:
http://www.sierrabiotech.com/bt_home.html
When you have finished viewing the video, click on the "X" box in the upper right corner to exit the video.
To return to the main program, click on the back arrow.
Other versions of the BIS system are more complicated and sophisticated, and are designed for scientific and professional use, as they display the actual user breathing signal for visual biofeedback training. Unfortunately the complexity of the advanced system, and the approximately $2,500 for the necessary hardware, is cost prohibitive for a home use program.
This home version is derived from the advanced research system. It provides an accurate breathing prompting display, which shows in graphics how to breathe in and out. To make this prompting display work, you must first configure the display for your particular needs.
Once you have an appropriate display, you must synchronize your breathing with the flashing cursor moving along the visual lines of inspiration and expiration. A special function key, the Esc key, will easily synchronize your breathing with the beginning of the prompting program. With a little practice you should be able to get the right timing and synchronize your breathing with the entire program prompting signal within two or three breaths.
Properly done, this will provide an accurate control of your breathing rate and the relative times of breathing in and out. It will also provide a TIDAL (Breath) VOLUME that is approximately correct, depending mainly on your breathing coordination skills in following the prompting display.
The display shows the Tidal Volume (i.e. the Breath Volume) on the vertical axis, and this volume is always set full scale, i.e. big breaths and small breaths look about the same. This may seem strange, but in fact is one of the reasons why this visual teaching method is so powerful.
The Respiratory Rate, i.e. the time of one breath in an out, is displayed on the horizontal axis, and is also always set to full scale. The Rate is set therefore to one full breath in and one full breath out, i.e. one complete respiratory cycle.
This means that slow breathing and fast breathing look much the same, and the only clue that they are different is the speed of the prompting cursor moving along the breathe in / breathe out program lines. Again, this may seem strange, but in fact this is also one of the reasons why this visual teaching method is so powerful.
If the visual cues of Tidal Volume and Respiratory Rate appear essentially identical, you will focus on the flashing cursor, and therefore the critically important timing requirements of breathing. Because visual prompt appears quite similar for the major components of this display, this display forces you to concentrate on the visual act of breathing and the related feeling of breathing. This is why this particular type of display is such a powerful teaching tool.
In attempting to synchronize with this breathing display you should try to FEEL within your chest the respiratory sensations of breathing in that particular manner. When you can feel these respiratory sensations you should then be able to remember and reproduce them, even without the Breathing Trainer prompt.
This is why this training method is so efficient as a learning tool, and so powerful as a method that can be used anywhere, any time, even without the use of this prompting system.
Unlike the more advanced scientific versions of the Biofeedback Incentive System the Breathing Trainer does not directly display your actual breathing. As noted before, the transducers and electronics needed for this are prohibitively expensive. The Breathing Trainer display will accurately provide correct breathing timing signals of Respiratory Rate and the relative times of Inspiration and Expiration. However, the breath Tidal Volume prompt is a more subtle approximation.
To understand this you need to consider the fundamental breathing equation:
Tidal (Breath) Volume = Air Flow X Time
Now, if the correct Volume of the breath is indicated on the screen (and it is, for every portion of the breathing cycle), and if the correct Time of the breathing cycle is indicated (and it is, by the flashing cursor), then the cursor is a real-time breath Flow controller. And it is controlling the Flow of air at every portion of the total breathing in and out cycle.
Note carefully that the Inspiration display line is straight, or linear. This means that you should inhale in a constant and steady manner to follow the prompting cursor correctly. This flow pattern is particularly easy to do on inspiration. With a little practice, usually within two or three breaths, you should be able to time your breathing flow to closely match the cursor time prompt from the exact beginning to the exact end of inspiration. And doing this correctly you will achieve a close approximation of the desired Tidal Volume. Your skill in correctly breathing exactly with the cursor timing prompter is the main factor determining the accuracy of the indicated breath volume. And for expiration, follow the timing signal in the same manner.
The initial screen you will see is the program Setup screen, with a number of input functions that require you to enter a number. As you enter numbers for the different breathing parameters you will see the breathing waveform change accordingly.
The Setup Screen shows the following parameters:
Tidal Volume - (or Breath Volume) (in cc's).
Respiratory Rate - (in breaths per minute).
Inspiration Time - (as a percent of the total breath cycle time).
Expiration Time - (likewise, which will automatically adjust when the Inspiration Time is set).
Inspiration Hold - (the slight hesitation between Inspiration and Expiration, as a percent of the Inspiration Time).
Expiration Hold - (the longer hesitation at the end of Expiration, before taking in the next breath, as a percent of the Expiration Time).
By manipulation of these inputs a wide variety of breathing prompting programs may be created.
Note that you may also enter your name, and that the date and time is automatically displayed. When you print out a copy it will identify you, and the date, and all the details of your breathing pattern for your record. A printed copy of your program is a good reminder of your visual breathing pattern to carry with you. In case of breathing difficulty you can then readily refer to it.
Use the Start button to go to the actual program display where you will be doing your practicing, and the Exit button to stop the program.
TIDAL VOLUME:
For most adults a Tidal Volume at rest is approximately 500 to 900 cc. Experiment and see what is comfortable for you. For training purposes a breath volume 200 to 300 cc larger than required for metabolic needs is more comfortable for many. Away from training sessions the natural breathing regulatory mechanisms should restore your breathing volume to an appropriate level. For the COPD patients these larger breaths are particularly desirable, as they are stretching and mobilizing your chest. This will eventually allow you to take larger breaths, and therefore give you more breathing reserve.
Note however, these larger Tidal Volumes sometimes induce symptoms of overbreathing (i.e. light headed sensations, tingling about the mouth and face, etc.). If these symptoms are noted, then reduce the volume accordingly.
RESPIRATORY RATE:
The normal adult Respiratory Rate is about 10 to 12 breaths per minute while resting. Breathing rates above 15 breaths per minute at rest may produce symptoms of overbreathing, i.e. the Hyperventilation Syndrome. But much more important for the COPD patient, breathing faster than 15 breaths per minute is likely to cause Air Trapping and Dynamic Hyperinflation.
INSPIRATION TIME:
Normally the time spent on inspiration is less than the time spent on expiration. For people with normal lungs, at rest, this time is approximately 40% of the entire respiratory cycle. By entering this number you will note the EXPIRATION TIME is automatically calculated, in this case 60%. Likewise if you enter a number into the Expiration Time, the Inspiration Time is automatically calculated.
For people with COPD / Emphysema / Asthma an exhalation time 2 or 3 or more times longer than inspiration may be needed, in order to get out the old stale air, and therefore make room for fresh air.
For the COPD patient an Inspiration Time of 30-35% or even 25-30% translates into the all important EXPIRATION TIME, or in this case 65-70% or even 70-75%. Patients understandably focus on Inspiration to relieve their breathing discomfort, but paradoxically, Expiration is where the therapeutic action is, and Expiration is the most difficult part of learning to breathe correctly.
These prolonged Expiration Times are needed to permit all of the air to get out of the chest and correct the problem of “Air Trapping” and resulting “Dynamic Hyperinflation.” For COPD patients it is critically important to always remember that it is not possible to take in a proper breath of fresh air until the old stale air has been removed by a longer exhalation time.
However, excessive prolongation of the Expiration Time in conjunction with a slowing of the Respiratory Rate must be balanced against other important factors. Slowing down breathing to the point where overall ventilation needs are not adequate must not be permitted to happen. Also, improving the size of the Tidal Volume breath will help more of the inspired breath to actually reach the alveolar air sacks. This is the so-called "Alveolar Ventilation," and improving this factor helps to maintain ventilatory needs, but improving the Tidal Volume also has its own mechanical limitations of excessive effort if pushed too far.
Deciding on an individual optimal COPD breathing pattern requires a delicate balance and compromises between the Tidal Volume increasing, the Respiratory Rate slowing, and the Expiration Time becoming greater. And in adjusting these parameters the Alveolar Ventilation must be maintained, and the overall Work of Breathing (the factor most associated with breathing distress) must be kept as low as possible.
The "Breathing Prescription" process is obviously a complex one. We will provide you with suggestions to guide you through this process. Preferably this should be done in conjunction with your physician and therapist.
INSPIRATION HOLD:
Normally there is a slight pause at end-inspiration as one switches over to the expiration phase of the breathing cycle. Usually this is about 3 to 5 % of the Inspiration Time. In order to begin the expiration phase correctly on time, it is important to begin exhalation near the beginning of the Inspiration Hold. There is a mechanical lag of the chest structures between when the Respiratory Center sends a signal and initiates exhalation, and exhalation actually begins. Understanding this timing will enable you to more exactly match the breathing prompting signal.
For the COPD patient a longer Inspiration Hold time of 5 to 10% or more, may sometimes provide an improved blood oxygen level. This is because the fresh air oxygen now has a longer time to circulate at the alveolar level and find better functioning blood capillaries, and therefore be absorbed. This must be balanced against other mechanical considerations, such as slowing down the overall breathing rate excessively, or causing inspiration to be too fast. Deciding the correct level of Respiratory Rate and Inspiration Hold times requires experimental adjustments while measuring your blood Oxygen Saturation levels. Fortunately these measuring instruments called "Oximeters" are now relatively inexpensive and easy to use. All respiratory clinics should have them, and in fact a number of patients now have their own Oximeters to monitor this very important aspect of breathing.
EXPIRATION HOLD:
Normally there is a longer, usually distinctive pause at end-expiration, as one is preparing to switch over to the inspiration phase of the next breathing cycle. At rest this is usually about 5 to 10% of the expiration time. In COPD this may need to be set a little higher, but never more than 14-15%.
Ideally, expiration should be totally relaxed and passive. During this time the respiratory muscles rest, and this rest is important. The contracting elastic forces within the chest wall and the lung that have been built-up during inspiration, then gently squeeze the lung and force the air out. These forces may be aided by the diaphragm being pushed upward towards the chest cavity by abdominal muscular contraction.
If full expiration has not been achieved with an optimal breathing pattern by the beginning of the Expiration Hold, it is a sign that active muscular contraction must be employed on expiration. As you learned in a previous module, this muscular effort should be done late in expiration (generally about three quarters to two thirds of the way through expiration), and be done as gently as possible, to minimize Dynamic Bronchial Compression which makes exhalation more difficult. Again the analogy of gently wringing water out of a wet bath towel.
The Expiration Hold is also important in initiating the next inspiration breath. If not initiated on time, the next inspiration breath will start late. Typically inspiration must be initiated about half way to three quarters of the way through the Expiration Hold. This is timing also required because of the mechanical lag of the breathing muscles to make the chest bellows mechanism move.
However, in COPD and Emphysema, the time between the Respiratory Center telling the respiratory muscles to move, and the time they move enough to really effect inspiratory movement, may be substantially longer. The reasons are complex, but basically involve chest stiffness and weakness, and lax lungs that must be moved enough to overcome internal pressures that must be exceeded in order for inspiration to commence. For this reason, inspiration initiation should begin about one quarter to one half way through the Expiration Hold, and occasionally at the beginning of Expiration Hold. And occasionally the Expiration Hold itself needs to be increased to about 11-12%.
It should be emphasized, all these adjustments can interact with each other. It may take time and a lot of trial and error to find breathing patterns that are suitable for your needs. Have patience, and don't be discouraged if your initial breathing pattern adjustments are not satisfactory.
However, once you have found a breathing pattern that is satisfactory, be sure to write down the input parameters, or make a copy of same by printing your breathing pattern. This way, when you need the program in future, it will take but a moment to re-enter your specific Breathing Prescription program.
You may easily experiment and fine tune your breathing program from the main User Working Screen. Note the abbreviated descriptions at the bottom of the screen:
TV - (Tidal Volume)
Rate - (Respiratory Rate)
TI - (Inspiratory Time)
TE - (Expiratory Time)
IH - (Inspiration Hold)
EH - (Expiration Hold)
While you are actually using the prompting program you may dynamically adjust these parameters by clicking on the appropriate Up/Down arrows. Or, you may place your cursor within the relevant box and type in the desired number, and press the Enter key on your computer. On the next breath your new values will appear.
Along the bottom of the main User Working Screen are four red function boxes:
Refresh - (or use the Esc function key)
Pause - (or use the F1 function key)
Print - (or use the F2 function key)
Setup & Exit - (or use the F12 function key)
Refresh / Esc starts the prompting display over again, and allows you to easily synchronize your breathing with the computer display. Simply breathe out comfortably, and then breathe in, and at the same time press Esc or Refresh. You and the prompting program are now synchronized.
Pause / F1 will stop the display, so that you or your breathing advisor may discuss what you are doing, and what might be done to obtain a better breathing program.
Print / F2 will tell your computer to print a hard copy of your program. Note, this will only work if you have first pressed Pause or F1.
Setup & Exit / F12 returns you to the Setup Screen, and from there you may make program adjustments or exit the program.
At this juncture you should have an understanding of basic breathing mechanics, mobilization and strengthening of your chest wall, proper diaphragmatic breathing control, an understanding of some essential pulmonary physiology, including the importance of Dynamic Hyperinflation, and a basic familiarity of the controls of the Breathing Trainer.
We will now guide you through adjustments of your Breathing Trainer to derive your Breathing Prescription.
DISCLAIMER: Breathing Control Associates (BCA) will assume no liability for the use of this product in any environments, including electrically sensitive areas where users might be at risk for microshock hazards.
The setup and proper use of this product is the entire responsibility of the user. BCA will not warrant that use of this technology will result in relief of shortness of breath or improvement of any respiratory related conditions.
Breathing pattern modification relies on the correct diagnosis of disease or user conditions that are potentially capable of being helped by this technique, and the generation of an appropriate breathing program. Good user cooperation and effort in learning the necessary skills to use this breathing prompter to advantage is essential. This is the sole responsibility of the user and/or the user's advisors.
Some pulmonary disease states will not be able to be helped by this methodology, and some otherwise treatable conditions may be too advanced to permit significant improvement of breathing distress with the Breathing Trainer.
If the user’s Physician, Psychologist, Therapist or Breathing Coach / Trainer or other advisor does not have this program, the user is granted permission to permit their advisor to copy their personal program. This does not permit the various advisors to copy the program for other users.