I am Dr. Deane Hillsman, a retired physician who practiced Internal Medicine and the specialty of Pulmonary Diseases. My particular interest is Pulmonary Rehabilitation, and chest physiotherapy and breathing training to help people with COPD and related problems.
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In 1987 I wrote the draft of a book RESPIRATORY SELF CARE: A Manual For Patients And Their Families." It was about 60% completed, and I showed it to a half-dozen or so of the major publishers of this type of work. None of them were interested in taking it on. Their concerns were generally that, the material was too technical for most patients and their families, and I therefore abandoned the project.
Times have changed, and in recent years patients and families are now demanding more in-depth understanding of their health concerns, and the concept of patient self-help and empowerment is fast becoming a significant factor in health care. I reject the notion that patients are somehow not capable of using more advanced health care information to their advantage. The contents of this web site are substantially taken from that long abandoned manual.
In the early 1960's during my residency training, quite by accident, I was privileged to see two British trained Physical Therapists work with a patient suffering from Emphysema using "breathing exercises" (which I had never heard of), and achieve significant dyspnea (shortness of breath) relief. I was impressed.
I was later told by many that "breathing exercises" were not of value in COPD. However, when you see such positive results it is difficult to ignore what you have seen. This led to a lifelong interest in trying to understand, and improve, the technology that is generally known as Chest Physical Therapy (or Chest Physiotherapyor simply "Chest Physio"). The modern name for those credentialed in this specialty by the American Association of Physical Therapy is Cardiovascular and Pulmonary Physical Therapist.
A major part of Chest Physiotherapy is "breathing pattern" training. This relates to how to breathe, to achieve more efficient patterns of breathing. To further this interest, in the 1970's I invented a sophisticated computer based device to visually define breathing pattern templates, and to visualize patient's real-time breathing, and their interaction with different breathing templates to achieve maximal breathing comfort. The Breathing Trainer, to be described later, is a simpler version of that original professional and research system, specifically designed for individual home use.
It is quite astonishing, but true, the scientific pulmonary community has never defined, even to this day, in any comprehensive manner, the most efficient way for a COPD / Emphysema patient to breathe. Because of this lack of scientific guidance as to how to program my breathing training system, I had to rely on the general guidelines provided by the Chest Physiotherapy community. And later, I observed a few patients in my practice with very advanced Emphysema, but with only mild complaints of dyspnea. I collected their breathing patterns, and observed they correlated well with the descriptions of Chest Physiotherapy techniques. Indeed, these few patients appeared to be a model of natural adaptation to the altered breathing mechanics of COPD. The lessons learned from these few very instructive patients have substantially guided my design of breathing pattern templates for others with COPD.
The first prototype of my breathing training invention was presented in 1978 before the California Thoracic Society. Since then I have had a great deal of learning experience with experimental adjustment of the various parameters that go into characterizing a breathing pattern for individual patients. Essentially I was trying to understand the optimal manner for the COPD patient to breathe comfortably. I am impressed how even small adjustments can make a significant difference in breathing comfort to many of these patients.
Chest Physiotherapy is substantially a creation of British Physical Therapists, and the subject is routinely taught in the U.K. schools of Physical Therapy. Chest Physiotherapy began there in the mid-1920's and was quite mature by the mid to late 1930's.
This ancient 1935 training manual obtained from the British Library is a quite remarkable document.
It is clear from this document, at a time when the physiologic understanding of COPD clinical problems was primitive, these early Physical Therapists understood the importance of chest overinflation (more later on this very important topic of Dynamic Hyperinflation), and basically how to correct this functional lesion.
How these early Chest Physiotherapists managed to figure this one out is remarkable, and certainly worthy of admiration.
Also quite astonishing is the general lack of awareness of this technology in North America. Surveys of general Physical Therapy training programs have documented usually only minimal time devoted to the subject. In fact, today there are only about 130 credentialed Cardio-Pulmonary Physical Therapy specialists in the United States. If COPD patients seek Chest Physiotherapy training, they are not likely to be able to find these services, at least from these properly qualified experts.
There is also ongoing and substantial physician resistance to the concept of breathing training, as "breathing exercises" are in some disrepute. Perhaps this is related to the many non-physicians offering various breathing services and devices, for many reasons, some of them of dubious value. Physicians instead have understandably relied on the very complex traditional regulatory feedback mechanisms that are essential to maintain life.
Are these traditional breathing control mechanisms infallible? Until recently most physicians appear to have had total faith in these important traditional control mechanisms. However, as we will see, that apparent traditional faith has not been justified. As we shall see, these natural breathing control mechanisms can indeed be tricked into abnormal pathologic behavior, to cause increased shortness of breath.
Recent research has characterized the breathing pattern response to exercising COPD patients, and patients who breathe too rapidly, as a "vicious circle" response, leading to the physiologic problem of progressive so-called "Dynamic Hyperinflation" of the lungs, and this in turn causing severe dyspnea limitation. Simply stated, this rapid breathing pattern causes too much air to become trapped in the lungs, and the lungs can no longer work properly.
This is a pulmonary mechanical defect, and any feedback control system that has a vicious circle mechanism causing failure of the overall system is a flawed system. An obvious option for the COPD patient seeking breathing comfort from a mechanical defect is a proper mechanical breathing control technique, in addition to the usual bronchial dilator drugs and other medications typically prescribed for shortness of breath. Corrective breathing mechanics is what breathing training is all about, and we will discuss this important topic of Dynamic Hyperinflation in a later instruction module.
This breathing training debate should now really be over, though many pulmonary physicians might still dispute that statement. The option of breathing control for patients with COPD and Emphysema, and for Asthma exacerbations, is indeed an important, and in fact necessary option for optimal breathing comfort.
The majority of formal pulmonary rehabilitation programs have a primary exercise focus, or an exercise-centric focus. These programs emphasize reconditioning the legs and other peripheral muscles, by using stationary bicycle ergometers, or treadmills, or stair climbing. Exercise makes these muscles more efficient as to oxygen needs and getting rid of waste carbon dioxide. This requires relatively less breathing, and therefore less dyspnea, to satisfy these metabolic oxygen and carbon dioxide requirements. Considerable research has been done in this approach, and there is no question that this is an effective strategy to get patients ambulating, and to reduce their overall level of dyspnea. And as patients feel more comfortable, they are able to get about more easily. However, exercise training that makes one more short of breath is not a pleasant training experience.
The other general approach, and the one that I personally favor, is a primary breathing training strategy, or a breathing training-centric focus. Ask COPD patients what their major concern is, and very few will complain about the inability to engage in exercise. COPD patients dominant concern is mainly about general and acute shortness of breath, and the large majority are most concerned about acute dyspnea attacks. Acute dyspnea is a very distressing experience, and COPD patients live in constant fear of these attacks. It makes logical sense therefore that initial therapy should concentrate on the patient's primary complaint of dyspnea.
Remember Willie Sutton, the famous bank robber? As Willie Sutton allegedly said, when asked why he robbed banks, ".....Because that's where the money is....." Applying this analogy, think of the primary breathing control focus in COPD re rehabilitation as the Sutton approach to pulmonary rehabilitation, because that indeed is where the action is.
Teach COPD patients breathing control and their overall breathing comfort improves. But more important, if patients know how to recognize an impending acute breathing attack and prevent the attack, or if having an attack how to control the attack, they will lose their fear of exerting themselves. And if the patient feels they are in control of their breathing, it takes only a little encouragement to get them to be more active, because patients usually want to be more active. And with increased activity, their leg and other peripheral muscles will become reconditioned, and strength will improve, and their overall rehabilitation program will therefore be enhanced. If you will, this is an alternative option to provide exercise reconditioning.
Please do not think that the techniques that I will be showing you are a complete substitute for proper instruction from a qualified therapist. However, if you do not have access to a qualified therapist, the modules of instruction I am providing may be of use to you.
And if you are presently receiving instruction in "breathing exercises" or "diaphragmatic breathing" perhaps your therapist might be interested in a few of the techniques and tips in these instruction modules.
It is my hope this series will provide information to patients, and their families and caregivers, that will empower them, in a self-help manner, to use these lessons to gain dyspnea control and relief in their activities of daily living. And when you have mastered dyspnea control, that you will then be able to be even more active, and more comfortable.
Throughout these instruction modules, which will require a lot of work on your part, please always remember, neither I nor your doctor or therapist can do dyspnea control for you. We can instruct you, but only you can do dyspnea control for your needs.
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