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This series of pictures are patient breathing training records using the advanced Biofeedback Incentive System®; ("BIS"®) designed for research. The Breathing Trainer v1.0 is a simplified version of this system, designed for home use.

The pictures are "screen dumps" taken directly from the computer display. In the upper picture, the patient's computer screen is turned off, in order to obtain their native breathing pattern, and to be able to systematically follow these breathing patterns. In this way one can see if the therapeutic breathing pattern was in fact being learned and retained properly.

The lower picture shows a patient training session. Note there are two traces. One is a "Breathing Prescription," a visual template of how to breathe in and out, for the patient to follow. The other is the patient's real time breathing signal. The object of the training session was to have the patient superimpose their breathing signal on top of the prompting template, immediately behind a moving cursor showing the patient where they should be. If the patient signal was above or below the Breathing Prescription template, they then had a visual biofeedback signal to instruct them how to breathe correctly. This system permitted the operator to literally see the patient breathe, in both a quantitative and qualitative manner, in comparison to the prescription template. This ability to see patients breathe provided much insight in working with patients to tailor a Breathing Prescription suitable to their needs.

The patient shown was lady with very severe Emphysema. When she began the rehabilitation program in 1987 she was 73 years old. She never smoked, but had an alpha-1 antitrypsin deficiency (alpha AT 7 micromoles). She was in Cor Pulmonale with evidence of right heart failure. Her FEV 1 was 0.5 lpm and her PCO2 in the mid 50's, and she required oxygen supplementation at 2 lpm. Her Total Lung Capacity was 5.18 L (109% of predicted) with a Functional Residual Capacity of 3.99 L (146% of predicted) and an RV / TLC ratio of 59%. Her CO Diffusing Capacity was 3.8 (predicted 20.0).

In this upper screen of native breathing, obtained on her first lesson August 5, 1987 her inspired breath volume, i.e. the Tidal Volume is 500 cc (These documentation screens of native breathing are always calibrated full scale 1000 cc volume on the vertical axis).

After one full breath in and out, it may be seen that she is breathing at a rate of about 19 breaths per minute (These native breathing pattern screens are always calibrated full scale 10 breaths per minute, on the horizontal axis).

Note carefully, her inspiration time and expiration time are almost identical.

This is a typical COPD and Emphysema breathing pattern, i.e. the Tidal Volume is relatively small (it should have been about 600-650 cc); the Respiratory Rate is rapid (it should have been about 10-12 per minute); and the expiratory time phase is shortened (in the normal person it should be about 60% of the breathing time).

Remember, rapid and shallow breathing, with a shortened expiration time is characteristic of COPD.

In the lower screen, the Breathing Prescription had been set full scale Tidal Volume of 800 cc, with a Respiratory rate reduced to 11 breaths per minute. The Inspiration : Expiration Ratio is now set to 1:2.4 (in the normal it is 1:1.4), i.e. the Expiration time in now almost three times longer that the Inspiration time. Note how well the patient is following the Breathing Prescription, even though her native breathing has been drastically altered.

Note particularly, despite the significant 300 cc increase in her Tidal Volume breath, she is still able to easily achieve full exhalation volume, and not develop Air Trapping and Dynamic Hyperinflation, simply by breathing slower and with a longer exhalation time.

She was given a photocopy of this native breathing and breathing training prescription, and told to practice only twice daily, and for only five minutes each session. It was emphasized she was to concentrate on her breathing and "put the breathing picture in your mind." She was also started on physiotherapy chest mobilization and diaphragmatic breathing training.

On her next office visit November 13, 1987 (about three months later) her native breathing pattern now shows her Tidal Volume at 750 cc (it was calibrated to 800 cc), and her breathing rate was now starting to slow, and expiration time now starting to get longer. This degree of improvement took somewhat longer than with most patients.

Note carefully that her breathing pattern is smooth and regular, not hesitant or irregular. This appears to indicate good breathing coordination, and seems to be a hallmark of patients who generally do well with breathing training. This visual qualitative aspect of breathing evaluation is probably very important, and to the best of my knowledge has not been reported in the scientific literature.



As on her initial training session, she followed her Breathing Prescription training with a high degree of skill.




There was still no sign of Air Trapping, even though her Tidal Volume was increased to 950 cc. This was done as it was anticipated that her chest physiotherapy with improved chest mobilization would allow for a greater breath volume.

Her next office visit was on January 28, 1988 (almost six months after starting breathing training). She was doing well.

Her native breathing pattern had now settled into a comfortable 675 cc Tidal Volume, with her Expiration time phase now further prolonged to about two and a half times longer than the Inspiration time.









Her breathing training skills remained excellent. The Tidal Volume was lowered to 800 cc.


At this juncture she seemed well trained in breathing skills, and essentially had completed the training program. She was then seen in routine follow-up about four times a year, and generally was doing well, though it was apparent her Emphysema was progressing. Her dyspnea became slowly worse, and she was having more dyspnea attacks, which she usually controlled fairly well with Dynamic Hyperinflation breathing tricks.

The last time her breathing skills were evaluated was on October 2, 1990 (about 39 months after starting breathing training and 33 months since last evaluated).


It seems clear that her Breathing Prescription has been well preserved as a native breathing pattern.








It is also clear that her breathing skills in following her Breathing Prescription remained very high.

In March 1992 her condition was deteriorating, as is typical with patients with alpha-1 antitrypsin deficiency. She developed dyspnea with even slight effort, but did find relief with breathing control. Her Cor Pulmonale and heart failure became difficult to control, and she died in November 1992, some five years after starting her rehabilitation program.

Again, this was a very severe case of progressive Emphysema. Based on this example, we will show you in another module how to use the Breathing Trainer.

If this severely diseased patient can do it, you can do it, to optimize your breathing pattern and gain maximal breathing control and comfort.

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