Pursed Lip Breathing: Pursed Lips Technique and Its Effects

Pursed lip breathing has been tested in many clinical trials.

Effects of overbreathing on brain oxygen levels - COPD ( Faager et al, 2008; Zhang et al, 2008; Nield et al, 2007; Puente-Maestu & Stringer, 2006; Garrod et al, 2005; Spahija et al, 2005; Bianchi et al, 2004; Opdekamp & Sergysels, 2003; Gigliotti et al, 2003; Sudo et al, 2002; Sudo et al, 2001; Truesdell et al, 2000; Onodera & Yazaki, 1998;  Bai, 1991)
- asthma (Lehrer et al, 2006; Tsunezuka et al, 2005; Lehrer et al, 2004; Ritz & Roth 2003; Meyer et al, 1997; Van der Schans et al, 1997)
- asthma in children (Lehrer et al, 2000)
- emphysema (Egli, 1960)
- stroke (Sutbeyaz et al, 2010)
- autonomic failure (Thijs et al, 2007)
- primary hypertension (Reyes del Paso et al, 2006)
Young woman practicing pursed lip breathing - major abdominal surgery (Fagevik et al, 1997)
- cystic fibrosis (Delk et al, 1994).
- myasthenia gravis (Fregonezi et al, 2005)
- myotonic muscular dystrophy (Ugalde et al, 2000)
- autonomic failure (Thijs et al, 2007)
- altitude adaptation (Burtscher, 2009).

Causes or purpose of pursed lips breathing technique

It can be applied:
- as a 3-5 minutes “rescue exercise” or an Emergency Procedure to counteract acute exacerbations or dyspnea (shortage of air or breathlessness) in COPD and asthma (Nield et al, 2007; Puente-Maestu & Stringer, 2006; Garrod et al, 2005; Bianchi et al, 2004;  Gigliotti et al, 2003; Truesdell et al, 2000; Van der Schans et al, 1997; Bai, 1991)
Man with COPD on oxygen sitting at the table - to increase baroreceptor cardiac function in primary hypertension (Reyes del Paso et al, 2006)
- during physical exercise or walking to improve oxygenation of the arterial blood (Spahija et al, 2005; Faager et al, 2008)
- as a 10-20 minutes daily systematic respiratory exercise to train breathing in complex with other rehabilitative activities (Zhang et al, 2008; Lehrer et al, 2006; Tsunezuka et al, 2005; Fregonezi et al, 2005; Lehrer et al, 2004;  Opdekamp & Sergysels, 2003; Ritz & Roth 2003; Gigliotti et al, 2003; Sudo et al, 2002; Sudo et al, 2001; Lehrer et al, 2000; Ugalde et al, 2000; Onodera & Yazaki, 1998; Fagevik et al, 1997; Meyer et al, 1997; Delk et al, 1994; Egli, 1960)

In overwhelming majority of published studies, their authors and participated patients report that pursed lip breathing is effective for acute attacks, during physical activity, and as a part of pulmonary rehabilitation programs.

Pursed lip breathing preliminary instructions

Doctor helps old man to walk 1. A quiet place to focus one’s attention on relaxation and breathing
2. Silence (no speaking)
3. Empty stomach, but not hungry
Warning signWarning. If you suffer from diabetes and use insulin or other blood glucose-lowering medication, the pursed lip breathing exercise can increase your sensitivity to medication. This can make your blood glucose level lower than usually. You may suffer then from hypoglycemic shock, which is much more dangerous than high blood sugar. You should have a small snack immediately after the breathing session.
4. Hydration (drink water any time if you get thirsty)
5. Clean and fresh air or good air quality
6. Good thermoregulation (do not overheat yourself or, for advanced training, be a little on a cold side)
7. Good posture that allows diaphragmatic breathing (during initial stages of learning for severe COPD, asthma, emphysema, and bronchitis, the exercise can be done while sitting in an armchair or on a couch; later, during clinical remission, it should be done with a straight spine, e.g., while sitting on a half of a chair and without leaning on the back of this chair).

Warning signWarning. Breathing exercises can cause powerful cleansing reactions and can be dangerous for pregnant women, people with organ transplants, GI problems, and panic attacks, as well as those who take medication for diabetes, hypertension, hypothyroidism, and other conditions. Consult your health care provider and follow special guidelines, which can be found in the Module Restrictions, limits, and temporary contraindications.

Pursed lip breathing instructions

- Relax all body muscles, especially your neck and shoulder muscles
- Make your usual inhalation through your nose and from the diaphragm for about two seconds only while keeping your mouth closed
- Exhale for about four seconds through pursed lips, while applying very light resistance as if you were going to whistle. Keep in mind that your exhalation should always be about twice as long as your inhalation.

Note that you should not blow too hard. Hyperventilation will worsen your symptoms. Blow out with the about same force that you would use to cool hot soup on a spoon so that you do not blow it off the spoon.

The most common mistake is too much resistance to air flow or high-pressure breathing. This results in muscular tension and sudden reduction of oxygen content in the lungs. It is important to reduce or slow down one's breathing pattern during pursed lip breathing, but do it very gradually.

Pursed lip breathing rationale

Lung alveoliSince the technique works, it is useful to find causes or its rationale. Most authors base their ideas on mechanical effects of pursed lip breathing assuming that lungs are influenced, during breath work, by the amplitude of the respiratory movements, stretching of alveoli, prevention of collapse and airway obstruction, reduction of dynamic hyperinflation of the lungs, and so forth. In reality, the change and improvement in lung tissue function is based on biochemical processes and the main effect or purpose of pursed lip breathing was suggested in 1987 Lancet article Pursed-lip breathing reduces hyperventilation-induced bronchoconstriction (Wardlaw et al, 1987).

Several research articles have found reduced arterial hypercapnia (excess of CO2 due to ventilation-perfusion mismatch) and improved oxygenation of the arterial blood. How is it possible, if patients breathe less during practice?

Alveolar hyperventilation in patients with COPD, asthma, bronchitis, emphysema, and cystic fibrosis is a proven fact. It leads to alveolar hypocapnia that causes constrictions of bronchi and bronchioles worsening the ventilation-perfusion ratio and prevents lung tissue healing. Pursed lip breathing, when correctly executed, leads to reversal of alveolar hyperventilation and increased alveolar CO2 tension.

CO2 model Summary. Physiology of pursed lip breathing. The main physiological effect of pursed lip breathing is reduction of hyperventilation and higher CO2 levels in the alveoli during and after training. Increased CO2 levels in the functioning parts of the lungs relaxes and dilates smooth muscles of airways. Relative alveolar hypercapnia immediately improves ventilation-perfusion ratio and oxygen levels in the arterial blood. Additionally, due to healing effects of CO2 on lung damage and lung injury, gradual breathing normalization leads to clinical remission even in more severe cases of COPD and other conditions.

Comparative analysis of 5 breathing techniques
(Pursed lip breathing, Resperate, Buteyko reduced breathing, Frolov device, and Strelnikova respiratory gymnastic)
Pursed lip breathing Resperate Buteyko reduced breathing Frolov breathing device Strelnikova breathing gymnastic
Easy to have diaphragmatic breathing + ++ - + +++
Easy to control gradual CO2 increase - + + +++ +/-
Leads to quick increase in body-oxygen test +/- +/- ++ +++ +
Can be learned without a breathing teacher + + - + +

Pursed Lip Breathing Abstract and clinical trials.

For comparative in-depth analysis of pursed lip breathing and other breathing retraining techniques (including hatha yoga, the Buteyko method, Frolov device, and Resperate), click here: Breathing techniques.

References for pursed lip breathing research

Bai CX, Application of pursed lips breathing to chronic obstructive pulmonary disease patients with respiratory insufficiency [Article in Chinese], Zhonghua Jie He He Hu Xi Za Zhi. 1991 Oct;14(5):283-4, 319.

Bianchi R, Gigliotti F, Romagnoli I, Lanini B, Castellani C, Grazzini M, Scano G, Chest wall kinematics and breathlessness during pursed-lip breathing in patients with COPD, Chest. 2004 Feb;125(2):459-65.

Burtscher M, Pursed-lips breathing for improved oxygenation at altitude, Sleep Breath. 2009 May;13(2):119-20. Epub 2009 Feb 6.

Delk KK, Gevirtz R, Hicks DA, Carden F, Rucker R, The effects of biofeedback assisted breathing retraining on lung functions in patients with cystic fibrosis, Chest. 1994 Jan;105(1):23-8.

Egli HJ, The pursed-lip technique in abdominal breathing exercises for pulmonary emphysema, Phys Ther Rev. 1960 May;40:368-71.

Faager G, Stâhle A, Larsen FF, Influence of spontaneous pursed lips breathing on walking endurance and oxygen saturation in patients with moderate to severe chronic obstructive pulmonary disease, Clin Rehabil. 2008 Aug;22(8):675-83.

Fagevik Olsén M, Hahn I, Nordgren S, Lönroth H, Lundholm K, Randomized controlled trial of prophylactic chest physiotherapy in major abdominal surgery, Br J Surg. 1997 Nov;84(11):1535-8.

Fregonezi GA, Resqueti VR, Güell R, Pradas J, Casan P, Effects of 8-week, interval-based inspiratory muscle training and breathing retraining in patients with generalized myasthenia gravis, Chest. 2005 Sep;128(3):1524-30.

Garrod R, Dallimore K, Cook J, Davies V, Quade K, An evaluation of the acute impact of pursed lips breathing on walking distance in nonspontaneous pursed lips breathing chronic obstructive pulmonary disease patients, Chron Respir Dis. 2005;2(2):67-72.

Gigliotti F, Romagnoli I, Scano G, Breathing retraining and exercise conditioning in patients with chronic obstructive pulmonary disease (COPD): a physiological approach, Respir Med. 2003 Mar;97(3):197-204.

Lehrer P, Vaschillo E, Lu SE, Eckberg D, Vaschillo B, Scardella A, Habib R, Heart rate variability biofeedback: effects of age on heart rate variability, baroreflex gain, and asthma, Chest. 2006 Feb;129(2):278-84.

Lehrer PM, Vaschillo E, Vaschillo B, Lu SE, Scardella A, Siddique M, Habib RH, Biofeedback treatment for asthma, Chest. 2004 Aug;126(2):352-61.

Lehrer P, Smetankin A, Potapova T, Respiratory sinus arrhythmia biofeedback therapy for asthma: a report of 20 unmedicated pediatric cases using the Smetankin method, Appl Psychophysiol Biofeedback. 2000 Sep;25(3):193-200.

Meyer A, Wendt G, Taube K, Greten H, Ambulatory sports in asthma improves physical fitness and reduces asthma-induced hospital stay, [Article in German], Pneumologie. 1997 Aug;51(8):845-9.

Nield MA, Soo Hoo GW, Roper JM, Santiago S, Efficacy of pursed-lips breathing: a breathing pattern retraining strategy for dyspnea reduction, J Cardiopulm Rehabil Prev. 2007 Jul-Aug;27(4):237-44.

Onodera A, Yazaki K, Effects of a short-term pulmonary rehabilitation program on patients with chronic respiratory failure due to pulmonary emphysema, [Article in Japanese], Nihon Kokyuki Gakkai Zasshi. 1998 Aug;36(8):679-83.

Opdekamp C, Sergysels R, Respiratory physiotherapy in lung diseases [Article in French], Rev Med Brux. 2003 Sep;24(4):A231-5.

Puente-Maestu L, Stringer WW, Hyperinflation and its management in COPD, Int J Chron Obstruct Pulmon Dis. 2006;1(4):381-400.

Reyes del Paso GA, Cea JI, González-Pinto A, Cabo OM, Caso R, Brazal J, Martínez B, Hernández JA, González MI, Short-term effects of a brief respiratory training on baroreceptor cardiac reflex function in normotensive and mild hypertensive subjects, Appl Psychophysiol Biofeedback. 2006 Mar;31(1):37-49.

Ritz T, Roth WT, Behavioral interventions in asthma. Breathing training, Behav Modif. 2003 Oct;27(5):710-30.

Spahija J, de Marchie M, Grassino A, Effects of imposed pursed-lips breathing on respiratory mechanics and dyspnea at rest and during exercise in COPD, Chest. 2005 Aug;128(2):640-50.

Sudo E, Tanuma S, Haraguchi N, Kobayashi C, Takahashi Y, Yoshida A, Ohama Y, A case of chronic obstructive pulmonary disease (COPD) followed by pulmonary rehabilition, [Article in Japanese], Nippon Ronen Igakkai Zasshi. 2002 Jul;39(4):439-43.

Sudo E, Tanuma S, Yoshida A, Takahashi Y, Kobayashi C, Ohama Y, The effects of pulmonary rehabilitation with chronic obstructive pulmonary disease (COPD), [Article in Japanese], Nippon Ronen Igakkai Zasshi. 2001 Nov;38(6):780-4.

Sutbeyaz ST, Koseoglu F, Inan L, Coskun O, Respiratory muscle training improves cardiopulmonary function and exercise tolerance in subjects with subacute stroke: a randomized controlled trial, Clin Rehabil. 2010 Mar;24(3):240-50. Epub 2010 Feb 15.

Thijs RD, Wieling W, van den Aardweg JG, van Dijk JG, Respiratory countermaneuvers in autonomic failure, Neurology. 2007 Aug 7;69(6):582-5.

Truesdell S, Helping patients with COPD manage episodes of acute shortness of breath, Medsurg Nurs. 2000 Aug;9(4):178-82.

Tsunezuka Y, Sato H, Hiranuma C, Ishikawa N, Oda M, Watanabe G, Spontaneous tracheal rupture associated with acquired tracheobronchomalacia, Ann Thorac Cardiovasc Surg. 2003 Dec;9(6):394-6.

Ugalde V, Breslin EH, Walsh SA, Bonekat HW, Abresch RT, Carter GT, Pursed lips breathing improves ventilation in myotonic muscular dystrophy, Arch Phys Med Rehabil. 2000 Apr;81(4):472-8.

Van der Schans CP, de Jong W, de Vries G, Postma DS, Koëter GH, van der Mark TW, Respiratory muscle activity and pulmonary function during acutely induced airways obstruction, Physiother Res Int. 1997;2(3):167-77.

Wardlaw JM, Fergusson RJ, Tweeddale PM, McHardy GJ, Pursed-lip breathing reduces hyperventilation-induced bronchoconstriction, Lancet. 1987 Jun 27;1(8548):1483-4.

Zhang ZQ, Chen RC, Yang QK, Li P, Wang CZ, Zhang ZH, A randomized controlled trial study of pulmonary rehabilitation with respiratory physiology as the guide o prognosis in patients with chronic obstructive pulmonary disease [Article in Chinese], Zhongguo Wei Zhong Bing Ji Jiu Yi Xue. 2008 Oct;20(10):607-10.

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