Pursed Lip Breathing: Pursed Lips Technique and Its Effects
Pursed lip breathing has been tested in many clinical trials.
- 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)
- 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)
- 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,
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;
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
1. A quiet place to focus one’s attention on relaxation and
2. Silence (no speaking)
3. Empty stomach, but not hungry
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).
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
Since 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,
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
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.
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
There is a Table right below here that provides practical comparison of several breathing techniques with pursed lip breathing. In addition, there is another page that compares and provides technical details related to pursed lip breathing and other breathing
retraining techniques (including hatha yoga, the Buteyko method, Frolov device, and
Resperate). All these resources are right below here as your bonus content.
Pursed Lip Breathing Abstract and clinical trials.
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.
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
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
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
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
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
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
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
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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