Pursed-lip Breathing

Issues of Concern

While PLB offers significant benefits for managing dyspnea and improving gas exchange in obstructive pulmonary diseases, several issues of concern should be noted. PLB relies on voluntary initiation and proper execution for effectiveness, requiring individuals to master the technique, which includes maintaining prolonged exhalation and coordinated breathing patterns. The method can exacerbate air trapping and carbon dioxide retention without accurate implementation, counteracting its intended therapeutic effects. Overuse or extended application of PLB can lead to fatigue of the respiratory muscles and, in normal individuals, potentially result in lower-than-normal carbon dioxide levels, reducing cerebral perfusion pressure and risking syncope.

The therapeutic effects of PLB are typically short-lived, and its use is often limited to 3 to 5 breaths due to the potential for muscle fatigue and metabolic strain. In conditions like interstitial lung disease (ILD), acute exposure to PLB during activities such as the 6-minute walk test has not shown significant improvement in symptoms, walking distance, muscle oxygenation, or oxygen saturation compared to normal breathing. Due to increased metabolic demand, PLB was found to reduce walking distance in patients with normoxemia and negatively affect exercise capacity or dyspnea in ILD.[2] These findings highlight the variability in PLB's effectiveness across different patient populations and underscore the importance of tailoring its use to specific clinical contexts.

Clinical Significance

PLB is a simple yet highly effective technique with extensive clinical applications, particularly for individuals experiencing dyspnea and air trapping. When performed correctly, PLB provides significant relief by allowing patients to regain control over their breathing, reduce the work of breathing, and alleviate respiratory distress. PLB can be easily learned and applied with proper teaching and guidance from trained professionals. In addition to its primary role in relieving carbon dioxide retention and improving oxygenation, PLB is an excellent relaxation tool, helping patients manage anxiety and enhance their overall well-being.

As a versatile and clinically significant technique, PLB is a valuable strategy for managing respiratory conditions. The benefits of this technique extend from offering immediate relief from respiratory symptoms to improving lung function, exercise capacity, and quality of life. Whether employed as a standalone intervention or integrated with other therapies, PLB is an effective, low-cost approach that supports respiratory health across various conditions, including chronic obstructive pulmonary disease (COPD), asthma, and COVID-19. PLB's adaptability and proven efficacy make it an indispensable tool in managing and rehabilitating respiratory diseases.

Role of PLB in Chronic Obstructive Pulmonary Disease 

PLB commonly helps patients with COPD. PLB may not be voluntary for these patients, but it is a compensatory mechanism to help splint open the airways.[8][9] Individuals with COPD may have chronic obstruction of their airways from mucus plugging, loss of integrity of the airways, or enlargement of the airways. These changes in the airways can prevent the appropriate driving pressure and airflow to maintain an adequate clearance of carbon dioxide due to increased airway resistance.[10] The increase in airway resistance also affects inhalation, preventing enough oxygen from reaching the alveoli to create a sufficient partial pressure of oxygen needed to drive the diffusion of oxygen across the alveoli-capillary interface adequately.

The defective driving pressure for oxygenation is further exacerbated due to the retention of carbon dioxide, causing less carbon dioxide to diffuse from the blood into the alveoli for excretion. Blunting the proper mechanism to excrete carbon dioxide and adequate oxygenation stimulates the central chemoreceptors to increase respiration until exhaustion. Chronic hypercapnia decreases the sensitivity of the central chemoreceptors, allowing peripheral receptors sensing oxygen levels to become the predominant drive for respiration.[11][12] Increased purse lip breathing in these patients may indicate impending respiratory failure.

Significant use of PLB in individuals with COPD may indicate respiratory distress or impending respiratory failure.[13] Recognizing this sign allows clinicians to escalate care, potentially including noninvasive or invasive ventilatory support. Even on mechanical ventilation, incorporating prolonged expiration and minimizing auto-PEEP is critical to prevent complications such as inefficient ventilation or oxygenation. Auto-PEEP can be misinterpreted as high peak pressures, delaying appropriate intervention.[14]

Benefits Beyond COPD

For older adults with stable COPD, PLB training has improved lung function and quality of life.[15] The technique is a valuable component of disease rehabilitation, promoting better symptom management and enhancing functional capacity. Evidence supports using PLB alongside other breathing exercises, such as diaphragmatic breathing (DB), in conditions like asthma and other chronic respiratory illnesses.[16] Combining PLB and DB forms a simple, low-cost therapeutic strategy that improves lung function and exercise capacity. These techniques are particularly beneficial for daily respiratory care and as part of comprehensive pulmonary rehabilitation programs.[17]

Applications in COVID-19 

In COVID-19, PLB and DB can play a vital role in rehabilitation.[18] Early pulmonary rehabilitation, including breathing exercises, airway clearance, and physical activity training, can help those hospitalized to maintain functional status, relieve dyspnea, and improve health-related quality of life after discharge. For patients recovering from COVID-19, incorporating PLB into pulmonary rehabilitation can help address dyspnea and support their overall recovery process.[18]

Nursing, Allied Health, and Interprofessional Team Interventions

Implementing PLB as a therapeutic intervention requires coordinated and ethical collaboration among advanced clinicians, nurses, pharmacists, and other health professionals. Advanced clinicians assess the patient’s respiratory condition, prescribe PLB within a broader care plan, and provide evidence-based guidance to the team. Teaching PLB involves explaining its benefits, potential adverse events, and underlying physiology. A proper demonstration should follow, with the trainee performing or explaining the technique to confirm understanding, ensure proper execution, and allow for correction of any mistakes that may occur during the learning process.[19][20] This process minimizes errors and optimizes therapeutic efficacy.

Nurses play a vital role in teaching and reinforcing PLB. They monitor patients for respiratory distress signs such as increased PLB use, dyspnea, or accessory muscle engagement. Nurses’ ability to promptly recognize distress ensures rapid initiation of response teams and prevents further deterioration.[21][22] For conditions such as COPD, congestive heart failure, or panic attacks, PLB can calm the patient, alleviate dyspnea, and potentially reduce the need for noninvasive mechanical ventilation.[23][24] Further, pharmacists optimize medication regimens to alleviate respiratory symptoms, complementing PLB’s benefits. Rehabilitation Specialists integrate PLB into physical therapy sessions, while mental health professionals address anxiety that may exacerbate dyspnea and hinder technique adherence.

Ethical responsibilities include respecting patient autonomy and addressing barriers like literacy or cultural differences during education. Interprofessional communication and care coordination ensure continuity, with regular team huddles and clear documentation fostering collaboration. By actively teaching and reinforcing PLB, health professionals empower patients to manage their symptoms effectively, improving outcomes, safety, and team performance.

Nursing, Allied Health, and Interprofessional Team Monitoring

Effective patient monitoring using PLB requires coordinated efforts by nursing staff, allied health professionals, and the interprofessional care team to enhance patient outcomes and ensure safety.

Nursing Role

Nurses play a pivotal role in teaching PLB, explaining its benefits and potential adverse events, and ensuring proper technique through demonstration and patient practice. They should also educate trainees or patients about when PLB is useful, such as during episodes of dyspnea related to COPD, congestive heart failure, or panic attacks. With frequent patient contact, nurses are well-positioned to identify respiratory distress signs, including dyspnea, use of accessory muscles, and increased respiratory rate. Recognizing these signs allows nurses to alert the appropriate response team and physicians for timely intervention, potentially preventing deterioration and the need for mechanical ventilation. Nurses should also monitor for respiratory muscle fatigue in COPD patients, a common consequence of compensatory PLB, and promptly report concerns to the care team.

Allied Health Professionals

Respiratory therapists refine PLB techniques, ensuring patients perform them correctly and tailor interventions to individual needs. Physical and occupational therapists integrate PLB into rehabilitation programs, assessing its utility during functional tasks or exertion. Mental health professionals provide support to address anxiety or panic that may interfere with effective technique use.

Interprofessional Team Coordination

Collaboration among all team members is vital for effective monitoring and patient-centered care. Advanced clinicians, nurses, respiratory therapists, and other allied health professionals should communicate regularly to evaluate patient progress and adjust care plans as needed. Pharmacists can optimize medications that improve respiratory function, complementing PLB's efficacy. The team must also thoroughly address patient questions and concerns, ensuring comprehension of the risks and benefits of PLB. By fostering comprehensive education, vigilant monitoring, and seamless communication, the interprofessional team can maximize the effectiveness of PLB, improve patient outcomes, and enhance safety.