Talking All Things Cardiopulm
This podcast is designed to discuss heart and lung conditions, treatment interventions, research, current trends, expert opinions and patient experiences.The goal is to learn, inspire and bring Cardiopulm to the forefront of conversation.
Talking All Things Cardiopulm
Episode 78: Enhancing Breath Control with Lateral Costal Breathing
Lateral costal breathing exercise technique is a versatile approach that can be used to help improve lateral costal (side ribs) movement in a variety of patient populations. It is a go-to technique to improve motor control and expansion, as well as decrease anxiety and dyspnea.
Join me in this episode and give this breathing exercise a try.
In this episode:
- How to perform lateral costal breathing technique
- Discuss multiple variations of the approach
- What patient diagnoses or conditions to utilize this approach
- Benefits of using lateral costal breathing
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Welcome to Talking All Things Cardiopulm. I am your host, r Rachel Barisi, physical therapist and board-certified cardiopulmonary clinical specialist. This podcast is designed to discuss heart and lung conditions, treatment interventions, research, current trends, expert opinions and patient experiences. The goal is to learn, inspire and bring cardiopalm to the forefront of conversation. Thanks for joining me today, and let's get after it.
Rachele Burriesci:Today's episode is sponsored by Jane. You might already be familiar with the name, but if it's new to you, jane is a HIPAA-compliant clinic management software and EMR. Chasing down patients for important information isn't anyone's idea of a good time, especially when there are forms to be filled, payments to be processed and consents to be collected. That's why Jane has designed user-friendly online intake forms so you can gather all the information you need prior to the appointment, whether that's health history, insurance details or a credit card on file. Jane will even send a friendly reminder 24 hours before the patient's appointment if they haven't completed their forms yet, saving you from having to manually follow up. To see Jane in action, head to the show notes. Click that link to book a personalized demo, and if you're ready to get started, you can use the code CARDIOPALM1MO at the time of sign up for a one month grace period applied to your new account. Thanks again, jane. All right, welcome back, I guess.
Rachele Burriesci:Life updates first. The garden is still going super strong. I'm trying to do my best to harvest as much as I can. Super strong, I'm trying to do my best to harvest as much as I can. This is always the time of the year where I feel like I run out of time trying to get things picked and canned and anything else, and I'm also always looking for ideas on how to keep certain things. For instance, I have three large squash left and instead of you know making multiple squash recipes in one week, I would love to be able to free some and be able to hold on to them for a longer period of time. So maybe next month if I want to make a zucchini pie, I have zucchini on hand, but zucchini is one of those weird ones where it's typically not advised to free. So if you have any suggestions, shoot me a DM. I would love to hear them. Zucchini is one of those hard ones that I wish I knew how to hold on to them longer so I can have them for future use. But I have three giant zucchinis left, and so I'm trying to figure out what I'm going to do with them.
Rachele Burriesci:Next, I made zucchini lasagna last night and that was amazing. The one thing I would advise I use a skinny taste recipe for the zucchini lasagna. She says an eighth of an inch thick on the mandolin. I cut them by hand and I definitely went bigger than an eighth of an inch because you have to grill them and if you slice them too thin it's just going to shrivel up. So the thicker slices actually held up really nice and had such great texture and flavor.
Rachele Burriesci:Adding that one to the rotation, what else we got? Basil, basil, basil, basil. I think I really basil, basil, basil. I think I really, truly think I need like a farm stand. Maybe I need to open a table at the farmer's market next year.
Rachele Burriesci:I love to share my vegetables Just because it's, I don't know, something that I grew up doing. It's also just like a friendly I don't know. Food is so important to me in the sense of like creating relationships and showing love, like if I make you something, that means I care about you. So I have basil, I'm making pesto, I freeze the pesto I think I'm like up to 16 at this point, and I typically give them to close friends and such for. You know an easy dinner night and it stays literally for a year, which is amazing, right? So I'll have pesto throughout the year and that's. That's super simple. Freeze is super nice. I even did some regular sauce this year and we didn't do like sauce day this year.
Rachele Burriesci:We still have enough probably to make it through half the year, and I really have a hard time finding Roma tomatoes in Kansas City like this is a problem. So again, I'm gonna throw it out to my listeners anyone in the Kansas area, missouri area, if you know someone who has like a farm that has Romas and sells them by the bushel, please let me know. This has been one of the hardest things to like find living here. Apparently, romas aren't very common in Kansas. Maybe there aren't as many crops, I'm not sure. Or I'm gonna have to start like really going to farmer's market markets and making friends with the farmers, because I can't. I can't get Romas by the bushel and when I do, they're either super underripe or way over. So I haven't had a good experience getting bushels of tomatoes here and I don't make enough in my garden to like. I usually do 10 bushels. I'm not even close to that. So I made six jars of actually pizza sauce so that I don't have to do the work when I'm making pizza in the future. So hopefully that works well. I've never done it the way that I did it, so we'll find out if it was successful. And then, of course, we have the paver patio Update.
Rachele Burriesci:On the paver patio I don't think we've made it much further since last time we spoke. Nikki is going through some triage on building a retaining wall because we have to add so much dirt in. She's afraid that it's going to spill out and not support the pavers. So we're working on that. I've been adding dirt kind of gradually so that it starts really stamping down. I've been oh God, what's that word? I want to say composting, but that's not the right word Basically slamming the dirt down manually. I want to say compost again composter, what is the word? There's a word, it'll come to me. Anyway, that's been going. We finally got the actual machine, so hopefully this Wednesday we'll make a little bit more progress.
Rachele Burriesci:I think I want to put bets out there. Who thinks that we're getting this project done before November? That's going to be like ultimate end deadline. Right, you have to do it before it starts freezing. My goal is, I want to say October 5th, but I feel like that's already next weekend. Let's say the weekend after that. It must be like October 12th or something. We'll say halfway through October is my guess. I'll put a date out there. Let's see October. Let's say October 20th. October 20th, the project will be done. You can hold me to this. We could put bets out there. Obviously, I have nothing to give away for this. But what you thinking? This one's going to take a little bit of time and at this point I don't think I have any free weekends. So it's going to be our Wednesday project. So we'll see October, october, actually, let's do October 23rd, because that's a Wednesday, october 23rd, that's the deadline. Putting it in the universe, the paver patio will be finished, all right. Well, back to the good stuff.
Rachele Burriesci:Now that you know all the craziness that is happening over here, I want to talk about lateral costal breathing. I haven't given it its own episode. I definitely have talked about it in previous episodes, where I've discussed multiple breathing exercises that I perform. So on a daily basis. I typically am doing inspiratory holds, personal breathing, diaphragmatic breathing to some extent, and lateral costal breathing. Lateral costal breathing is something I throw in more frequently than I think I realize because it's such a versatile technique. It can help with both inhale and exhale, and the list of diagnoses that I would use this technique for is pretty endless. So, in theory, lateral costal breathing is a technique where you're placing your hands on the lateral costals or the side ribs to encourage lateral costal movement, whether that's, you know, moving up and out on inhale or down and in on exhale.
Rachele Burriesci:I've used this technique with patients who have, like one-sided, specific low bar pneumonia. I've used it with patients that have old rib fractures. I've used it with patients that have new rib fractures that are non-displaced Um, but I'll get into the detail about that. I would never do overpressure on that, but the the tactile cue is super helpful. Patients that have sternotomies, thoracotomies, clamshell incision, neurologic conditions that are either one-sided or just kind of total due to weakness. So like CVA is a good example, where we have one-sided weakness and maybe one side of the rib cage really just isn't activating well versus like Guillain-Barre MS might be a more global sort of weakness.
Rachele Burriesci:Patients that have been in the hospital for a long period of time, where they have been in bed for a number of days and just have global weakness, can also benefit from this technique and tend to have some motor dysfunction or just, you know, poor sequencing of their breathing techniques. Patients who are apical breathers, so where they're just upper chest breathing all the time and they just don't use their lateral costals much, one-sided pleural effusion or bilateral pleural effusions, someone who has a recent chest tube or a chest tube recently removed. Patients that were currently intubated, or patients that are intubated that are awake and following commands and you're working with them. This is a really cool technique that I have used with the intubated patient whose respiratory rate is increasing either due to anxiety or just because their work of breathing is increasing from the activity that they're doing. This is my go-to move for this patient. And then outside of intubation, same deal If your patient is getting really anxious increased shortness of air, dysmyc on exertion, and they're just having a hard time coming down from that activity, or we compound that with decreasing SATs, my hands are on the lateral costals and this is the technique that I'm doing. So really, sky's the limit with this one.
Rachele Burriesci:When you're using lateral costal breathing, in theory you have decreased lateral costal movement, either bilaterally or one-sided, and you would assess that prior to using this technique. But again, it can be used for that anxious patient who may have normal lateral costal movement but this can actually help calm them down, down. So you can perform this technique in supine sitting or standing as well as side lying or side bending. So essentially you can aim bilaterally supine sitting, standing or you can really isolate it with, excuse me, a side lying technique or abending technique. Either can be super helpful.
Rachele Burriesci:Oh, I'm going to throw one more person on that list Patients with COPD so I'm talking emphysema, chronic bronchitis, that real barrel-chested patient tend to have minimal lateral costal movement and I will throw this technique in quite a bit just to get a little bit of motion, more distally and can have really good benefits. So, like I said, this one has a laundry list of patients, patient type conditions that can be used and benefit from. So if we're using a bilateral technique and we can say patience and sitting, I tend to put my hands in a flat position, fingers pointing up towards the rib cage, palm side down, so that you're kind of hugging the rib cage and you're going to follow the motion of normal movement right. So when we inhale we're expecting a up and out type movement and on exhale we're expecting a down and in type movement.
Rachele Burriesci:Whenever I perform this type of technique, I always place first ask permission or let them know what you're doing, but I let them breathe just with my hands on their chest wall before I get into the technique, because it allows you to sync with their breathing pattern and it also allows them to pay attention to your hands. So my first cue is really pay attention to my hands, and that's might be as much as I say that mind body connection is so important, that tactile cue is so powerful. So first thing I do is just say pay attention to my hands when you're breathing. Then I'll say I want you to try to breathe into my hands on the next breath, the exhale I don't give any cues to them. So when you're doing lateral costal breathing you can literally just have hands on the lateral costals and cue the inhale and exhale. You're just following them through the pattern and just provide a tactile cue.
Rachele Burriesci:Or you can do what's called lateral costal breathing with manual overpressure. This is the technique that I typically use when it's appropriate. So who wouldn't I use it with Someone who has an acute rib fracture, maybe someone who has an active chest tube, maybe someone who has an active chest tube, anyone else who I wouldn't do it with? I think those are like my top two and the chest tube. One really is hand positioning and just making sure that you're not providing pressure over that tube. The rib fracture is the obvious one.
Rachele Burriesci:So when you're giving the overpressure, what you're doing is placing your hands same spot, having them breathe into your hands on inhale, and then on exhale you're providing an overpressure down and in through that exhale. When they go to inhale again, you have two options. One, you just maintain the pressure so they're almost inhaling through resistance, or you let go of that pressure right, and so it depends on your person. It depends on if they have a weakness, it depends on if you're really trying to get them to cue. Sometimes providing that overpressure and maintaining it through the inhale gives them a better cue to really push your hands out. So you have to play with it. You have to kind of see how your patient is feeling with the technique. But that overpressure to really extend the exhale can be so beneficial for your emphysema, chronic bronchitis patient because you can literally help them extend that exhale.
Rachele Burriesci:What I haven't mentioned yet is pairing another breathing technique alongside the lateral costal breathing. So I tend to do lateral costal breathing with an IE ratio, so a one to two, a two to four, three to six. But if that person happens to be a patient with emphysema, I will do a two to four ratio with per slip breathing and give that overpressure on exhale with the lateral costal breathing, kind of getting the most bang for your buck. And I feel like I do that more now, where I'm doing combination techniques, versus we're going to do personal breathing first, then we're going to do lateral costal breathing, then we're going to provide overpressure, you sort of combo it to get the most benefit out of your exercise, and that's something that you can then carry over with your patient. There are times, though, that I do those exercises separately and maybe in different scenarios or across the treatment session, so you have to sort of feel what's going to maximize your patient, what else when we're, we'll add one more thing into the bilateral lateral costal breathing with manual overpressure.
Rachele Burriesci:There is another technique that you can sort of piggyback on this, where you're providing a quick stretch. This is a technique I learned from Mary Massery and what she does, and she uses this typically with a neurologic population is she's providing tactile cues for the inhale, she's providing overpressure on the exhale and then right at the end of exhalation, just before you're about to start inhalation, you do a quick stretch, so like a quick down and in, and that helps provide a more like a rebound effect for your inhale and it gets an even bigger inhale effect. And that's how it's a really cool technique to benefit both inhale and exhale and, like I said, you can adjust it to your patient and their diagnosis. Right, sometimes you're really just concentrating on the inhale and providing a tactile cue on exhale, sometimes you are providing pressure on inhale and exhale and then again, with that neurologic population, you might be adding a quick stretch to the end to really get most bang for your buck on that. You can also isolate. Oh, actually, let me back up, I'm going to stick to the bilateral so I don't switch back and forth.
Rachele Burriesci:You then can teach your patient to do this on themselves. So I always have them do flat hands and then they're actually going to do different. They're not going to have hands up, they're going to have hands down, like hands in the pocket, and same deal they're going to be following the rib cage and they can provide tactile cue for inhale and even give a little overpressure on exhale. They tend to have a hard time providing pressure to themselves, just from a sequencing and timing perspective, but it can be done. The limitation with them using their own hands tends to be lack of shoulder range of motion, so many of my patients just can't get in the position to put their hands on their lateral costals appropriately. In that case you can actually give them a sheet or a blanket or a towel and you would roll it up, wrap it around the back, cross it in front and you're going to give a little tension. So you have a little tension, tactile cue for the inhale and then on exhale you're pulling down and in crossing those hands throughout the exhale so they can literally provide lateral costal breathing to themselves independently and this is a great progression. This is a great technique to use if you're doing virtual therapy. This is a great technique to use if you want to add it to their home exercise program and they physically can't get into the position. The one patient population I would not use the towel is an acute rib fracture because they're going to be providing pressure through the exhale and you just don't want to take any risks with that.
Rachele Burriesci:If this is truly a one-sided deficit, maybe one-sided pleural effusion, maybe they had a recent thoracentesis. Maybe they had an old rib fracture on one side, maybe like multi-level it's been about a year. They never did anything about it. Maybe they had a thoracotomy that's well healed and you really want to isolate that side. There are two ways that you can kind of hone in on that. Number one is sideline. Get the patient in sideline, have the arm up over their head. You can again we can throw in a combo technique where you do a paired breathing with sidelying. You can simply have your hand on the lateral costals and, same deal, breathe into my hand, provide overpressure on exhale.
Rachele Burriesci:If it is a new thoracotomy or a new fracture, you can still do the sideline technique, just no overpressure on exhale, but you're really going to isolate that side and encourage expansion, which sometimes is all you need is just kind of getting that side to go. Maybe they have profound atelectasis on one side. This is a great technique to just really focus in on that one side. You can also do it in sitting or standing, except now we're going to throw a side bend in so we can side bend, place one hand on the ribs, have them breathe in on inhale, out on exhale, with overpressure down and in In on inhale, tactile cue for the hand, overpressure down and in on exhale, and again you can have the patient put their hand on their rib cage. You can use the sheet technique with the side bend technique as well. It's just one hand is doing the pulling and the other just maintains tension. It's a great technique, gives a lot of independence, really facilitates movement of that one side and can really localize that breathing technique, which is very beneficial, that breathing technique, which is very beneficial. And then you can even do a side bending, paired breathing activity where they're going to inhale on the side bend, which is opening up the cage on that side, on the right side, on the facilitated side, and then you're going to exhale and come to neutral. So you just have to play with it. When you're adding the combo techniques, you also have to have the right person to do that. Sometimes just getting them to sequence, just getting them to cue to the lateral costal is enough mental focus. Don't add in a paired technique, pursed lip breathing, counting all of the things if they can't sequence.
Rachele Burriesci:For the patients that are having a really hard time with just getting motion, a really hard time with just getting motion facilitating a calm breathing pattern. You're going to use other techniques. A lot of times I use counting. Counting can work wonderfully for patients. So I go with 1-1000, so 1-1000, 2-1000, and then out 1-1000, 2-1000, so on and so forth. Right, some people do great with that. Some people get really anxious and cannot tolerate the talking. Sometimes I'll just do a normal count 1-2, and I space it out so that I can control that it's a true timing. But sometimes it just gives them anxiety If counting and verbal stimulus is making it worse.
Rachele Burriesci:One of my favorite techniques is just to audibly breathe. I do the breathing pattern. They follow me. If you have someone who is super anxious, if you have someone who's really short of breath, dyspneic on exertion, I find that when you audibly breathe with the patient they tend to come down faster than the auditory. Verbal cues Telling patients to extend the exhale can be beneficial in those situations, but sometimes it's just words in that moment. So physically breathing with them can be super beneficial in getting them to sequence and do two things at once. So if you're having a really hard time with them learning the technique or sequencing, like just the motor learning piece of it, and you're trying to get them to utilize an IE ratio and they just can't. You know dual task that try breathing with them. So I'll do the count in my head, right, and I'm going to breathe and out for four, in for two, out for four, and instead of saying in for two, out for four, I am literally just breathing with them and they tend to be able to follow that really nicely. I think it kind of calms the system. You sort of sync up, obviously, make sure that you're you're utilizing an IE ratio that they can maintain or hit, and you might have to adjust it in the beginning, especially if someone is actively dysmic. You have to sort of meet them and then start extending slowly and they come out of it. It's just a very easy technique.
Rachele Burriesci:The patient who is intubated this is by far my favorite technique to use. You really can't facilitate a ton when a patient is intubated. They can only control so much, especially depending on the settings that they're on. If they're on a setting that is providing most of the pressure, they're not going to be able to coordinate anything because they're being pushed air in. But if their respiratory rate is increasing, whether it's due to anxiety, whether it's because it's increased aerobic capacity, in that moment they're increasing their activity more than they have been doing, even if it's just bed exercises or they're sitting up for the first time, and that postural control is really increasing their respiratory rate. Put your hands on their lateral costals, follow their breathing pattern it will be quick and then slowly try to extend that exhale with manual pressure, and they tend to slow down. Watch the respiratory rate on the monitor. It is by far my favorite technique to help calm down that anxiety and decrease respiratory rate in the patient who has poor control or who is just requiring more support to do, you know, low level activity. So give that a try, Play with it.
Rachele Burriesci:Play with your cues, your hand positioning what patient you're utilizing it with. Pay attention to your patient's facial cues. Make sure that your overpressure isn't aggressive. You're really just providing a helpful assist through exhale. Right, you just want to follow that breathing pattern. You want to provide an in and down pressure.
Rachele Burriesci:One of the things I have seen with students who are just trying these things for the first time is either over or under pressure. This is something that takes time and skill to develop. Make sure that you're not doing like a CPR press. You want to make sure that you're following the rib cage, not horizontally. You know, pushing in the down and in sequence. The together motion is really the most important. So practice on a family member. Have them give you feedback. Practice on another student, practice on another PT before trying it with a patient. The same stuff that we do with everything else, but give it a try, see how it feels.
Rachele Burriesci:Get used to your cueing, whether it's more verbal cues, auditory, breathing cues, tactile cues, whatever it is, it's going to be different for each patient and you have to have multiple ways to get that message across. All right. So if this was new information for you, or you haven't tried this, or you got something out of, maybe a technique that you're already doing, let me know if this was helpful. Hope it was helpful. Reach out to me if you have any questions. I think that's all I have for you today. So I hope you all have a wonderful day. Whatever you have to do, I get after it.
