As the world continues to grapple with the effects of COVID-19, the importance of pulmonary rehabilitation has come to the forefront. Pulmonary rehab is essential for patients recovering from the virus, as it helps restore lung function and improve overall health. Incorporating targeted breathing exercises for the lungs can significantly enhance this rehabilitation process, promoting better oxygenation and respiratory efficiency. Additionally, utilizing a breathing exercise device for lungs can further aid recovery by providing structured support for lung function improvement. Many individuals can benefit from pulmonary rehab exercises at home, allowing them to engage in effective recovery routines in a comfortable environment. This article explores the role of breathing and HRV biofeedback in optimizing pulmonary rehabilitation after COVID-19, highlighting how these techniques can support patients on their journey to recovery.
COVID-19 ASSOCIATED PNEUMONIA
SARS-CoV-2, the virus that causes COVID-19, is part of the coronavirus family.
When the virus gets in your body, it comes into contact with the mucous membranes that line your nose, mouth, and eyes. The virus enters a healthy cell and uses the cell to make new virus parts. It multiplies, and the new viruses infect nearby cells.
Think of your respiratory tract as an upside-down tree. The trunk is your trachea or windpipe. It splits into smaller and smaller branches in your lungs. At the end of each branch are tiny air sacs called alveoli. This is where oxygen goes into your blood, and carbon dioxide comes out.
As the infection travels the respiratory tract, the immune system fights back. The lungs and airways swell and become inflamed. This can start in the alveoli of one part of the lung and spread to the nearby alveoli of other parts.
In pneumonia, air sacs in the lungs fill with fluid, limiting their ability to take in oxygen and causing shortness of breath, cough, and other symptoms.
Doctors can see signs of respiratory inflammation on a chest X-ray or CT scan.
On a chest CT, they may see “ground-glass opacity” because it looks like the frosted glass on a shower door.
(a) Axial thin-section non-contrast CT scan shows diffuse bilateral confluent and patchy ground-glass (solid arrows) and consolidative (dashed arrows) pulmonary opacities. (b) The disease in the right middle and lower lobes has a striking peripheral distribution (arrow). [Radiological Society of North America].
THE EFFECT OF COVID-19 IN SHORT-TERM AND LONG-TERM FOLLOW-UP
The effect of COVID-19 will vary significantly throughout the disease, with most people experiencing some of the following symptoms:
- fever,
- cough, sputum production, shortness of breath,
- fatigue,
- anorexia,
- myalgia,
- central nervous system manifestations (such as headaches, migraines, dizziness, and ataxia),
- and peripheral nervous system manifestations (such as nerve pain, speech, vision, and taste problems).
While some of these symptoms may resolve naturally, some people may have impairments that persist, particularly following a prolonged hospital and ICU stay.
Doctors in Hong Kong (March 13, 2020) reported the findings of the first follow-up clinics of recovered Covid-19 patients. They suppose some recovered patients have lost between 20% and 30% of their previous lung function (South China Morning Post). The doctors report that lung scans of recovered patients also reveal substantial lung damage.
Researchers revealed that six weeks after hospital discharge, more than half of the patients had at least one persistent symptom, predominantly breathlessness and coughing. CT scans still showed lung damage in 88% of patients. However, by the time 12 weeks after discharge, the symptoms had improved, and lung damage was reduced to 56% (COVID-19 Patients Suffer Long-Term Lung and Heart Damage – But They Can Recover With Time – By European Lung Foundation, September 7, 2020). There’s the initial injury to the lungs, followed by scarring. Over time, the tissue heals, but it can take three months to a year or more for a person’s lung function to return to pre-COVID-19 levels.
In the recovery period, people with COVID-19 may be expected to present with significant muscle wasting in both the locomotor and respiratory muscles. This may contribute to ongoing breathlessness and fatigue, reduced exercise capacity, poor balance, and loss of functional independence (Rehabilitation following COVID-19 in the pulmonary rehabilitation setting. JUNE 2020. Respiratory Network).
PULMONARY REHABILITATION PROGRAMS AFTER COVID-19
Changes in the anatomical and physiological properties of the chest’s tissues and organs caused by disease lead to decreased elasticity in the lungs and surrounding tissues. As a result, the energy cost of ventilation increases. The respiratory muscles must work harder to overcome both elastic and bronchial resistance, significantly raising their workload. This increased energy cost, combined with the depletion of respiratory muscles, contributes to shortness of breath and a sensation of air hunger. Together, these sensations form the complex experience commonly referred to as “shortness of breath.”
Many pulmonary diseases reduce the respiratory surface of the lungs and lead to ventilation disorders, such as restrictive syndrome. This decrease in lung volume occurs for two main reasons. First, hardening of the lung tissue contributes significantly. Second, restricted lung mobility also plays a crucial role. Together, these factors lead to a notable reduction in lung volume. Adhesions can form and prevent the lungs from expanding fully. When pleural inflammation also occurs, chest movement becomes intentionally limited, as severe pain restricts chest excursion.
Exercise therapy in pulmonology has several key tasks. First, it aims to achieve regression of reversible changes in the lungs. Second, it focuses on stabilizing irreversible changes. Additionally, exercise therapy promotes compensation and normalization of lung function.
- General tonic effect: stimulation of metabolic processes, increase in neuropsychic tone, recovery, and increase of tolerance to physical activity, stimulation of immune processes;
- Preventive effect: mastery of breathing control technique, an increase of the protective function of the respiratory tract, reduction of intoxication;
- The pathogenic (therapeutic) effects include several essential improvements. First, exercise therapy enhances external respiration functions. Second, it corrects the mechanics of breathing. Additionally, it accelerates resorption during inflammatory processes and improves bronchial patency. Furthermore, it removes or reduces bronchospasm. Finally, it regulates external respiration functions and increases their reserves.
General Tonic and Special Breathing Exercises
In exercise therapy for respiratory issues, various techniques are applied to improve overall health and target specific respiratory functions.
First, general tonic exercises help enhance the function of all organs and systems, while moderate and high-intensity exercises specifically stimulate external respiration.
Low-intensity exercises, however, lack a training effect on the cardiovascular and respiratory systems.
Additionally, special breathing exercises strengthen the respiratory muscles, increase chest and diaphragm mobility, and reduce congestion. These exercises promote pleural stretching, ease sputum excretion, and enhance breathing coordination and movement.
Furthermore, breathing gymnastics techniques focus on correcting pathological breathing patterns, relaxing tense muscle groups, and improving respiratory muscle function.
Muscle Relaxation Techniques
Techniques such as autogenous training, post-isometric muscle relaxation, and physical exercises for associative and segmental muscles are helpful to support relaxation. Therapeutic massages, including myofascial release and segmental reflex massage, also address myofascial muscle changes. Exercises involving segmental and associative muscles are most effective for these issues. Moreover, incorporating weights like sandbags in breathing exercises strengthens the abdominal and intercostal muscles and increases diaphragm mobility.
Fundamental Lows of Breathing
Performing breathing exercises requires compliance with the fundamental laws of breathing:
- before any physical activity, it is necessary to remove residual air from the lungs, for which it is necessary to exhale through the lips folded into a tube;
- inhalation is mainly (80%) carried out by the diaphragm, while the muscles of the shoulder girdle should be relaxed;
- the duration of the exhalation should be approximately 1.5-2 times longer than the inhalation;
- Inhalation occurs when the chest is extended, and exhalation occurs when it is compressed (for example, when bending over).
Techniques for Exhalation and Breathing Rate Control
Exhalation is usually carried out by relaxing the muscles involved in inhalation under the influence of the chest’s gravity; delayed exhalation occurs with the dynamic inferior work of these muscles. The elastic forces of the lung tissue remove air from the lungs.
Forced exhalation happens when the muscles responsible for exhalation contract. You can strengthen exhalation by tilting the head forward, bringing the shoulders together, lowering the arms, flexing the trunk, and raising the legs forward. Additionally, breathing exercises allow you to adjust the breathing rate freely.
More frequently, exercises focus on voluntarily slowing down the respiratory rate. In this case, it is helpful to count silently to yourself. This practice reduces the speed of air movement and decreases resistance as air passes through the airways. Increased breathing frequency increases breathing speed. Consciously learning to regulate breathing starts with static exercises. Incorporate rhythmic static breathing exercises, as these help decrease respiratory movements by deepening them. At the same time, this practice strengthens the respiratory muscles and tones the intercostal muscles.
Enhanced Breathing Techniques and Muscle Strengthening
Breathing with additional resistance (inhalation through lips folded into a tube, through a tube, inflation of rubber toys) reduces the frequency. It increases the depth of breathing and activates the work of the respiratory muscles. Breathing through the nose is recommended because it moistens and purifies the inhaled air. Moreover, irritation of the receptors in the upper respiratory tract reflexively expands the bronchioles. As a result, this deepens breathing and increases blood oxygen saturation.
If necessary, to spare the affected lung, apply the initial positions that limit the chest’s mobility from the affected side (lying on the affected side).
Using weights such as sandbags when performing breathing exercises helps strengthen the abdominal and intercostal muscles and increases the mobility of the diaphragm.
To dose physical activity effectively, you can adjust several factors. First, change the initial position. Second, modify the pace and amplitude of the movements. Additionally, vary the degree of muscle tension, the number of exercises performed, and their duration. Finally, rest pauses and relaxation exercises should be incorporated to enhance the overall effect.
- THE ONLY RMT DEVICE FEATURING INDEPENDENT INSPIRATORY/EXPIRATORY DIAL CONTROL.
The Breather functions as both an inspiratory and expiratory muscle trainer, with adjustable dials for independent resistance settings for inhalation and exhalation. It is the ultimate device for respiratory care. Think of it as a lung trainer, supporting respiratory health and efficiency by promoting diaphragmatic (belly) breathing. - DESIGNED TO HELP IMPROVE OXYGEN FLOW.
This inspiratory exerciser benefits those undergoing respiratory treatment. The Breather is a respiratory trainer or exerciser that improves lung strength and capacity by increasing oxygen uptake to vital organs. - DRUG-FREE THERAPY FOR COPD, CHF, AND DYSPHAGIA
The Breather is used by those affected by COPD, CHF, dysphagia, and neuromuscular disease. Continued use has improved dyspnea, peak cough flow, laryngeal function, QOL, vent weaning, and speech and swallowing performance. - ONLINE VIDEOS AND A DEDICATED MOBILE APP.
PN Medical, creators of The Breather, offers self-paced, online video protocol training for therapists, patients, and consumers. Additionally, the Breather Coach mobile app lets you track and monitor your progress from your phone. - There are five expiratory and six inspiratory adjustable independent pressure settings. You can adjust the resistance on each inhalation and exhalation. The higher the setting, the higher the resistance.
CLINICAL BENEFITS
The Breather exercise optimizes the blood flow to your working muscles, increasing your performance capacity and extending your exercise limits. It improves the strength of your diaphragm and other respiratory muscles while maximizing lung function. The exercise strengthens your cardiac system and circulation, reducing blood pressure and improving sleep.
Special techniques of breathing exercises
Sound gymnastics
It is a unique breathing exercise consisting of pronouncing consonant sounds in a certain way – buzzing (zh, z), sibilant and hissing (s, f, ts, ch, sh), growling (r), and their combinations. In this case, the vibration of the vocal cords is transmitted to the smooth muscles of the bronchi, lungs, and chest, relaxing the spasmodic bronchi and bronchioles. Sound gymnastics aims to develop the correct ratio of inhalation and exhalation – 1: 2 (1.5). All sounds should be pronounced in a strictly defined way, depending on the purpose of gymnastics. For example, in bronchial asthma, buzzing, growling, and hissing sounds are pronounced loudly, energetically, exciting, and in chronic obstructive bronchitis with severe respiratory failure – softly, quietly, acceptable in a whisper (soothing).
Method of volitional elimination of deep breathing (VEDB) K.P. Buteyko
This technique originated in 1960 when Novosibirsk doctor K.P. Buteyko developed it. Its goal is to voluntarily correct incorrect (deep) breathing and gradually eliminate it. This is important because deep breathing can lead to a lack of carbon dioxide in the blood. Consequently, this deficiency causes a shift in the acid-base balance towards alkalosis and results in tissue hypoxia. When low carbon dioxide levels, oxygen binds firmly to hemoglobin and fails to enter cells and tissues.
The main tasks of the VEDB method are:
- to normalize the ratio of inhalation and exhalation,
- to reduce the speed and depth of inhalation,
- to develop a compensatory pause after a long and calm exhalation,
- to normalize the carbon dioxide content in the blood,
- to reduce the number of asthma attacks and prevent their occurrence.
Paradoxical breathing exercises
These exercises help relieve an attack of suffocation. Gymnastics is called “paradoxical” because inhalation and exhalation are performed simultaneously with the movements of the arms, trunk, and legs, complicating this breathing phase. When the chest is compressed, inhalation is made, and when the chest expands, exhalation is made. The inhalation should be short, sharp, noisy, active, and forced by the diaphragm; exhalation occurs passively and spontaneously. Inhalation is carried out only through the nose, exhalation independently, passively (so that it is not audible), preferably through the mouth. You should not delay exhalation.
The action mechanism of paradoxical respiratory gymnastics on the body consists of restoring disturbed nasal breathing, improving the drainage function of the bronchi, and activating the work of the diaphragm and chest muscles. Gymnastics promotes the resorption of inflammatory formations, the restoration of normal lymph and blood supply, and the elimination of local congestion. Eliminating morphological changes in the bronchopulmonary system enhances alveoli and tissue respiration gas exchange. It leads to an increase in oxygen absorption by tissues, which has a positive effect on metabolic processes. The coordination of breathing and movement helps to restore the regulation of breathing by the central nervous system, improves the psycho-emotional state, and has a general tonic effect.
The Role of Modern Oriental Respiratory Techniques and Pulmonary Rehabilitation in Health Recovery
Modern oriental respiratory systems, such as qigong, tai chi, and hatha yoga, focus on voluntarily controlling breath depth and frequency while balancing inhalation and exhalation. In these practices, the diaphragm plays an active role in breathing, and concentration and relaxation are equally important. Learning specific types of breathing—such as upper chest, costal, diaphragmatic, and full breathing—also becomes essential. Eastern breathing techniques are often promoted by enthusiasts and used in alternative medicine. Beyond their physical benefits, these techniques carry philosophical meanings to achieve harmony, harness inner strength, and enhance overall health.
To determine if a technique is suitable, one should consider one’s health status after exercise. Physical activity, in general, directly improves muscle function, motivation, mood, and symptoms. It also positively impacts the cardiovascular system, contributing to overall well-being.
Video – How to perform pulmonary rehab exercises at home
Special Considerations for COVID-19 Pulmonary Rehab
For individuals recovering from COVID-19 and undergoing pulmonary rehab, it is essential to consider the risk of pulmonary rehab exercise at home desaturation due to impaired gas transfer. Monitoring oxygen saturation levels may be necessary, and some individuals may require supplemental oxygen during rehabilitation exercises. Pulmonary rehabilitation programs should integrate both physical and psychological components and begin as early as possible after hospital discharge. Ideally, rehabilitation should continue for weeks or months to promote full recovery. By extending this support, patients are less likely to experience long-term disability after pneumonia and more likely to regain health.
THE ROLE OF RESPIRATORY (BREATHING) AND HRV BIOFEEDBACK IN PULMONARY REHAB AFTER COVID-19
Respiratory (breathing) and Heart Rate Variability (HRV) Biofeedback is a relatively new method of teaching people to change the parameters of respiration and cardiac activity. Recent research indicates the effectiveness of these biofeedback modalities in the treatment of many medical and psychological conditions, including:
- anxiety disorders,
- depression,
- asthma,
- chronic obstructive pulmonary disease,
- cardiovascular diseases,
- cardiac rehabilitation,
- hypertension of various origins,
- chronic fatigue,
- chronic muscle pain,
- post-traumatic stress disorder (PTSD),
- insomnia
- and other conditions, as well as to improve performance and professional efficiency.
Since the onset of the coronavirus pandemic, breathing and HRV biofeedback have been widely used in pulmonary rehabilitation after COVID-19.
Breathing and HRV biofeedback are not separate forms of therapy/training but are part of a larger multimodal team approach to pulmonary rehab exercises after COVID-19.
What is the mechanism of action and effectiveness of breathing and HRV biofeedback in pulmonary rehabilitation after COVID-19?
The HRV biofeedback technique includes training in breathing at the resonant frequency of the cardiovascular system. Breathing at this rate causes the heart rate to increase and decrease in the same phase as breathing. The heart rate increases with inhalation and decreases with exhalation. Then, the efficiency of gas exchange in the respiratory tract is maximal. The higher the HRV indicator (that is, the greater the difference in heart rate during inhalation and exhalation), the higher the degree of organism adaptation to the different external and internal stressors.
HRV biofeedback stimulates a specific reflex in the cardiovascular system with a particular rhythm. It is called “baroreflex” and helps control blood pressure. It also helps control emotional reactivity and improves breathing efficiency. Baroreflex is controlled by the nucleus of the solitary tract located in the brainstem. This center communicates directly with the amygdala, the center of emotional control, through a pathway through the islet. It is perhaps for this reason that various studies have shown the beneficial effects of respiratory biofeedback and HRV in the treatment of anxiety, phobias, and depression.
When blood pressure goes up, the baroreflex causes the heart rate to go down, and when blood pressure goes down, the heart rate goes up. This causes a rhythm in heart rate fluctuations. The baroreflex system resonates when a person breathes at this exact rhythm (which varies among people, generally between 4.5 and 6.5 times a minute).
How do we find the frequency at which the baroreflex system resonates for each person?
This frequency will produce the most significant swings in heart rate between inhaling and exhaling. To find this frequency, a person should try to breathe at various rates per minute to find the exact frequency at which the cardiovascular system resonates. This will be his/her resonance breathing frequency. This frequency varies from individual to individual, but it is approximately 0.1 Hz or six breaths per minute. The baroreflex system is stimulated and strengthened when people breathe at this frequency. Through projections to other systems in the body (e.g., inflammatory and limbic systems), different events occur that produce the many beneficial effects of HRV biofeedback. These changes are achieved with the help of HRV biofeedback training.
The Benefits of Controlled Breathing and HRV for COVID-19 Recovery
At around six breaths per minute, controlled breathing enhances internal regulation by establishing a balanced respiratory cycle. With each cycle, this method creates pronounced shifts in the autonomic nervous system, smoothly transitioning from parasympathetic to sympathetic states and back again. Heart rate variability (HRV) reflects this dynamic balance between sympathetic and parasympathetic influences on the heart rate, which signals autonomic flexibility. This flexibility represents the body’s ability to respond in a well-regulated way to various stimuli.
The resonance of the baroreflex circuit amplifies respiratory sinus arrhythmia, resulting in significant fluctuations in vascular tone, heart rate, and blood pressure. This ideal balance of relaxation and alertness supports homeostatic functions, optimizes neurovisceral integration, enhances efficient gas exchange in the lungs, reduces pain perception, stimulates anti-inflammatory responses, and builds resistance to both physical and emotional stress. Because of these benefits, patients with COVID-19 are encouraged to practice controlled breathing at a rate of six breaths per minute in the early stages of the disease. This practice promotes neuromodulation and may help prevent vascular and immuno-inflammatory complications.
Pulmonary Rehabilitation with Breathing and HRV Biofeedback
Incorporating breathing exercises and HRV biofeedback into COVID-19 pulmonary rehabilitation accelerates lung function recovery, restores tone in respiratory and skeletal muscles, and improves gastrointestinal and psychoemotional health. This comprehensive approach may also prevent pulmonary complications following COVID-19, offering holistic support for full and sustained recovery.
HOME-USE PERSONAL BIOFEEDBACK DEVICES FOR PULMONARY REHABILITATION AFTER COVID-19
Today, thanks to the development of technology, there are many HRV and breathing biofeedback devices for personal use at home.
Various companies have developed and presented commercial products ranging from $80 to $200.
The main requirements for HRV and breathing biofeedback devices for personal use are that the equipment must have a sensor for measuring heart rate (heart rate variability) using an electrocardiogram (ECG) and a respiration sensor using a breathing belt (recording the respiratory rate).
The eSense Respiration and eSense Pulse HRV Biofeedback devices are the most effective home-use devices for breathing and HRV biofeedback, allowing individual home comfort training.
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