By Lee Guion, MA, RRT, FAARC

Neurorespiratory Clinical Specialist.

You can maximize lung function at every stage of ALS, even before you experience symptoms of shallow breathing. Beginning with this column, I will describe a variety of techniques to choose from with links to instructional videos.

The goal of all the exercises is to stretch lung muscles and recruit air sacs that may be underinflated due to reduced physical activity or decreased lung capacity.

General benefits include: stronger cough, better voice projection, improved gas exchange (more oxygen in/more carbon dioxide out), and helping the lungs do their job of moving the mucus lining up and out of the airways

Additional benefits may include: a sense of wellbeing and relaxation that accompanies slow, deep inhalation and full exhalation, reduced stress, and lessened anxiety.

“No-tech” strategies include:

Breath stacking

Segmental and diaphragmatic breathing

Glossopharyngeal “frog” breathing
Active cycle breathing
Huff coughing
Manual cough assistance

“Low-tech” strategies include:

Incentive spirometry
Breath stacking with manual ventilation “Ambu” bag

Mechanical “high-tech” strategies will follow.

Breath stacking

Two short training videos can be found on Amy & pALS’ Solutions Media Gallery Tab under Breathing Exercises:

Simple Breath Stacking and Breath Stacking with Resuscitation Bag.

It’s never too early to start focused segmental breathing and practice lung hyper-expansion. This is a pro-active approach for maximizing your existing lung function. By expanding and recruiting under-inflated  air sacs (alveoli) and expanding air passages (bronchi and bronchioles), you help the lungs do what they do naturally – move oxygen in and carbon dioxide out of the alveoli and move hydrating mucus up and out of the airways so it does not pool and contribute to lung infection.

The lungs are sterile and self cleaning. We need to help them do their job by making sure they are well expanded and by keeping oral bacteria, food, and liquids from passing through the vocal cords. Making breath stacking part of your daily routine, even one or two times a day, will make it easier to incorporate it as a treatment when you begin to experience breathing discomfort with daily activities or walking up inclines or stairs.

A series of deep breaths followed by coughing to clear air passages goes a long way in keeping the lungs expanded and clear. There is no set number of breaths that is proven to be effective. Your time constraints and energy levels will dictate your home program. However, I will suggest a routine below:

  • 5 repetitions (hyperinflation breath – on your own or with a manual resuscitation “Ambu” bag)
  • 6 sets of 5 repetitions (with rests between each 5 reps) for a total of 30 breaths.

Followed by “huff coughing”.

Huff Coughing is a forced exhalation technique. It may be more effective than a longer, forceful cough but less exhausting. It requires strong contraction of the expiratory muscles, which includes the abdominal muscles.

Huff Coughing Technique

Relax your vocal chords and leave them open so air freely moves from the lungs. Open your mouth and relax your jaw. Quickly clinch your abdominal muscles so your abdomen pushes your diaphragm upward releasing a quick burst of air (and a “huff” sound) for three short coughs.

“Huff, huff, huff.”

Relax. And take in a full breath.

Repeat twice.

Unless you have pooled secretions waiting to be expelled you may not notice any mucus moving into the back of your throat. However, this technique helps move the naturally occurring mucus layer up so that it is eliminated by swallowing. This is usually involuntary and goes unnoticed.

Huff coughing is a technique that can be used successfully if the muscles of speech and swallowing (bulbar muscles) are weakening.

Manually assisted coughing 

If your core (lower abdominal) muscles are weakened, a partner can thrust inward and upward with the pads of the hands just below the belly button (while you are sitting and leaning slightly back) as you affect a cough to increase the air flow on exhalation. This is called a “manually assisted cough.” With coordination and practice it is quite effective.

Active Cycle Breathing

All put together the techniques of breath stacking, huff coughing (and manual assisted coughing) are called Active Cycle Breathing Technique (ACBT). It was designed for spontaneously breathing patients and can be practiced alone or with a partner. I recommend it early in ALS, when FVC falls to 80% of predicted. It can be incorporated into daily activities throughout ALS progression. ACBT can be used as a preventive technique to keep lungs healthy, or to mobilize and remove lung secretions if you develop a lung infection.

Steps for Active Cycle Breathing:

1.  Place yourself in relaxed sitting or slightly reclining position.

2.  Spend a few minutes enjoying relaxed abdominal breathing. Gently move your shoulders back and away from your ears. Keep your upper chest, neck, and jaw muscles relaxed. Allow your diaphragm to drop downward and ribcage to expand outward with each breath. Imagine your lower ribcage expanding outward to the sides for three breaths. Then focus on your lungs expanding from front to back, away from your spine; then focus on expanding the lungs downwards towards the floor and upwards the ceiling; then in all 6 directions at once. Return to quiet breathing.

3.  Alone or with your breathing partner use your manual resuscitation “Ambu” bag to stack 3-to-4 breaths on top of one another to full expand the lungs, ending with a 3-to-4 second breath hold.  Exhale passively.

4.  Return to relaxed breathing, noticing if you feel it is easier to breathe or if one area of your lungs feels better inflated than another.

5.  Repeat breath stacking,  breath hold, and end with passive exhalation.

6.  Return to relaxed breathing, again noticing any changes in lung expansion or overall sensations.

7.  Perform 3 “huff” coughs independently or with a partner assisting using the manually assisted coughing technique described above. (Abdominal thrusts should be shallow at first, but deeper as this exercise progresses, providing increasing exhaled volume and flow of air from the lungs.)

8. Return to relaxed breathing.

9. Repeat this sequence 2-to-4 times or as tolerated.

It may be helpful to have a partner read aloud the breathing sequence as you are doing them. Relaxing music can be helpful. You may think of this as a practice in itself, or as an adjunct to other breathing, stretching and strengthening practices you currently enjoy, or those recommended by your physical or occupational therapist.

Find your own way with these techniques and see what works for you.

Feedback about your success with these techniques (as clinician, pALS or partner of pALS) is welcome and appreciated. Lee