The Art of Breathing

Breathing seems pretty basic. Inhale. Exhale. Repeat. When you stop … well … you have a problem.

Obviously, if you can't breathe, you've got problems. For some spinal cord injury survivors, that's just a part of the injury. For others - those to whom this article is addressed - it could become or is becoming a problem. The issues boil down to four major categories:

1. strength of the breathing muscles
2. things that compromise the muscles and their ability to work
3. things that interfere with smooth breathing
4. coughing.

Believe it or not, your lungs are not affected by spinal cord injury. However, the muscles of your chest, abdomen, and maybe even your diaphragm can be affected - and, except for perhaps the lowest para, every person with a spinal cord injury needs to understand how these muscles affect your breathing. As your various breathing muscles contract, they allow your lungs to expand, which changes the pressure inside your chest so that air rushes into your lungs. This is inhaling. Normally as you relax those same muscles, the air flows back out of your lungs, and you exhale. It is during exhalation that we talk and speak. In normal breathing, inhaling is work, requiring muscle strength, but exhaling is passive - it just happens as those inhalation muscles relax. There are exceptions. Examples of active or forced exhalations - where you use muscle strength - include blowing and coughing. So, if any or all of your breathing muscles are weakened or paralyzed, how much and how deeply you can breathe in will be affected, as will your ability to cough.

Anything that makes breathing difficult or shallow can lead to problems. Your whole lung is ready and able to process oxygen to give you … well … life. A shallow breath fills up only part of the lungs - typically, the upper part. Deeper breaths, which use your whole lungs, give your body more oxygen per breath, since every part of your lung works at pulling oxygen out of the air. Perhaps more important, moving the air through all of your lungs reduces the collections of natural secretions in your lungs, and breaks up and moves the secretions that are there. Also, the frequent moving around of highly active people helps break up and move around the fluid in the lungs. Otherwise, these secretions can act as glue causing the sides of your airways to stick together and not inflate properly. This is called atelectasis or a collapse of part of the lung. Many people with SCI are at risk for this. First, because of muscle weakness they may breathe more shallowly, "neglecting" the lower areas of their lungs. Secondly, they are less mobile, and so don't have the advantage of frequent position changes to break up any secretions that are there. Third, many of them can't get the same strong cough that they had before they were injured and so are further unable to clear secretions. They may have a harder time getting rid of any colds or respiratory infections that they do catch, leaving what feels like a constant chest cold. And, if all those secretions become the breeding ground for various nasty organisms, you're likely to end up with pneumonia.

Another issue that can affect breathing for people with spinal cord injuries is posture. Postural changes can impair breathing ability even for those able to use all the breathing muscles. They can squeeze the lungs, making it harder to expand the lungs and get air. SCI survivors who experience severe scoliosis - a sideways spinal deformity - or severe kyphosis - which causes a person to slump forward - can find their breathing significantly compromised. While not always avoidable, these spinal deformities can be at least partially treated with wheelchair modifications, postural supports, or corsets. Treating or avoiding scoliosis and kyphosis can improve your endurance and fatigue by helping you breathe easier and deeper.

What are things you can do to stack the respiratory odds more in your favor?

• The assisted cough technique involves an assistant firmly pushing against the outside of the stomach and upwards, substituting for the abdominal muscle action that usually allows for a strong cough. Use it when you're congested, or when you feel you need to cough, but just can't drum up enough force to feel like you've "done the job." Be careful: although this looks a lot like the Heimlich maneuver, it is not the same. It is much gentler, and it's important that your helper coordinates his or her pushes with your natural breathing rhythm. You should breathe in deeply, expanding your stomach out or up as you inhale. At the end of your inhalation - just as you are about to relax your stomach and breathe out - your helper should use his or her clenched hands (palm down) to push in on your stomach. It is not like a punch in your stomach - the helper's hand should be there, resting right below your ribcage, in position and ready to go for several breaths before making the actual push. Also - don't do the assisted cough over and over again, one breath after another. You'll get light headed, nauseated, and maybe even sore. Take several normal breaths in between each cough - and don't do more than a couple at each sitting.
• Percussion is basically a light drumming on the ribcage to help loosen up those clods of gunk in your lungs. Use it when you're congested, or have a cold and your chest feels "gunky" or "crackly." Lie on your side, with the side that you think is "gunky" facing up. If you can't tell, do both sides. (Hint: for an anatomical reason that's not worth explaining, the left lung gets "gunky" and congested more often than the right!) Have your helper cup his or her hands and essentially pretend he or she is playing the bongo drums on your rib cage. The "cupping" is important - that's what creates the effect that breaks and shakes the secretions loose. The sound should be hollow, almost like a "galloping." If your helper's hands are too flat, you'll hear a slapping noise; it will hurt, and you'll end up red and sore. If need be, have him practice clapping his own cupped hands, until he's able to produce a low, dull, hollow sound. That's what he should be shooting for hearing when he percusses your chest.
• For less vigorous clearing of the gunk, postural drainage may help. This is especially useful if you don't have a helper, if your helper can't get the hang of percussion, or if all the pounding and clapping is just too uncomfortable. Postural drainage uses gravity to drain those secretions from the bottoms of your lungs, up higher into your chest where you can either cough them up and out, or get them up high enough so you can swallow them. Lay on your side, and if possible, prop the foot of your bed or sofa up so your head is lower than your feet. If you lie this way for 15 or 20 minutes, you'll probably feel things start to move. Again - lie with the gunky side up; if you can't tell which side is worse, rely on statistics, and start with the left side up.
• Weight training can actually make your breathing muscles stronger - and, hopefully, help lessen the need for the above interventions. If you have control over your diaphragm muscle, you can actually strengthen that muscle, believe it or not, by doing resistance exercises. When you are lying on your back, you can place a small weight or book on your stomach and try to push against it as you breathe. If you're doing it right, you'll notice that it raises up every time you inhale, and drops back down as you exhale or relax. Try to breathe this way even when you are not using the weight. Get in the habit of breathing from your stomach rather than your chest; it will better fill those lower areas of your lungs, and lessen your chances of secretions building up that can lead to pneumonia and atelectasis. While you're at it, regular aerobic exercise - which gets you breathing hard and your heart beating faster - will also help your respiratory system and ward off respiratory compromise.

The thing is: breathing is important. Most respiratory problems are easily treatable. None of these problems should be taken casually, because all of them, if not properly treated, can cause serious permanent damage. A doctor, nurse, or physical or respiratory therapist can help you with more information.

We first wrote this article on breathing for Paraplegia News, where it appeared in the April 2001 issue. It is reprinted here with the permission of PVA Publications. It is part of a library of educational brochures developed by Craig Hospital with a federal grant titled, "Marketing Health Promotion, Wellness, and Risk Information for Spinal Cord Injury Survivors in the Community." The opinions expressed here are not necessarily those of the funding agency, the National Institute on Disability and Rehabilitation Research of the US Department of Education.

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