Resistive Breathing With Inspiratory Hold Technique in Patients With Adult COPD
DOI:
https://doi.org/10.61919/d75aqh30Keywords:
Chronic Bronchitis; COPD; Pulmonary Rehabilitation; Resistive Breathing; Inspiratory Hold Technique; Spirometry; Dyspnea.Abstract
Background: Chronic bronchitis is a clinically important obstructive airway condition associated with mucus hypersecretion, impaired airway clearance, dyspnea, and reduced pulmonary function. Pulmonary rehabilitation techniques such as resistive breathing and inspiratory hold technique are commonly used to improve respiratory function, but comparative evidence between these approaches remains limited. Objective: To compare the effects of resistive breathing and inspiratory hold technique on pulmonary function and dyspnea in patients with chronic bronchitis. Methods: This randomized clinical trial included 26 clinically stable patients with chronic bronchitis allocated equally to a resistive breathing group or an inspiratory hold technique group. Both groups received baseline diaphragmatic breathing exercises and performed their assigned intervention for six weeks. Outcomes included FEV1, FVC, FEV1/FVC ratio, PEFR, and modified Borg dyspnea score. Between-group comparisons were analyzed using the Mann-Whitney U test after assessment of normality. Results: No statistically significant between-group differences were observed for FEV1, FVC, FEV1/FVC ratio, or dyspnea at baseline or after six weeks. PEFR differed significantly between groups at baseline (p=0.005) and after six weeks (p=0.004), with higher mean ranks in the resistive breathing group. However, the baseline PEFR imbalance limits causal interpretation of the post-intervention difference. Conclusion: Resistive breathing and inspiratory hold technique showed no clear between-group difference for most pulmonary and dyspnea outcomes. PEFR findings require baseline-adjusted confirmation in larger trials.
References
1. Widysanto A, Goldin J, Mathew G. Chronic bronchitis. In: StatPearls [Internet]. Treasure Island: StatPearls Publishing; 2025 [cited 2026 Apr 23]. Available from: https://www.ncbi.nlm.nih.gov/sites/books/NBK482437/
2. Stuart-Harris CH. Definition and classification of chronic bronchitis. Lancet. 1965;775–9.
3. Guillien A, Soumagne T, Dalphin JC, Degano B. COPD, airflow limitation and chronic bronchitis in farmers: a systematic review and meta-analysis. Occup Environ Med. 2019;76(1):58–68.
4. Mejza F, Gnatiuc L, Buist AS, Vollmer WM, Lamprecht B, Obaseki DO, et al. Prevalence and burden of chronic bronchitis symptoms: results from the BOLD study. Eur Respir J. 2017;50(5):1700621.
5. Huang X, Mu X, Deng L, Fu A, Pu E, Tang T, et al. The etiologic origins for chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis. 2019;14:1139–58.
6. Gumeniuk G, Gumeniuk M, Denysov O, Denysova O, Opimakh S. The study of the viral etiology in the infectious exacerbations of chronic bronchitis in Ukraine. Eur Respir J. 2020;56 Suppl 64:2381.
7. Odashima K, Kagiyama N, Kanauchi T, Ishiguro T, Takayanagi N. Incidence and etiology of chronic pulmonary infections in patients with idiopathic pulmonary fibrosis. PLoS One. 2020;15(4):e0230746.
8. Khalloufi A, Ouarssani A, Er-Rami M, Fellah H, Sebti F, Moudden MK. A rare infectious etiology of COPD exacerbation. Rev Mal Respir. 2018;35(9):956–8.
9. Maselli DJ, Bhatt SP, Anzueto A, Bowler RP, DeMeo DL, Diaz AA, et al. Clinical epidemiology of COPD: insights from 10 years of the COPDGene study. Chest. 2019;156(2):228–38.
10. Dotan Y, So JY, Kim V. Chronic bronchitis: where are we now? Chronic Obstr Pulm Dis. 2019;6(2):178.
11. Hooper LG, Young MT, Keller JP, Szpiro AA, O’Brien KM, Sandler DP, et al. Ambient air pollution and chronic bronchitis in a cohort of US women. Environ Health Perspect. 2018;126(2):027005.
12. Hikichi M, Hashimoto S, Gon Y. Asthma and COPD overlap pathophysiology of ACO. Allergol Int. 2018;67(2):179–86.
13. Higham A, Quinn AM, Cançado JED, Singh D. The pathology of small airways disease in COPD: historical aspects and future directions. Respir Res. 2019;20(1):49.
14. Eapen MS, Hansbro PM, Larsson-Callerfelt AK, Jolly MK, Myers S, Sharma P, et al. Chronic obstructive pulmonary disease and lung cancer: underlying pathophysiology and new therapeutic modalities. Drugs. 2018;78(16):1717–40.
15. Guillien A, Soumagne T, Dalphin JC, Degano B. COPD, airflow limitation and chronic bronchitis in farmers: a systematic review and meta-analysis. Occup Environ Med. 2019;76(1):58–68.
16. Kaplan AG. Chronic cough in adults: make the diagnosis and make a difference. Pulm Ther. 2019;5(1):11–21.
17. Good JT Jr, Rollins DR, Kolakowski CA, Stevens AD, Denson JL, Martin RJ. New insights in the diagnosis of chronic refractory cough. Respir Med. 2018;141:103–10.
18. Mendy A, Salo PM, Cohn RD, Wilkerson J, Zeldin DC, Thorne PS. House dust endotoxin association with chronic bronchitis and emphysema. Environ Health Perspect. 2018;126(3):037007.
19. Mathioudakis AG, Janner J, Moberg M, Alonso-Coello P, Vestbo J. A systematic evaluation of the diagnostic criteria for COPD and exacerbations used in randomised controlled trials on the management of COPD exacerbations. ERJ Open Res. 2019;5(4):00136–2019.
20. Marçôa R, Rodrigues DM, Dias M, Ladeira I, Vaz AP, Lima R, et al. Classification of chronic obstructive pulmonary disease according to the new Global Initiative for Chronic Obstructive Lung Disease 2017: comparison with GOLD 2011. COPD. 2018;15(1):21–6.
21. Corlateanu A, Mendez Y, Wang Y, Garnica RDJA, Botnaru V, Siafakas N. Chronic obstructive pulmonary disease and phenotypes: a state-of-the-art. Pulmonology. 2020;26(2):95–100.
22. Wadhwa R, Aggarwal T, Malyla V, Kumar N, Gupta G, Chellappan DK, et al. Identification of biomarkers and genetic approaches toward chronic obstructive pulmonary disease. J Cell Physiol. 2019;234(10):16703–23.
23. MacLeod M, Papi A, Contoli M, Beghé B, Celli BR, Wedzicha JA, et al. Chronic obstructive pulmonary disease exacerbation fundamentals: diagnosis, treatment, prevention and disease impact. Respirology. 2021;26(6):532–51.
24. Zeng Y, Jiang F, Chen Y, Chen P, Cai S. Exercise assessments and trainings of pulmonary rehabilitation in COPD: a literature review. Int J Chron Obstruct Pulmon Dis. 2018;13:2013–23.
25. Ryrsø CK, Godtfredsen NS, Kofod LM, Lavesen M, Mogensen L, Tobberup R, et al. Lower mortality after early supervised pulmonary rehabilitation following COPD exacerbations: a systematic review and meta-analysis. BMC Pulm Med. 2018;18(1):154.
26. Wouters EF, Wouters BB, Augustin IM, Houben-Wilke S, Vanfleteren LE, Franssen FM. Personalised pulmonary rehabilitation in COPD. Eur Respir Rev. 2018;27(147):170125.
27. Oates GR, Niranjan SJ, Ott C, Scarinci IC, Schumann C, Parekh T, et al. Adherence to pulmonary rehabilitation in COPD: a qualitative exploration of patient perspectives on barriers and facilitators. J Cardiopulm Rehabil Prev. 2019;39(5):344–9.
28. Kerti M, Balogh Z, Kelemen K, Varga J. The relationship between exercise capacity and different functional markers in pulmonary rehabilitation for COPD. Int J Chron Obstruct Pulmon Dis. 2018;13:717–24.
29. da Silva Guimarães B, de Souza LC, Cordeiro HF, Regis TL, Leite CA, Puga FP, et al. Inspiratory muscle training with an electronic resistive loading device improves prolonged weaning outcomes in a randomized controlled trial. Crit Care Med. 2021;49(4):589–97.
30. Verges S. Respiratory muscle training. In: Cogo A, Bonini M, Onorati P, editors. Exercise and sports pulmonology. Cham: Springer; 2019. p. 143–51.
31. Faghy MA, Brown PI, Davis NM, Mayes JP, Maden-Wilkinson TM. A flow resistive inspiratory muscle training mask worn during high-intensity interval training does not improve 5 km running time-trial performance. Eur J Appl Physiol. 2021;121(1):183–91.
32. Louvaris Z, Van Hollebeke M, Clerckx B, Muller J, Gosselink R, Hermans G, et al. The effects of inspiratory muscle training with tapered flow resistive loading on breathing characteristics and inspiratory muscle oxygenation during weaning: a preliminary data analysis. Eur Respir J. 2019;54 Suppl 63:PA2201.
33. Urme NA, Alam F, Rahman E. Effectiveness of active cycle of breathing technique for the patients of bronchiectasis: a narrative review study. J Clin Respir Care. 2019;5(2):2–5.
34. Zuriati Z, Surya M. Effectiveness active cycle of breathing technique with pursed lips breathing technique to tripod position in increasing oxygen saturation in patients with COPD, West Sumatera. Enferm Clin. 2020;30:164–7.
35. Dempsey TM, Scanlon PD. Pulmonary function tests for the generalist: a brief review. Mayo Clin Proc. 2018;93(6):763–71.
36. Caron M, Hoa S, Hudson M, Schwartzman K, Steele R. Pulmonary function tests as outcomes for systemic sclerosis interstitial lung disease. Eur Respir Rev. 2018;27(148):170102.
37. Balbi M, Conti C, Imeri G, Caroli A, Surace A, Corsi A, et al. Post-discharge chest CT findings and pulmonary function tests in severe COVID-19 patients. Eur J Radiol. 2021;138:109676.
38. Wang G, Hallberg J, Bergström PU, Janson C, Pershagen G, Gruzieva O, et al. Assessment of chronic bronchitis and risk factors in young adults: results from BAMSE. Eur Respir J. 2021;57(3):2002120.
39. Milne S, Jetmalani K, Chapman DG, Duncan JM, Farah CS, Thamrin C, et al. Respiratory system reactance reflects communicating lung volume in chronic obstructive pulmonary disease. J Appl Physiol. 2019;126(5):1223–31.
40. Baloira A, Abad A, Fuster A, García Rivero JL, García-Sidro P, Márquez-Martín E, et al. Lung deposition and inspiratory flow rate in patients with chronic obstructive pulmonary disease using different inhalation devices: a systematic literature review and expert opinion. Int J Chron Obstruct Pulmon Dis. 2021;16:1021–33.
41. Ponce MC, Sankari A, Sharma S. Pulmonary function tests. In: StatPearls [Internet]. Treasure Island: StatPearls Publishing; 2023 [cited 2026 Feb 25]. Available from: https://www.ncbi.nlm.nih.gov/sites/books/NBK482339/
42. Timothy CN. Evaluation of peak expiratory flow rate in pet owners. Indian J Public Health Res Dev. 2019;10(8).
43. Swan F, Newey A, Bland M, Allgar V, Booth S, Bausewein C, et al. Airflow relieves chronic breathlessness in people with advanced disease: an exploratory systematic review and meta-analyses. Palliat Med. 2019;33(6):618–33.
44. Hamasaki H. Effects of diaphragmatic breathing on health: a narrative review. Medicines. 2020;7(10):65.
45. Fiorentino G, Esquinas AM, Annunziata A. Exercise and chronic obstructive pulmonary disease. In: Xiao J, editor. Physical exercise for human health. Singapore: Springer; 2020. p. 355–68.
46. Derakhtanjani AS, Jaberi AA, Haydari S, Bonabi TN. Comparison the effect of active cyclic breathing technique and routine chest physiotherapy on pain and respiratory parameters after coronary artery graft surgery: a randomized clinical trial. Anesthesiol Pain Med. 2019;9(5):e94654.
47. Gao LN, Lyu J, Wang ZF, Yu DD, Sun MH. Meta-analysis of randomized controlled trials on effect of Tanreqing injection combined with Western medicine on acute exacerbation of chronic bronchitis. Zhongguo Zhong Yao Za Zhi. 2019;44:5313–21.
48. Rooddehghan Z. Nursing care in COPD. Iran J Allergy Asthma Immunol. 2018;17.
49. Richardson CR, Franklin B, Moy ML, Jackson EA. Advances in rehabilitation for chronic diseases: improving health outcomes and function. BMJ. 2019;365:l2191.
50. Mahamed Said DA. The effect of aerobic exercise on some physical variables and respiratory functions for patients with chronic bronchitis. Assiut J Sport Sci Arts. 2021;2021(1):169–84.
51. Shen MD, Li YW, Xu LQ, Shi HY, Ni YY, Lin HJ, et al. Role of active cycle of breathing technique for patients with chronic obstructive pulmonary disease: a pragmatic, randomized clinical trial. Int J Nurs Stud. 2021;117:103880.
52. Athawale VK, Lalwani LL, Mishra GP. Comparison of the active cycle of breathing technique versus active cycle of breathing technique with flutter in bronchiectasis. Natl J Med Res. 2020;10(4).
53. Kubincová A, Takáč P, Kendrová L, Joppa P, Mikul’áková W. The effect of pulmonary rehabilitation in mountain environment on exercise capacity and quality of life in patients with chronic obstructive pulmonary disease and chronic bronchitis. Med Sci Monit. 2018;24:6375.
54. Elnaggar RK. A randomized placebo-controlled study investigating the efficacy of inspiratory muscle training in the treatment of children with bronchial asthma. J Asthma. 2021;58(12):1661–9.
55. Üzmezoğlu B, Altıay G, Özdemir L, Tuna H, Süt N. The efficacy of Flutter and active cycle of breathing techniques in patients with bronchiectasis: a prospective, randomized, comparative study. Turk Thorac J. 2018;19(3):103–9.
