Observational Study Medicine ®

OPEN

Effects of pursed-lip breathing and forward trunk

lean postures on total and compartmental lung
volumes and ventilation in patients with mild to
moderate chronic obstructive pulmonary disease
An observational study
∗
Nutsupa Ubolnuar, PTa, Anong Tantisuwat, PT, PhDa, , Premtip Thaveeratitham, PT, PhDa,
Somrat Lertmaharit, MScb, Chathipat Kruapanich, PT, MSca, Jaturong Chimpalee, PTc,
Witaya Mathiyakom, PT, PhDd

Abstract
This study identified the effects of pursed-lip breathing (PLB), forward trunk lean posture (FTLP), and combined PLB and FTLP on
total and compartmental lung volumes, and ventilation in patients with chronic obstructive pulmonary disease (COPD). Sixteen
patients with mild to moderate COPD performed 2 breathing patterns of quiet breathing (QB) and PLB during FTLP and upright
posture (UP). The total and compartmental lung volumes and ventilation of these 4 tasks (QB-UP, PLB-UP, QB-FTLP, PLB-FTLP)
were evaluated using optoelectronic plethysmography. Two-way repeated measures ANOVA was used to identify the effect of PLB,
FTLP, and combined strategies on total and compartmental lung volumes and ventilation. End-expiratory lung volume of ribcage
compartment was significantly lower in PLB-UP than QB-UP and those with FTLP (P < .05). End-inspiratory lung volume (EILV) and
end-inspiratory lung volume of ribcage compartment were significantly greater during PLB-FTLP and PLB-UP than those of QB
(P < .05). PLB significantly and positively changed end-expiratory lung volume of abdominal compartment (EELVAB ) end-expiratory
lung volume, EILVAB, tidal volume of pulmonary ribcage, tidal volume of abdomen, and ventilation than QB (P < .05). UP significantly
increased tidal volume of pulmonary ribcage, tidal volume of abdomen, and ventilation and decreased EELVAB, end-expiratory lung
volume, and EILVAB than FTLP (P < .05). In conclusion, combined PLB with UP or FTLP demonstrates a positive change in total and
compartmental lung volumes in patients with mild to moderate COPD.
Abbreviations: COPD = chronic obstructive pulmonary disease, EELV = end-expiratory lung volume, EELVAB = end-expiratory
lung volume of abdominal compartment, EELVRC = end-expiratory lung volume of ribcage compartment, EILV = end-inspiratory lung
volume, EILVRC = end-inspiratory lung volume of ribcage compartment, FTLP = forward trunk lean posture, PLB = pursed-lip
breathing, QB = quiet breathing, UP = upright, VTAB = tidal volume of abdomen, VTRCp = tidal volume of pulmonary ribcage.
Keywords: chronic obstructive pulmonary disease, forward lean, optoelectronic plethysmography, pursed-lip breathing

1. Introduction increase in the work of breathing, abnormal ventilation,

Chronic obstructive pulmonary disease (COPD) directly affects accumulation of air trapping, and dyspnea experienced by
the respiratory system. As the disease progresses, there is an patients with COPD.[1,2] Without appropriate intervention, these

Editor: Takeshi Saraya.

This study was supported by The Thailand Research Fund (MRG-5980084) and also supported by “The 100th Anniversary Chulalongkorn University Fund for Doctoral
Scholarship” and “The 90th Anniversary Chulalongkorn University Fund (Ratchadaphiseksomphot Endowment Fund).
The authors have no conflicts of interest to disclose.
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
a
Department of Physical Therapy, Faculty of Allied Health Sciences, b Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University,
Bangkok, c Department of Physical Therapy and Rehabilitation, Central Chest Institute of Thailand, Nonthaburi, Thailand, d Department of Physical Therapy, California
State University, Northridge, CA, USA.
∗
Correspondence: Anong Tantisuwat, Department of Physical Therapy, Faculty of Allied Health Sciences, Chulalongkorn University, 154 Rama I Road, Pathumwan,
Bangkok 10330, Thailand (e-mail: [email protected]).
Copyright © 2020 the Author(s). Published by Wolters Kluwer Health, Inc.
This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to
download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal.
How to cite this article: Ubolnuar N, Tantisuwat A, Thaveeratitham P, Lertmaharit S, Kruapanich C, Chimpalee J, Mathiyakom W. Effects of pursed-lip breathing and
forward trunk lean postures on total and compartmental lung volumes and ventilation in patients with mild to moderate chronic obstructive pulmonary disease: an
observational study. Medicine 2020;99:51(e23646).
Received: 6 April 2020 / Received in final form: 9 November 2020 / Accepted: 11 November 2020
http://dx.doi.org/10.1097/MD.0000000000023646

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Ubolnuar et al. Medicine (2020) 99:51 Medicine

adverse consequences of COPD will significantly interfere with 031.1/61), and The Research Ethics Review Committee of The
patients’ ventilation, particularly during physical activities, and Central Chest Institute of Thailand. During screening sessions,
negatively impact patients’ quality of life (QoL).[3,4] Identifying participants were recruited using a convenience sampling method
effective interventions to improve respiratory function and at The Central Chest Institute of Thailand. Demographic data
dyspnea is essential to promoting QoL of patients with COPD. collection and testing sessions occurred at the Department of
Pursed-lip breathing (PLB) is commonly used to improve Physical Therapy, Faculty of Allied Health Sciences, Chulalong-
ventilation and alleviate dyspnea[5,6] as it increases the tidal korn University. Each patient read and signed an informed
volume (VT) and reduces respiratory rate (RR) in patients with consent form prior to participating in the study.
COPD.[7–11] However, it was found that the effect of PLB on the
changes in compartmental lung volumes differed among patients
2.2. Participants
with COPD.[7,8] Patients who responded positively to PLB
decreased end-expiratory lung volume of the abdominal The sample size was calculated based on our pilot study results
compartment (EELVAB) and the total chest wall end-expiratory using ten subjects with COPD with the inclusion and exclusion
lung volume (EELV), and an increase in end-inspiratory lung criteria and research protocol similar to those used in this current
volume of the ribcage (EILVRC) compartment and the total chest study. The pilot study results indicated that the tidal volume of
wall (EILV). In contrast, patients who did not respond to PLB the pulmonary ribcage (VTRCp) was greater during PLB-UP than
increased end-expiratory lung volume of ribcage compartment in other tasks. VTRCp during PLB-FTLP was also found to be
(EELVRC) , EELV, EILVRC, and EILVAB. As a result, their VT was higher than quiet breathing (QB-UP and QB-FTLP). With a
significantly lower than that of the patients with a positive moderate effect size (ES=.65) of VTRCp based on the pilot study, a
response to PLB. The decrease in EELV was also related to a significance criterion of 0.05, and power of 0.80, the total sample
decreased dyspnea score in patients with a positive response to size required for this study was determined to be 16.
PLB.[7] Thus, the compartmental EELV and EILV changes were Patients with COPD were included in this study if they were:
found to be significantly correlated with improvement in (1) diagnosed as mild to moderate COPD[21] by a pneumologist
ventilation resulting from PLB.[8] Collectively, these studies at The Central Chest Institute of Thailand,
indicate that the ability to detect compartmental lung volumes (2) clinically stable without exacerbation for at least 4 weeks
provides us with a better understanding of the control of the before the screening test,
respiratory system, which in turn allows us to make better clinical (3) with a mild to moderate dyspnea score (Medical Research
decisions when selecting treatment strategies for patients with Council dyspnea score = I-III),
COPD.[12] (4) with a history of smoking, and
A forward trunk lean posture (FTLP) is also a common strategy (5) without other conditions that prevented them from com-
used to relieve dyspnea,[5,9,13] and improve lung volume and pleting the study protocol.
ventilation in patients with COPD.[14,15] However, little is known
about the effects of FTLP or combining FTLP with PLB on the Potential patients were excluded if they met 1 of the following
compartmental lung volumes and ventilation. The inability to criteria:
identify changes in the compartmental lung volumes in a previous (1) having pain or discomfort, or had a history of chest wall
study[9] was primarily due to limitations associated with operation,
respiratory inductive plethysmography.[16] To overcome these (2) unable to perform the FTLP in sitting position, or
limitations, an optoelectronic plethysmography (OEP) was used (3) receiving ventilatory support or long-term oxygen therapy.
to measure both compartmental and total lung volumes.[17,18]
This system has been shown to have good validity in measuring The exclusion criteria allowed us to complete our data
compartmental lung volumes in various body positions among a collection while minimizing confounding factors such as pain
healthy population.[19,20] However, to our knowledge, no study limiting chest wall movements and lung volume and maximizing
has used an OEP to identify the effect of FTLP alone, or in patients’ comfort and safety during the data collection.
combination with PLB, in patients with COPD.
This study aimed to identify the effects of PLB, FTLP, and
2.3. Intervention
combined PLB and FTLP on total and compartmental lung
volumes, and ventilation in patients with COPD. This study took During the preparatory session, the demographic data were
advantage of the recent developments in OEP technology to collected. The level of dyspnea at baseline and during physical
overcome the technical difficulties associated with the previously activity were assessed using a modified Borg scale score and the
used respiratory inductive plethysmography. The knowledge modified medical research council, respectively. Physical
gained from this study will provide clinicians with rationales to activity level was recorded using the Baecke physical activity
support the use of these strategies to improve lung volume and questionnaire.
ventilation in patients with mild to moderate COPD. During the testing session, an OEP system was used to measure
total and compartmental lung volumes and ventilation during 2
different body postures of self-selected upright posture (UP) and
2. Material and methods FTLP in a sitting position, and 2 breathing patterns of QB, and
PLB. The FTLP was defined as a 45° anterior inclination of the
2.1. Design
trunk.[9,13,22] While sitting in a chair, patients placed their
This cross-sectional study with repeated measure design was forearms on their thighs such that the trunk was at a 45° forward
approved by The Research Ethics Review Committee for lean posture with knee flexion at 90° and both feet on the floor.
Research Involving Human Research Participants, Health QB was defined as spontaneous breathing where patients were
Sciences Group, Chulalongkorn University (Protocol number breathing in and out through the nose. For the PLB, the patients

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were asked to breathe in through the nose and breathe out

Patients with COPD through partially closed-lips. The duration of breathing-out was
approximately 2 times longer than that of breathing-in.[23,24]
The combination of 2 breathing patterns (QB and PLB) and 2
Screening session body postures (UP and FTLP) allowed 4 testing tasks:
(1) QB with UP (QB-UP),
(2) PLB with UP (PLB-UP),
(3) QB with FTLP (QB-FTLP), and
Included participants (n=16)
(4) PLB with FTLP (PLB-FTLP) (Fig. 1).
The patients were asked to perform 3 trials of each testing task
without speaking or coughing. Each trial lasted 1 minute. The
Preparatory session resting period was 1 minute between trials, and 2 minutes
between tasks or until dyspnea returned to the baseline.

• Demographic data
collection 2.4. Measurement and outcomes
• Baseline assessment
An OEP system (BTS engineering, Milan, Italy) was used to
capture chest wall movement by tracking 89 reflective markers
Testing session placed on the patient’s chest wall.[17] The positions of the
reflective markers were tracked by the SMART Tracker software
(BTS engineering, Milan, Italy) and then were used to compute
chest wall movements. These data were used to derive the 3
QB with an upright QB with a forward trunk
posture (QB-Up) lean posture (QB-FTLP)
compartmental lung volumes of RCp, RCa, and AB (Fig. 2) as well
as the total lung volume using Gauss theorem.[12] All variables
were extracted by a custom software written in MATLAB (The
PLB with an upright PLB with a forward trunk MathWorks, Massachusetts, United State).
posture (PLB-Up) lean posture (PLB-FTLP) The outcomes related to lung volume were EELV, EILV, and
VT. EELV and EILV consisted of 2 compartments of ribcage
Figure 1. Flow chart of patients. (EELVRC and EILVRC) and abdomen (EELVAB and EILVAB). VT
had 3 compartments of pulmonary ribcage (VTRCp), abdominal

Figure 2. Chest wall compartment divided by OEP: Pulmonary rib cage (RCp), Abdominal rib cage (RCa), and Abdomen (AB).

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Table 1 Table 3
Demographic characteristics of the 16 patients with COPD. Combined effects of breathing pattern and body posture on
Characteristics Mean ± SD % (N) ventilation.
Upright Posture FTLP
Age (yr) 63.69 ± 6.34
Weight (kg) 63.05 ± 9.47 Parameters QB (a) PLB (b) QB (c) PLB (d) P-value
Height (m) 1.67 ± 0.06 Ti (s) 1.33 ± 0.45 2.58 ± 0.99 1.36 ± 0.48 2.49 ± 1.05 .490
BMI (kg/m2) 22.73 ± 3.1 Te (s) 2.11 ± 0.5 5.21 ± 4.41 2.21 ± 0.7 4.79 ± 3.69 .081
FEV1 (%) 73.13 ± 18.64 RR (bpm) 18.4 ± 3.72 9.48 ± 3.23 17.95 ± 4.11 10.11 ± 3.57 .252
FEV1 (L) 1.88 ± 0.46 VT/Ti (L/s) 0.41 ± 0.18 0.76 ± 0.26 0.26 ± 0.29 0.68 ± 0.24 .432
FVC (L) 3.24 ± 0.63 VT/Te (L/s) 0.31 ± 0.1 0.44 ± 0.17 0.27 ± 0.1 0.4 ± 0.16 .971
FEV1/FVC (%) 60.81 ± 11.38
Stage of COPD Data expressed as mean and standard deviation. Upright (Up); Forward trunk lean posture (FTLP);
- Mild 31.25% (5) Quiet breathing (QB); Pursed-lip breathing (PLB); Inspiratory time (Ti); Expiratory time (Te); Second (s);
Respiratory rate (RR); breath per minute (bpm); Mean inspiratory flow (VT/Ti); Mean expiratory flow (VT/
- Moderate 68.75% (11)
Te); ratio of liters per second (L/s).
Year of COPD (yr) 5.69 ± 5.5
Smoking (Pack-Year) 39 ± 13.52
Co-morbidity set at .05. All data analysis was done using SPSS software version
- Cardiac disease 18.75% (3)
22 (SPSS Inc., Chicago, Illinois).
- Metabolic disease 56.25% (9)
- Musculoskeletal disorder 25% (4)
Dyspnea level 3. Results
- MMRC score 1.19 ± 0.4
- Modified Borg scale 0±0 Table 1 describes the demographic data of the sixteen subjects.
Physical activity level 7.64 ± 1.34 The effect of breathing patterns, postures, and their combinations
(Baecke physical activity) on total and compartmental lung volume and ventilation are
- Sedentary 0% (0) represented in Tables 2–4.
- Active 56.25% (9) EELV and EELVAB were significantly lower during PLB as
- Athlete 43.75% (7) compared to QB (P < .01), and during UP as compared to FTLP
Data expressed as mean and standard deviation (SD). (P < .01) (Table 2). EELVRC was significantly lower during PLB-
BMI = body mass index, COPD = chronic obstructive pulmonary disease, FEV1% = Percentage of UP as compared to PLB-FTLP and QB-FTLP (P < .05, ES = 1.16)
force expiratory volumes in 1 second, MMRC = modified medical research council dyspnea score. and during QB-UP as compared to QB-FTLP (P = .04) (Fig. 3).
EILVAB was significantly greater during PLB as compared to
QB (P < .001), and during FTLP as compared to UP (P = .008)
ribcage (VTRCa), and tidal volume of abdomen (VTAB). Ventila- (Table 2). EILV and EILVRC were significantly greater during
tion-related outcomes were respiratory rate (RR), inspiratory PLB-UP and PLB-FTLP than those with QB-UP and QB-FTLP
time (Ti), expiratory time (Te), mean inspiratory flow (VT/Ti), and (P < .01; Fig. 4). The effect sizes of these comparisons were large
mean expiratory flow (VT/Te). (ES = 1.55–2.51).
VTAB and VTRCp were significantly greater during PLB than QB
(P < .001), and greater during UP than FTLP (P < .05) (Table 2).
2.5. Data analysis
Additionally, VT and VTRCa were significantly greater for PLB-UP
Demographic characteristics and outcome measurements are as compared to other positions (P < .05; Fig. 5). The effect size
presented in mean±standard deviation (SD) for continuous data, ranged from 1.48 to 2.36.
and in percentage of sample size (%N) for categorical data. Two- Ti, Te, RR, VT/Ti, and VT/Te were significantly greater during
way repeated measured analysis of variance (2 breathing patterns PLB than QB (P < .05; Table 4). Additionally, VT/Ti was
x 2 postures) was used to compare the effects of breathing significantly greater during UP as compared to FTLP (P = .01;
patterns and body postures on outcome measures. Post-hoc Table 4). There was no significant combined effect of breathing
analysis with Bonferroni adjustment was used to control for type patterns and body postures on all ventilation parameters (P>.05;
I error during multiple comparisons. The significance level was Table 3).

Table 2
Main effect of breathing pattern and body posture on lung volume.
Breathing Pattern Body Posture
Parameters QB PLB Effect size P-value Up FTLP Effect size P-value
∗
EELVAB (L) 7.53 ± 1.87 7.31 ± 1.83 3.01 <.001 7.26 ± 1.86 7.58 ± 1.86 2.18 .001#
∗
EELV (L) 22.71 ± 3.64 22.41 ± 3.55 2.19 .001 22.26 ± 3.63 22.86 ± 3.56 2.77 >.001#
∗
EILVAB (L) 7.86 ± 1.91 8.22 ± 2.02 3.67 <.001 7.93 ± 2.04 8.15 ± 1.89 1.59 .008#
∗
VTRCp (L) 0.16 ± 0.12 0.46 ± 0.2 4.28 <.001 0.33 ± 0.16 0.29 ± 0.14 1.17 .038#
∗
VTAB (L) 0.33 ± 0.09 0.92 ± 0.26 5.37 <.001 0.67 ± 0.23 0.58 ± 0.12 1.13 .045#
Data expressed as mean and standard deviation. Quiet breathing (QB); Pursed-lip breathing (PLB); Tidal volume (VT); End-expiratory lung volume (EELV); End-inspiratory lung volume (EILV); Pulmonary ribcage
(RCp); Abdominal ribcage (RCa); Ribcage (RC); Abdomen (AB); liter (L); Upright (UP); Forward trunk lean posture (FTLP).
∗
Significant of main effect of breathing pattern.
#
Significant of main effect of body posture.

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Table 4
Main effect of breathing pattern and posture on ventilation.
Breathing Pattern Body Posture
Parameters QB PLB Effect size P-value Up FTL Effect size P-value
∗
Ti (s) 1.34 ± 0.4 2.54 ± 1 2.46 <.001 1.96 ± 0.62 1.92 ± 0.57 0.20 .701
∗
Te (s) 2.16 ± 0.54 5 ± 4.04 1.50 .011 3.66 ± 2.29 3.5 ± 1.97 0.56 .294
∗
RR (bpm) 18.17 ± 3.62 9.8 ± 3.28 4.18 <.001 13.94 ± 2.76 14.03 ± 3.02 0.11 .830
∗
VT/Ti (L/s) 0.34 ± 0.19 0.72 ± 0.24 4.04 <.001 0.59 ± 0.19 0.47 ± 0.23 1.42 .015#
∗
VT/Te (L/s) 0.29 ± 0.09 0.42 ± 0.16 2.31 <.001 0.37 ± 0.12 0.34 ± 0.11 0.99 .073
Data expressed as mean and standard deviation. Quiet breathing (QB); Pursed-lip breathing (PLB); Inspiratory time (Ti); Expiratory time (Te); Second (s); Respiratory rate (RR); breath per minute (bpm); Mean
inspiratory flow (VT/Ti); Mean expiratory flow (VT/Te); ratio of liters per second (L/s).
∗
Significant of main effect of breathing pattern.
#
Significant of main effect of body posture.

4. Discussions Our results are consistent with previous studies where PLB-UP
was found to positively impact total (VT), 2 compartmental (VTRC,
This study described and compared the effect of PLB, FTLP, and VTAB) lung volumes and ventilation (RR, Ti, Te, VT/Ti) as
combined PLB-FTLP on total and compartmental lung volumes and compared to QB.[7–9,11] Furthermore, a positive end-expiratory
ventilation in patients with mild to moderate COPD. Significant pressure (PEEP) generated during PLB prevents airway collapse
changes in EELVAB, EELV, EILVAB, VTRCp, VTAB, and all and air trapping in the lungs.[25,26] An increase in airway PEEP with
ventilation parameters were demonstrated with PLB compared longer Te results in a decrease in RR and an increase in VT/Te.[24]
to QB. UP significantly increased VTRCp, VTAB, and VT/Ti as All of these lead to an increase in VT, compartmental volumes, and
compared to FTLP. However, EELVAB, EELV, and EILVAB were all ventilation parameters during PLB. Additionally, our study
significantly increased during FTLP as compared to UP. The demonstrates that, during PLB, VTAB has the largest contribution
combined PLB-UP significantly lowered EELVRC as compared to to the VT, followed by VTRCp and VTRCa. Since the changes in VTAB
QB-UP and compared to both breathing patterns with FTLP. The and VTRCp are closely related to diaphragmatic function[27] and
combined PLB-FTLP and PLB-UP each demonstrated significantly accessory muscle activities,[16] respectively, these results suggest a
higher EILV and EILVRC than those observed during QB-FTLP synergistic function of the diaphragm and accessory muscles
and QB-UP. Additionally, PLB-UP demonstrated significantly during PLB. Thus, the PLB pattern may prevent the diaphragm
greater VTRCa and VT as compared to other testing tasks. from getting fatigued.[28] However, our study did not directly

Figure 3. End-expiratory lung volume and its compartment during performed breathing patterns and postures. Upright ∗
(Up); Forward trunk lean posture (FTLP);
Quiet breathing (QB); Pursed-lip breathing (PLB); End-expiratory lung volume (EELV); Ribcage (RC); Abdomen (AB). significance interaction effect of breathing
patterns and postures at P < .05; #significance main effect of breathing patterns at P < .05; ##significance main effect of body postures at P < .05.

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Figure 4. End-inspiratory lung volume and its compartment during performed breathing patterns and postures. Upright ∗
(Up); Forward trunk lean posture (FTLP);
Quiet breathing (QB); Pursed-lip breathing (PLB); End-inspiratory lung volume (EILV); Ribcage (RC); Abdomen (AB). significance interaction effect of breathing
patterns and postures at P < .05; #significance main effect of breathing patterns at P < .05; ##significance main effect of body postures at P < .05.

Figure 5. Tidal volume and its compartment during performed breathing patterns and postures. Upright (Up); Forward trunk lean posture∗(FTLP); Quiet breathing
(QB); Pursed-lip breathing (PLB); Tidal volume (VT); Pulmonary ribcage (RCp); Abdominal ribcage (RCa); Ribcage (RC); Abdomen (AB). significance interaction
effect of breathing patterns and postures at P < .05; #significance main effect of breathing patterns at P < .05; ##significance main effect of body postures at P < .05.

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measure diaphragm activity. Further study is needed to identify the PLB-FTLP contradicts the non-significant interaction effect
diaphragm activity during PLB in patients with COPD. between body postures and breathing patterns on VT and RR
The decreased EELV and EELVAB and increased EILV and in patients with moderate COPD previously reported.[9] The
EILVRC during PLB-UP observed in our results are similar to previous results showed that VT and RR were positively changed
those previously reported in patients with severe COPD.[7] In a during PLB compared to QB, regardless of the body posture.[9]
previous study, patients with severe COPD who responded well Additionally, lung volume and other ventilation parameters were
to PLB demonstrated a significant increase in EILV and a not measured in the earlier study due to instrument limitations.[9]
significant decrease in EELV during PLB.[7] The changes in EELV In our study, PLB-UP significantly increased VT and positively
and EELVAB were associated with a longer Te and an increase of changed lung volumes compared to all other testing tasks. The
tidal volume. As a result, the patients who responded positively to ability to detect small but significant changes in compartmental
PLB had relatively lower air trapping and experienced less lung volumes in our study is most likely due to the advantages
dyspnea with PLB.[7] Our results extend the potential effect of provided by the OEP. Based on our results, PLB-UP and PLB-
PLB to patients with mild to moderate COPD. FTLP should be used in pulmonary rehabilitation programs to
The severity of lung hyperinflation impacts the effectiveness of improve total and compartmental lung volumes in patients with
PLB on lung volume in patients at different stages of COPD.[7] mild to moderate COPD.
Although the positive effect of PLB on EELV and EILV was
observed in the patients with mild to moderate COPD, our study
4.1. Limitations
did not measure lung hyperinflation or air trapping. Lung
hyperinflation can be present in an early stage of COPD, and it Firstly, our patients were mild to moderate COPD and quite
progressively worsens as the disease progresses.[29] A ratio of active, as indicated by their activity level and self-reported non-
residual volume (RV) to total lung capacity (TLC) greater than significant dyspnea prior to and during the testing tasks.
120% of the predicted value was used to indicate lung Therefore, our results apply to patients with minimal dyspnea
hyperinflation.[30] In patients with mild COPD, TLC and RV related to COPD. Secondly, this study did not focus on the effect
were significantly higher than the predicted values, while of interventions on the activities of the chest wall and trunk
inspiratory capacity, vital capacity, and FEV1 decreased.[29] muscles. In contrast, our study infers the functions of the involved
Thus, further study is needed to confirm the effect of PLB on lung muscles based on the changes of compartmental lung volumes.
volume, along with assessment of lung hyperinflation. The Adding a direct method of electromyography (EMG) to an OEP
resulting knowledge will provide more detail for clinical decision- should provide a clearer picture of these breathing patterns and
making when using PLB in patients at different stages of COPD. body postures in patients with COPD. Lastly, our study sample
Positive changes in EILV and EILVRC were noted during PLB- size is relatively small and has a combination of patients with mild
FTLP. PLB promotes a reduction of EELV and longer Te, while and moderate COPD. Due to this small sample size, the results of
FTLP has a positive effect on respiratory muscles and increased this study should be considered preliminary, and further studies
EILVRC.[9] Moreover, significant increases in EELVAB, EELV, and will be needed to confirm its results. Additionally, this small
EILVAB were observed during FTLP compared to upright posture. sample size also limited our ability to perform sub-group analysis.
During FTLP, gravity pulls the abdominal wall forward, resulting Further studies with a larger sample size and separate groups of
in lengthening of abdominal muscles,[15] which leads to an increase patients with mild and moderate COPD are needed to confirm the
in abdomen circumference and EELV. Although our result was effect of PLB, FTLP, and combined strategies.
consistent with the previous study,[15] an increase in EELV has
usually been reported as a factor inducing dyspnea.[15] Although 4.2. Clinical Implications
no adverse effect of high EELV was founded in this study or
previous study,[15] our study investigated the effect of FTLP for a PLB is an effective strategy for positively changing the total and
duration of only 1 minute. A longer duration of performing FTLP compartmental lung volumes and ventilation in patients with mild
may provide a different result on EELV and dyspnea in patients to moderate COPD. It can be used in combination with UP or FTLP
with COPD. Thus, a further study focusing on the effect of the time since there was no significant difference observed between these 2
duration of FTLP may confirm that there is no adverse effect of postures. During FTLP, PLB is be recommended over QB since it
increase EELV during a long period of FTLP. According to our significantly and positively due to its significantly greater positive
results, FTLP should be used along with PLB to improve lung change in the total and compartmental lung volumes.
volume in patients with mild to moderate COPD. In conclusion, a combination of PLB with UP or FTLP
There was no significant impact found from either UP or FTLP demonstrates a positive change in the total and compartmental
on any ventilation parameters except VT/Ti. The changes in VT/Ti lung volumes in patients with mild to moderate COPD. In these
may have occurred due to a greater increase in VT/Ti during UP patients, PLB is more beneficial than QB in improving ventilation.
posture than during FTLP. For the other ventilation parameters, Further studies with subgroup analyses and a relatively larger
our results were consistent with previous studies.[9,15] No sample size are needed to confirm these effects in patients with
significant difference was found between VT and ventilation specific stages of COPD. Additional measurements of lung
during performed FTLP as compared to upright posture.[9,15] hyperinflation and muscle activity during PLB and FTLP will
Taken together with previous studies, ventilation was found to be further elucidate the effect of these strategies in patients with
positively changed by the change in the breathing pattern of PLB, different stages of COPD.
but not by the body postures.
In this study, the combined effect of PLB-UP and PLB-FTLP
Author contributions
resulted in positive changes in the compartmental and total lung
volumes of EELVRC, EILVRC, EILV, VTRCa, and VT as compared Conceptualization: Nutsupa Ubolnuar, Anong Tantisuwat,
to those with QB. Our positive combined effect of PLB-UP and Premtip Thaveeratitham, Witaya Mathiyakom.

7
Ubolnuar et al. Medicine (2020) 99:51 Medicine

Data curation: Nutsupa Ubolnuar, Anong Tantisuwat, Chathi- [13] Kim K-s, Lee W-H, Cynn H-S, et al. Influence of sitting posture on tidal
volume, respiratory rate, and upper trapezius activity during quiet
pat Kruapanich, Jaturong Chimpalee.
breathing in patient with chronic obstructive pulmonary disease. Sci Res
Formal analysis: Nutsupa Ubolnuar, Anong Tantisuwat, Somrat Essays 2013;8:1166–70.
Lertmaharit. [14] Cavalheri V, Camillo CA, Brunetto AF, et al. Effects of arm bracing
Funding acquisition: Nutsupa Ubolnuar, Anong Tantisuwat. posture on respiratory muscle strength and pulmonary function in
Investigation: Nutsupa Ubolnuar, Anong Tantisuwat. patients with chronic obstructive pulmonary disease. Rev Port Pneumol
2010;16:887–91.
Methodology: Nutsupa Ubolnuar, Anong Tantisuwat. [15] Ogino T, Mase K, Nozoe M, et al. Effects of arm bracing on expiratory
Project administration: Anong Tantisuwat. flow limitation and lung volume in elderly COPD subjects. Respir care
Supervision: Anong Tantisuwat, Premtip Thaveeratitham, 2015;60:1282–7.
Somrat Lertmaharit, Witaya Mathiyakom. [16] Romagnoli I, Lanini B, Binazzi B, et al. Optoelectronic plethysmography
has improved our knowledge of respiratory physiology and pathophysi-
Validation: Nutsupa Ubolnuar, Anong Tantisuwat, Witaya
ology. Sensors (Basel, Switzerland) 2008;8:7951–72.
Mathiyakom. [17] Parreira VF, Vieira DSR, Myrrha MAC, et al. Optoelectronic plethysmog-
Visualization: Witaya Mathiyakom. raphy: a review of literature. Braz J Phys Ther 2012;16:439–53.
Writing – original draft: Nutsupa Ubolnuar. [18] Bastianini F, Schena E, Saccomandi P, et al. Accuracy evaluation of
Writing – review & editing: Anong Tantisuwat, Premtip dynamic volume measurements performed by opto-electronic plethys-
mograph, by using a pulmonary simulator. Conf Proc IEEE Eng Med Biol
Thaveeratitham, Witaya Mathiyakom. Soc 2013;2013:930–3.
[19] Romei M, Mauro AL, D’Angelo MG, et al. Effects of gender and posture
on thoraco-abdominal kinematics during quiet breathing in healthy
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