Accepted Manuscript

Title: Do COPD patients taught pursed lips breathing (PLB)

for dyspnoea management continue to use the technique
long-term? A mixed methodological study

Author: S.E. Roberts F.M. Schreuder T. Watson M. Stern

PII: S0031-9406(16)30026-8
DOI: http://dx.doi.org/doi:10.1016/j.physio.2016.05.006
Reference: PHYST 911

To appear in: Physiotherapy

Received date: 16-10-2015

Accepted date: 21-5-2016

Please cite this article as: Roberts SE, Schreuder FM, Watson T, Stern M, Do COPD
patients taught pursed lips breathing (PLB) for dyspnoea management continue to
use the technique long-term? A mixed methodological study., Physiotherapy (2016),
http://dx.doi.org/10.1016/j.physio.2016.05.006

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Do COPD patients taught pursed lips breathing (PLB) for dyspnoea
management continue to use the technique long-term? A mixed
methodological study.
SE Robertsa, FM Schreuderb, T Watsonb, M Sternc

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a
Whittington Hospital Physiotherapy, Whittington Health, London, UK

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b
Department of Allied Health Professions and Midwifery, School of Health and Social Work
University of Hertfordshire, UK

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c
Dept Respiratory Medicine, Whittington Health, London, UK

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Acknowledgements: Leon Poltawski, Research Assistant, School of Health & Social Work,
University of Hertfordshire; collaborated on interview schedules, conducted telephone interviews

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and focus group, provided review of write up of qualitative interviews as part of validation.

Corresponding author: SE Roberts

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uzanr@yahoo.com
19, Colebrooke Pl., London N1 8HZ
Telephone +4420 7288 0920
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Ethical Approval: Ethical approval for the study was obtained from the Brent Medical Ethics
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Committee. Reference number 09/H0717/63

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Funding: Funding for taxi fares to attend the focus group was supplied by a donation from PJ
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Maitland who had no role in the study design, the collection, analysis and interpretation of data;

in writing of the manuscript; or in the decision to submit the manuscript for publication.

Page 1 of 24
Do COPD patients taught pursed lips breathing (PLB) for dyspnoea

management continue to use the technique long-term? A mixed

methodological study.

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Abstract

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Objective: To investigate whether COPD patients taught pursed lips breathing (PLB) for

dyspnoea management continue to use the technique long-term and, if so, their experience of this.

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Design: A mixed methodological approach using semi-structured telephone interviews, a focus

group and observation of current PLB technique was used. Qualitative analysis was based on

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grounded theory

Setting: Participants were recruited from the two inner city London (UK) boroughs
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Participants: A purposive sample of 13 patients with COPD taught PLB 6 - 24 months

previously. 11 participants took part in the telephone interviews; focus group participation and
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observed PLB was 5/11 and 6/11 respectively.

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Main outcome measures: A thematic analysis of interviews and focus group; observation of

PLB technique.
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Results: Nine reported on-going use of PLB with 8 reporting definite benefit. Observed
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technique showed ongoing ability for PLB to reduce RR and increase SpO2. Four distinct themes

emerged from the data: use of PLB when short of breath due to physical activity (8/9), increased
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confidence and reduced panic (4/9), use as an exercise (3/9), use at night (3/9). Those that had

discontinued PLB had done so because it didn't help (2) and they had forgotten/were too busy to

continue.

Conclusion: This study found 9 of 13 of patients taught PLB continued with long-term use and 8

of 13 reporting definite benefit from PLB. The role of PLB in increasing patients’ confidence in

their ability to manage their breathlessness and, use at night, were novel findings.

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Key words: Chronic Obstructive Pulmonary Disease; dyspnoea; breathing exercises;

rehabilitation

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Introduction

Pursed lips breathing (PLB) is a breathing retraining strategy, adopted spontaneously by some

patients, that has been advocated for the treatment of exertional dyspnoea in Chronic Obstructive

Pulmonary Disease (COPD) [1, 2]. It has been used in clinical practice for over 40 years and is

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customarily integrated into pulmonary rehabilitation (PR) programmes [3-6]. PLB is carried out

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by exhaling through partially closed lips i.e. through pursed lips as if making the flame of a small

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candle flicker [7]. Review of the PLB literature [8] identified 11 quantitative studies, 10 short-

term studies and one that looked at the effects of PLB over 12 weeks. The aim of this study was

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to document the subjective experience of people with COPD taught PLB at least 6 months

previously. The principle research question was: “what are the key themes expressed about the

use of PLB by these patients,”

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Method
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Ethical approval was gained to recruit patients taught PLB more than 6 months and less than 24
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months previously as part of the randomised controlled study investigating the effects of PLB in

stable COPD [9]. This study comprised three components: a semi-structured telephone
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questionnaire, a focus group and, for those still using PLB, a home visit (HV). The sample was a
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purposive sample of all the patients who met the characteristics of interest for this study. The

characteristics being: diagnosis of COPD; taught PLB according to a standardised protocol (see
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Table 1) six to 24 months previously. The effects of PLB on respiratory rate (RR) and oxygen

saturation (SpO2) were also measured and compared both to spontaneous breathing and to the

same measurements made when PLB was first taught. The home diaries kept by the participants

when taught PLB, were available to compare with observations made at the HV. The protocol

followed for teaching PLB is provided in supplementary information on line.

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Telephone interview: A short questionnaire was administered to investigate participants’

recollection of learning PLB, if they had continued to use PLB or not and why, and when they

used or stopped using PLB.

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Focus group: All patients who completed the telephone interview were invited to attend a focus

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groups and focus group questions were generated from analysis of the telephone interviews.

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Patients were also asked about their initial expectations of PLB and how it compared with

subsequent experience, ways in which PLB might be taught, and any negative effects

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experienced. Finally patients were asked to speculate on how they thought PLB worked.

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The telephone interviews and focus group were audio recorded and the focus group was observed

by a physiotherapist who acted as scribe to augment the recording. To minimise bias the
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telephone interviews and focus group were conducted by a physiotherapist not involved in

teaching PLB. The audio recordings were transcribed and analysed using a manual process to
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identify the key themes [10]. This was followed by checking for accuracy and over-representation
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of themes by the physiotherapist who conducted the interviews and the focus group scribe. At HV
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to observe PLB focus group participants reviewed the transcript to check accuracy.
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Home visit: Observation of current PLB technique was carried out after a minimum five minutes
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rest. RR and SpO2 were measured using a pulse oximeter (Finger pulse oximeter model 950,

Healthdyne Technologies, Brussels) and were recorded for one minute of spontaneous breathing

and one minute of PLB. Observations were compared with those recorded at the time of learning

PLB.

Results

At the time of learning PLB, the 13 participants identified for the study had a mean(SD) age of

65(10.85) years and a mean predicted (SD) FEV1 of 42.8(0.18)%. Their COPD had been stable

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and optimally managed according to NICE guidelines [11]. The median time from learning PLB

to the telephone interview was 17 months (range 6 to 23 months). A figurative trajectory of

participation in the study is given as supplementary information on line (on line figure 1). The

response rate for the telephone interviews was 11 of 13 with 5 agreeing to take part in the focus

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group, and 6 to be observed demonstrating their PLB technique

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Long-term benefit: 11 of 13 possible study participants agreed and could be contacted for

telephone interview. 9 of 13 participants reported continued use of PLB and 8 of 13 reported

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long-term benefits; two had not found PLB helpful and had stopped and one was not sure but still

used PLB. For those who reported a definite benefit, three emphasised that it helped their

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breathlessness but not always or not completely. Of those attending the focus group (5) all agreed

that the benefits exceeded their initial expectations. For the two who had stopped using PLB little
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further information was gained; both declined to attend a focus group. Representative quotes for

perceived benefit from PLB and recollection of initial thoughts with regard to learning PLB are
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given as supplementary information on line (on line table 1).

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A review of the diaries from the time of learning PLB indicated all had tried to use PLB as
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instructed and 11 had, at the time, found it helpful; neither of those who initially found PLB

unhelpful took any part in this follow-up study. At long-term follow up the number who had
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found PLB un-helpful, were uncertain of any benefit, or were not using it had increased from 3 to

5. Of those still using PLB (9), all at some point said they used it when they were short of breath.

This was the first reason mentioned by four. The remaining five gave more specific individual

reasons (see Table 2). There was an equal split between using it many times a day, once or twice

a day, and a few times a week.

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PLB Themes: Four distinct themes emerged from analysis of the data collected by telephone

interview (see Table 3). The acute episodes of anxiety and panic reported were predominantly,

although not exclusively, related to episodes of breathlessness. These themes were explored

further in the focus group and example quotes from both the telephone interviews and the focus

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group transcript are provided in Table 4. Further clarity was gained from the focus group as to

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what was meant when they reported PLB was used to help with breathlessness during an activity.

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Specifically they were asked whether they used PLB during the activity or to help them recover

their breath, having stopped to rest. When out and about, all but one agreed that they had to:

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stop for a little while and do it (F2).

For the one person who did use PLB whilst walking she described it thus:

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I do mine often when walking...I’ve got a shopping trolley....you’re walking along the street you

feel a little bit breathless and I do it (F4).

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Additional to these themes, in both the focus group and in some telephone interviews there were

times when participants diverted from PLB to talk about their inhalers. Two participants reported
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reduced use of short-acting beta agonist (SABA) inhalers after learning PLB. One recounted a
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story of being locked out of her house, where her inhalers were; she used PLB to control the
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situation to get back to her car to another inhaler:

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you can leave your inhalers behind but you can always do PLB (F7).
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Learning PLB: The best place for learning PLB was explored in the focus group. All had first

learnt PLB in a one-to one situation but some had subsequently had this re-enforced at pulmonary

rehabilitation (PR). One of the group felt the one-to-one situation was important for her:

I think you take more notice, or I do (F4).

In contrast the majority of the group thought learning it in a group situation could be beneficial:

Now with me it was going to the class [PR]

that made me conscious of it (M11).

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There was general agreement expressed with the idea that more opportunities could be taken to

teach PLB:

if you went to your GP when you were diagnosed, any time, hospital, anywhere, to be given PLB

something you could practise...it’s not as available as it should be (F7).

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The idea of being taught PLB in a normal environment was also expressed:

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doing it in the gym is not the same, to do it outside properly on a proper incline with a bit of wind

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coming along I think people would take it more seriously.....even on a treadmill might be better...

you would be doing it (PLB) because you needed it not because you were told to (F4).

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PLB technique: At telephone interview some comments were made on the technique of PLB

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from simple to more detailed descriptions. PLB technique was also explored further in the focus

group (see supplementary information in on line table 2). The general emphasis was that the
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breath out should be longer than the breath in and that upper chest breathing was not helpful.

Discussion also indicated that some had combined PLB with diaphragmatic breathing,
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particularly when performed as an exercise i.e. not when breathless. When PLB was observed
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during a home visit, it was noted that, whilst the focus was on breathing out through pursed lips
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the depth of inspiration varied considerably between participants; those that used deeper
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inspiration (about half) demonstrated the greatest reduction in RR. Changes in respiratory rate

(RR) and oxygen saturation (SpO2%) with PLB compared to spontaneous breathing were
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observed and compared to those recorded when the technique was first taught (see Table 4). This

showed comparable reductions in RR and improvement in SpO2% both in this group over time

and compared to the published literature [8] but numbers were not sufficient to test for statistical

significance.

Page 8 of 24
Negative effects: Only one participant reported a negative effect (F7). At telephone interview,

she felt that it possibly encouraged her to focus too much on her breathing. She repeated this idea

at the focus group but the other group members did not agree.

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Perceived mechanism of effect: In drawing the focus group to a close, participants were asked

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to speculate on the mechanism of PLB effect. The participants found this difficult to answer and

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either reported how it made them feel or were unable to comment. Three mentioned that it gave

them more confidence to manage their breathlessness:

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I feel better, I feel more confident, I don’t panic so much...It helps you, obviously when you are

out of breath, it brings you confidence in yourself (F2)

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Two found it more difficult to say:

If I’m out of breath and I do the pursed lip breathing it helps me...that’s it (M11).
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Discussion
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Main Findings: In this mixed-methods study of the perceived impact of PLB on breathlessness 8
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of 13 study participants reported long-term benefit; this assumed a “worst-case scenario” i.e. that
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those that could not be contacted or declined contact had found PLB unhelpful and had not
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continued to use the technique. Of those who did participate in the study 8 of 11 reported definite

benefit. Use of PLB as a tool for managing breathlessness was associated with physical activity
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and improved confidence in their ability to cope with breathlessness. Participants reported no

significant adverse effects.

Strengths and Limitations: The main limitation of this study was that only one focus group was

held. Small numbers are acceptable for qualitative studies because of the richness of data

generated but, optimally, a focus group study should consist of repeated groups until no new

information is gained. Repeated group meetings balance out any idiosyncrasies from an

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individual session [12] p.36 and reduce the risk of including outlier experiences. However one-to-

one interviews carried out prior to the focus group helped to minimise bias from group members

giving socially desirable responses; in the telephone interviews three participants expressed the

opinion that PLB did not work all the time however only one repeated this in the focus group

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with the other two failing to endorse the opinion. A further limitation was the lack of information

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from those who did not find PLB helpful. Different reasons for discontinuation of its use may be

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speculated. One reason might be a difference in lung volume response to PLB i.e. the finding

[13, 14] that PLB results in a decrease in end-expiratory lung volumes and a reported decrease in

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breathlessness in some patients with COPD but the reverse in others. Another reason may relate

to issues of self-efficacy associated with a person’s beliefs regarding the taking on of new ideas

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that might benefit their health [15]. Further qualitative studies may give insight into different

illness and health behaviours which may have an influence on uptake of PLB [16] p.34-5.
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Interpretation of findings in relation to previously published works: To our knowledge, there
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are currently no published studies of long-term benefits from PLB. However four categories of
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dyspnoea management strategies (DMS) used by people with severe COPD have been reported
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[17]: changing activity, relaxation, inhaled medication, and altered breathing pattern. PLB was

identified as the 11th most effective DMS and the author reported concern over this relatively low
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ranking given that PLB is taught routinely for dyspnoea management. An alternative
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interpretation might view the four categories as reflecting different but essential components of a

comprehensive COPD dyspnoea self-management programme in which each individual

interventions provides only small reductions in dyspnoea but, added together, they produce

clinically meaningful change [1]. In our study three patients commented that PLB does not

always help, particularly when the breathlessness is experienced in more extreme circumstances.

This mirrors the DMS study observation [17] that patients rated PLB as 55% effective in

relieving breathlessness.

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From focus group discussion and observation at home visits, it was evident that adaptations to the

original technique had occurred. The combining of PLB with diaphragmatic breathing

demonstrated by one patient has been described in the literature [17]. This technique may have

been spontaneously adopted by the patient or learned at PR. Despite the variations in techniques

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equivalent changes in RR and SpO2 to those seen when the technique was first taught were

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observed and the various techniques were subjectively assessed as falling within what might be

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termed PLB. It should be noted that the demonstrations given by patients at the home visits were

of PLB “as an exercise” at rest. The actual practice of PLB during acute breathlessness was not

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observed and may have been different.

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Two themes emerged from the interviews that were unexpected: the use of PLB at night and an

association in the participants’ discussions between use of PLB and use of SABA inhalers. Use of
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PLB to manage nocturnal symptoms was not suggested to participants when taught PLB although

disturbed sleep is an issue reported to affect quality of life for people with COPD [19, 20].
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Although the participants in this study did not specifically refer to use of PLB to reduce panic and
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anxiety associated with their night time breathlessness, a previous qualitative study investigating
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COPD patients perspective on sleep [20] identified nocturnal anxiety and fear of breathlessness as
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a key themes. The second unexpected theme was the introduction by participants into the

discussion comments on their use of SABA inhalers and how this had, for some, reduced since
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learning PLB. It can be hypothesised that this may have been due to their improved sense of

confidence in their ability to cope with their breathlessness by using PLB. It is also interesting to

note that one of the proposed, mechanism for PLB [13, 14, 23, 24] is a reduction in dynamic

hyperinflation. This has been proven as a mechanism by which use of SABA inhalers results in

reduced breathlessness [ 21, 22] and raises the possibility of an underlying mechanistic

association for PLB reducing the use of SABA inhalers and warrants further study.

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Implications for future research: In line with good practice, replication of this study is needed

in order to confirm or refute the findings, in particular of the focus group of which only one was

held. This study also raised the interesting distinction between the sensation of dyspnoea

experienced and the degree of dyspnoea, and this again warrants further study. When asked how

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they thought PLB worked participants either found this difficult to answer or emphatically related

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it to an improvement in their confidence in their ability to cope with breathlessness. This suggests

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that PLB may impact on the sense of control over breathlessness and is essentially a new finding.

This was proposed as a mechanism of action for PLB 20 years ago [25] but not further explored

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in the published literature. It could be hypothesised that the role of PLB in improving self-

efficacy with respect to managing breathlessness is only as a distraction technique however it

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may relate to the reported shortened recovery time from exercise induced breathlessness [26] and

the developing body of evidence suggestion its role in reducing dynamic hyperinflation [13, 14,
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23, 24].
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Conclusions
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In this study demonstrated 8 of 13 patients with stable COPD who were taught PLB continue to
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use the technique with perceived long-term benefit. This observation is consistent with short term
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studies in which up to 63% of COPD patients reported benefit [8]. While the association between

benefits from PLB and exercise have been previously reported the effects on reducing fear and
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anxiety associated with breathlessness and, use at night, are novel findings and need further

study.

Ethical Approval: Ethical approval for the study was obtained from the Brent Medical Ethics

Committee. Reference number 09/H0717/63

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Funding: Funding for taxi fares to attend the focus group was supplied by a donation from PJ

Maitland who had no role in the study design, the collection, analysis and interpretation of data;

in writing of the manuscript; or in the decision to submit the manuscript for publication.

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Conflict of interest: None

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Table 1: PLB teaching protocol
Standardised protocol used when participants were taught PLB
PLB taught in sitting, at rest, at two home visits 3 – 4 weeks apart
“Imagine a small candle, make the flame flicker but don’t blow it out” (6)

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Practise PLB every day for 2 minutes as an exercise

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Use PLB as a means of delaying the onset of breathlessness when active
Use PLB as a means of regaining control of breathing when breathlessness caused distress

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The protocol followed for teaching PLB (Supplementary on line information)

All participants had been taught PLB according to a standardised protocol.

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PLB was taught at a home visit with the participant in a sitting position, either leaning forward

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with their elbows on a table or with their elbows on their knees. The instructions given were
solely focused on the breath out with no direction given regarding the breath in; “to imagine a

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small birthday cake candle and aim to make the flame flicker but not blow it out” [7]. They were
encouraged to use PLB as a means of delaying the onset of breathlessness when active and as a

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means of regaining control of breathing when breathlessness caused distress, achieving this by
means of concentrating on exhalation and, if required to stop, to consider using a forward-lean
position.

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Before learning PLB oxygen saturation and respiratory rate was recorded at rest. After learning
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the technique they were then recorded again after 1 minute of PLB. Oximetry was not used as
biofeedback when learning the technique.
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Participants were asked to undertake daily practise sessions over the 6 to 8 weeks of the
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intervention once daily for 2 minutes each day and to record this in a home diary. The home diary
also had a summary of the verbal explanation given on the front page (see below). The
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participants were then visited again at three to four weeks to review the information given and
their PLB technique.
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Think OUT…OUT…OUT…
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Think “BLOW AS YOU GO”

Remember:
To practise your pursed lips breathing for 2 minutes each day
To try pursed lips breathing at any time when you are aware of being breathless
To try to coordinate your breathing with the effort of exertion during activities that usually lead

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 On line Figure 1: To show the trajectory of study participation with respect to telephone
interview, focus group and home visit study limbs (Supplementary on line information)

Purposive sample

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n = 13

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(M1,F2,M3,F4,F5,M6,F7,F8,M
9,M10,M11,M12,F13)

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Unable to contact 1 (M6)

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Decline interview 1 (F8)

Participants interviewed by an
Agreed to attend focus Agreed to home visit
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telephone n = 11 group n = 7 n= 8
(M1,F2,M3,F4,F5,F7,M9,M (M1,F2,F4,F5,F7,M9,M11) (M1,F2,F4,F5,F7,M9,
M11,M12)
10,M11,M12,F13)
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Still using PLB 9, report: Unable to attend on day 2 Subsequently

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Benefit 8 (M1,M9) unavailable 2

Uncertain benefit 1 (F13) (M1,M9)
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Still using PLB and report

No longer using PLB 2: benefit 5 Still using PLB and
No benefit (M3,M10) report benefit 6
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M male, F female, 1 - 13 order participants taught PLB, where 1 is the person first taught PLB.

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On line Table 1: Perceived benefit from and, initial thoughts with regard to learning PLB

(Supplementary on line information)

Helpful [8/11] I do, I do indeed and for me it helps me very

much (F2); It’s fantastic its helps me so much it

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really does (M9)

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Reflection on initial thoughts when first heard It can’t help (F5) Well I’ll try it and see how I

about PLB; exceeded expectations [5/5] go (F2).

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Helpful but not all the time [3/8] It does, I mean it doesn’t clear it but it does

help (F4); I’m not even saying it works half the

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time, but at the moments when you are really

out of breath and you are stuck you do have

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that to kind of go back to (F7)

Not helpful [2/11] They weren’t making much difference really...I

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don’t remember to do it (M10); You get so busy

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I know it sounds strange but you do you know,

you do one thing and then you forget

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everything about it (M3).

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Table 2: First reasons given for using PLB
When short of breath [4/9] Well you know like when I’m out of breath,

sometime I do that, and I find it eases it a bit

(M11); Recently I’ve had this bad cough so my

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breathing, when I’m walking I get out of

breath, so I use the pursed lip to try and get me

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breathing back to normal (F4).

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Panic attacks/relaxing thing to do [2/9] I started getting panic attacks ... and I found

that when this was about to happen if I used the

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pursed lip way of breathing it would allow me

enough time not to hyperventilate (M9);

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Obviously because I think it helps....it’s a

moment everyday where you focus on your

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breathing and it helps ... it’s quite relaxing

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(F7)

Habit [1/9] I seem to do it without even thinking about it. It

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seems to occur naturally, I feel like if I didn’t

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do that I would be hard of breathing, you know

(M1).
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To recover from coughing {1/9] Sometimes when I bring up phlegm, I get a bit

winded…so I immediately start doing the

breathing exercises (M12)

Unsure [1/9] I’ll try anything (F13)

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Table 3: Themes extracted from telephone interview and focus group transcripts
Physical activity [8/9] If I do the hoovering, if I make the bed, I find

myself doing it more (M1); I can’t get out of

the car immediately. I will do the breathing and

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then get out and walk, that’s…a transition I

find quite difficult, from driving to walking

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(F7)

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Using it at night [3/9] Last night...I woke up, and after I finished

(coughing) I was, you know breathing heavily,

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and I sat up in bed took a long deep breath and

let it out very slowly, pursed lips (M12); At

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night time when I’m in bed and I can’t get my

breath I do the breathing and it’s marvellous

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(F5).
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As an exercise [3/9] If I sit up in the night, watching the telly ... I

wouldn’t be out of breath....just as an exercise

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(M11).
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Anxiety, panic attacks and hot flushes [3/9] It gives me time to concentrate on relaxing and

not going off into that place you go to when

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your panicking (M9).

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On line Table 2: PLB technique and timing (Supplementary on line information)
Techniques You breath in you use your tummy, and when

you let out you use your lips, pursed lips (M11)

When I’m standing...there’s something about

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pushing down…to take the breathing down,

away from my chest... just get it in another

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place (F7); Short breath in and a long breath

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out… like when you are blowing a candle out,

but not heavy (F2); I don’t need to count any

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more... (but) breath in for 2, breath out for 4

(F7).
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How long About a minute or a minute and a half (F2);

For about 5 minutes (M12); Three or four

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minutes (PLB demonstrated) just slowly (F2)

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Frequency of PLB use I do it all the time…unless I’m sitting down

doing absolutely nothing (M1); It’s part of my

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morning routine with my coffee, whilst doing

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the dishes (F7); Sometimes I do it, I wouldn’t

say exactly every day but maybe two or three

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times a week (F2).

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Table 4: Median change in respiratory rate and oxygen saturation from resting breathing to PLB
when initially taught and at follow-up 6 to 24 months later

Initial teaching Long term follow up

n = 11 n=6
median change

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(range) RR bpm -7 ( +1 – -13) -8 (-3 – -16)

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median change
+2 (-1 – +4) +1.5 (0 – +6)
(range) SpO2%

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bpm breaths per minute RR respiratory rate
SpO2% Pulse oximetry oxygen saturation

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