Blow Out the Candles…

If there is any treatment that I feel like gets used in a cookie-cutter fashion, it’s pursed-lip breathing. As much as I hate seeing this technique used for every single patient that has shortness of breath, it does have clinical usefulness. So let’s talk about how to implement pursed-lip breathing properly based on patient presentation and medical history so that you can use this most effectively and appropriately. This is going to take up down some roads, both general and specific, to help you understand what pursed-lip breathing does and how it should be used. But, first, let’s watch a pretty decent video on pursed-lip breathing. This video incorporates several different techniques along with pursed-lip breathing, but doesn’t give a whole lot of clinical specifics which makes it GREAT for patient education. You’ll need to clarify the specifics for your patient based on their needs.

American Lung Association

Let’s start at the beginning: What is Pursed Lip Breathing?
Pursed-lip breathing is a respiratory technique with many uses depending on how it is implemented. The general purpose of pursed lip breathing is to prolong exhalation, slow respiration, and provide positive pressure to breathing. Overall, this technique can improve vital capacity and tidal volume.

Sounds simple enough right? We hear the same cues used all the time: “Smell the roses, blow out the candles,” but I have to tell you… If you think you know, you have no idea. This is so much more complex than we give it credit for. Let’s break this down by diagnosis…

Restrictive lung diseases:
Lung resection, sarcoidosis, chronic atelectasis, pulmonary fibrosis including interstitial lung diseases, COVID-19 and other viral/bacterial pneumonias, pleural effusion

There is no amount of deep, diaphragmatic, or pursed lip breathing you can do that will change the fact that these patients have restricted lung volume. You can’t get air in if there is nowhere to put it, you cannot use what just isn’t there. Pursed lip breathing can still be used for these patients, but the use is NOT to improve vital capacity, because that won’t happen. When people with restrictive lung conditions become short of breath, it is typically associated with a high level of stress and anxiety because they literally can’t breathe. Their lungs are closing down or scarring up or any other mechanism that reduces viable lung tissue amount or function.

Pursed-lip breathing can help these folks, for sure, but it is through mechanisms that are emotionally and autonomically linked to breathing. Mindfulness of breathing has been shown by numerous studies (thank you, yoga and tai chi!) to change a person’s emotional state and physiological function. This mechanism is well studied but very complex and involves chemical transmitters as well as stretch-response mechanisms in the musculoskeletal, vascular, cardiac, olfactory, and limbic systems (and probably several others). It is important to note that the slowed rate of breathing is the emphasis of the research, not necessarily the “pursed-lip” portion of the technique.

Photo by Anna Shvets on

That all being said, please use pursed lip breathing in this individuals for the purpose of decreasing anxiety and respiratory rate. Keep in mind that this may only be a band-aid and that medications, increased oxygen titration, and other medical interventions may be necessary to recover shortness of breath. Pursed lip and diaphragmatic breathing can be used together to stimulate the autonomic nervous system (chemo-, baro-, and stretch-receptors) to reduce respiratory rate and chemically alter emotional state to reduce stress and anxiety and lessen symptoms of shortness of breath. This is based in parasympathetic activation which slows heart rate and relaxes smooth muscles throughout the body. This means arteries relax and are able to carry more oxygen rich blood to needed organ systems, blood pressure lowers, and cardiac effort is reduced due to reduced peripheral resistance. All good things for someone who is experiencing shortness of breath 🙂

Unfortunately, research shows us that pursed lip breathing may also increase the overall metabolic workload of breathing in patients with restrictive lung diseases, which may outweigh the benefits if you are attempting to increase oxygen saturation with activity. It has also been found that pursed lip breathing is not effective to reduce shortness of breath during activity in patients with restrictive lung diseases. So, although it may seem pretty simple, this intervention does need to be used with caution and for the right reasons.

Obstructive Lund Diseases:
Chronic Obstructive Pulmonary Disease, Bronchitis, Bronchiolitis, Emphysema, Cystic Fibrosis, Asthma

This one is the big red flag for me. The video does a pretty decent job of showing how to accommodate pursed-lip breathing to obstructive conditions, but doesn’t exactly explain the reasoning. The big problem with obstructive lung disease is that you can’t get enough air OUT of the lungs. Therefore, telling someone to breathe in deeply through their nose is NOT going to improve their symptoms! In fact, it will actually make things worse because you are just attempting to pack more air in to a space that is already full of dead air. This does not improve ventilation, and significantly reduces ventilation/perfusion matching requirements of activity. In essence, the more you have them breathe deeply, the less oxygen they have left in their blood supply to actually perform the mechanical work of breathing!

To perform pursed lip breathing properly in a patient who has obstructive lung disease, you have to have them focus on the breathing OUT portion of pursed lip breathing. And this activity is two-fold in benefits! Here’s why:

The video instructs pretty well on the importance of breathing out and incorporates a great tool I teach to my patients all the time: Counting! Patients with obstructive lung conditions need to get more air out than they take in. This helps remove the dead air from their lungs and replaces it with new air. The more air they breathe out, the more room they have to put new air in. Make sense? So having your patient count, “1, 2” for their breath IN and “1, 2, 3, 4” for their breath OUT helps them focus on getting the air out. Sometimes I add in a PEP device to help shift to focus to getting air OUT for patients with obstructive conditions.

Photo by Anna Shvets on

The second bonus to focusing on exhalation is the actual performance of the “pursed-lip” portion of pursed-lip breathing. This maneuver, when done properly, causes some of the air coming out of the lungs to bounce off the inside of the lips and cheeks and rebound into the airway and lungs. This is similar to PEEP (positive end-expiratory pressure). We provide PEEP when patients are mechanically ventilated with the exact same purpose it fulfills with pursed lip breathing: to provide back pressure that splints open smaller or collapsed airways, allowing for exhalation of greater volumes of carbon dioxide, therefore improving vital capacity. That means that the little bit of back pressure holds the airways open longer to allow for more dead air to escape, making room for more good air to get back in.

And when I say “done properly,” I don’t mean that you try to force air out through whistle-tight lips. That just doesn’t allow for that back pressure to build up correctly. Just like in mechanical ventilation, too much PEEP can be a problem. Lips should still be open somewhat and the cheeks should be loose and allowed to flare so that air can gather and build pressure. Here’s a terrible up-close video of me pursed-lip breathing so you can get the idea.

Like I said, pretty terrible up-close video, but I’m not pinching my lips together super tight and my cheeks are relaxed and that’s really the point here.

There have been some recent studies that have shown that a simulated pursed-lip breathing during non-invasive ventilation (NIV) can actually be more effective than NIV alone for patients with COPD who are in hypercapnic respiratory failure! This intervention even held up under activity demands of a functional maximal exercise capacity test (the 6 minute walk test).

Did you know there was that much to it? I know I was shocked to find out something that seemed so simple was actually so complex and that it could be used in such varying ways if it was used correctly. I hope that you are able to repurpose this old stand-by technique with better clinical application for your patients.

I’ve gotta tell you all something… I love this stuff. I love getting down to the absolute basics, figuring out the “why” of it all, applying it in the best possible way for my patients, and then telling all of you about it! Now, pucker those lips and get to breathing!

Do you find that pursed-lip breathing recovers shortness of breath better for your restrictive or obstructive patients? Let me know in the comments!

Read more from the Pulmonary Rehab Toolbox!

Bellissimo, G., Leslie, E., Maestas, V., & Zuhl, M. (2020). The Effects of Fast and Slow Yoga Breathing on Cerebral and Central Hemodynamics. International journal of yoga13(3), 207–212.

Jünger, C., Gaede, K. I., Herzmann, C., Lange, C., Reimann, M., Rüller, S. (2020). Pursed-lip breathing ventilation for the treatment of hypercapnic respiratory failure in COPD. ERJ Open Research. 6: 41; DOI: 10.1183/23120541.RFMVC-2020.41

Jünger, C., Rüller, S., Reimann, M., Krabbe, L., Gaede, K., Lange, C., Herzman, C. (2019). Mechanical non-invasive pursed-lip breathing ventilation for hypercapnic patients with COPD. European Respiratory Journal. 54: PA4237; DOI: 10.1183/13993003.congress-2019.PA4237

Nguyen J, Duong H. Pursed-lip Breathing. [Updated 2020 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from:

Parisien-La Salle, S., Rivest-Abel, E., Boucher, V. G., Lalande-Gauthier, M., Poirier, C., Dube, B. P., Manganas, H., Morisset, J., Comtois, A. S. (2017). Effect of pursed lip breathing on dyspnea and walking distance in interstitial lung disease: a randomized crossover study. European Respiratory Journal 50: PA2246; DOI: 10.1183/1393003.congress-2017.PA2246

Russo, M. A., Santarelli, D. M., & O’Rourke, D. (2017). The physiological effects of slow breathing in the healthy human. Breathe (Sheffield, England)13(4), 298–309.

Zaccaro, A., Piarulli, A., Laurino, M., Garbella, E., Menicucci, D., Neri, B., & Gemignani, A. (2018). How Breath-Control Can Change Your Life: A Systematic Review on Psycho-Physiological Correlates of Slow Breathing. Frontiers in human neuroscience12, 353.

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