Optimal Diaphragmatic Breathing Patterns through Exercise Can Light Some Medical Problems

Breathing is an absolute human need. In an emergency, airway and breathing are the main problems that must be addressed immediately. Empirically, breathing techniques that people do in general are varied. Of all breathing patterns, it is believed that there must be the most optimal. One of them is diaphragmatic breathing (DB). DB plays the role of the diaphragm as the main muscle that performs the activity of inhaling and exhaling. Optimal breathing patterns, including certain DB, have the ability to relieve several medical problems. The aim of this study was to examine whether an optimal DB pattern could alleviate some medical problems. We conducted a literature study on 40 references consisting of 27 journals and 13 other appropriate literature sources. We searched library resources using the PubMed search engine through keywords: effectiveness of breathing, DB, and breathing exercises. Literature analysis was based on requirements, including inclusion and exclusion criteria. There were 26 journals which met the criteria. Optimal DB pattern can be a solution for chronic obstructive pulmonary disease (COPD), asthma, chronic stroke, congestive heart failure (CHF), gastroesophageal reflux disease (GERD), cerebral palsy (CP), labor pain management, and anxiety. It can be therapeutic to relieve some medical problems.


INTRODUCTION
Breathing is an absolute human need. In emergency case, breathing is the most important thing that must be evaluated (air, breath, circulation). 1 Although humans breathe every day on a regular basis, it turns out that breathing is not necessarily effective. 2 In general, humans breathe 12-20 times per minute in adults aged 19-59 years old One indicator of effective breathing would be relatively little energy is expended 4 Breath training is able to increases the strength of the respiratory muscles, breathing exercises practice good and correct breathing, train effective expectoration,. 4 Diaphragmatic breathing (DB) is one type of effective breathing. During inhalation, the diaphragm contracts, hence the lungs can expand into extra space and let in as much air as needed. 5 It is stimulating deep breathing and expanding the lungs into the diaphragm rather than using the abdomen or ribs. 6,7 DB technique is specific on the moderate rate of breath using processes such as counting breaths while increasing the stomach and inhaling deeply through the nose, pausing, followed by contraction of the stomach and exhaling slowly and completely through the mouth. [6][7][8] This technique includes developing an inhalation and exhalation pattern to decrease the respiratory rate. 7-11 DB requires no special equipment, easy to practice, and saving costs. Optimal DB can produce a therapeutic effect to relieve diseases; such as chronic obstructive pulmonary disease (COPD), asthma, chronic stroke, congestive heart failure (CHF), gastroesophageal reflux disease (GERD), cerebral palsy (CP), pain management in labor, and anxiety.
World Health Organization (WHO) notes that COPD is the fifth highest prevalence disease worldwide, with the death rate increasing every year. The prevalence of COPD in the moderate-severe category occurs at the age of 30 years old and over, with an average of 6.3% worldwide. 12 COPD is a progressive inflammatory lung condition which seriously affects human health. It is not only contributed to dyspnea and reduced lung function, but also accompanied by complex and systemic comorbidities which contributed to respiratory distress that further impairs capacity training. 13 Asthma symptoms include recurrent episodes of coughing, shortness of breath, and chest tightness, along with symptoms that worsen periodically, known as exacerbations. [14][15][16] Exacerbations can be fatal and are more frequent and more serious in high-risk patients or patients with uncontrolled asthma. 15 Asthma is one of health problems which is a major cause of disability and the use of health resources for those affected, who may require emergency care including hospital admission. It affects about 1 to 18% of the population worldwide. WHO and Global Initiative for Asthma (GINA) estimated that 300 million people suffer from asthma worldwide. WHO report stated that 5 main lung diseases are 17.4% of all causes of death in the world. 15,17 According to WHO, 17.5 million people died from cardiovascular disorders worldwide. 18 Dyspnea is a main symptom of CHF. 19 GERD is a digestive system disorder and the prevalence is increasing from year to year. It is caused by disturbances in the movement of the upper digestive tract and reflux of stomach acid in the esophagus, which causes various sores and makes the body uncomfortable. 20 Stroke is a condition that occurs when the blood supply to the brain is reduced due to a blockage (ischemic stroke) or rupture of a blood vessel (hemorrhagic stroke). The respiratory function of stroke patients is directly/indirectly affected by a decrease in oxygen transport related to the function of the cardiovascular system and heart rate function as well as a decrease in paresis of the breast wall movement and a drastic decrease in the function of the cardiovascular system due to a decrease in the frequency of physical activity. 21,22 Anxiety is a state of understanding or worrying that something bad will happen soon. 23 It is also associated with characteristics of COPD parameters, including FVC, chest symptoms, and dyspnea. 13 CP is a non-progressive syndrome of posture and motor impairment that causes activity limitation and is often accompanied by cognitive impairment or visual deficits. Brain damage is permanent and irreversible, but the symptoms of CP can be minimized. 24 DB interventions were presented in this systematic review, might be more cost-effective of improving health outcomes when proven. Therefore, this systematic review aimed to examine DB exercise to reduce all kinds of medical problems through a Mendeley literature search with several topics identified for their feasibility. Other inclusion criteria were the existence of groups of variables or the existence of variations in the treatment of variables. The treatment for the variable was prioritized in the form of DB exercises, but other exercises that were still in the respiratory optimization corridor could also be included as comparison material. A study or review could be included in one of the treatment models in the previous sentence or both. The exclusion criteria were if in one study breathing exercises were combined with other exercises and the results of the study/review did not give positive results between breathing exercises and certain medical problems.

This
Then, all potential studies which met the inclusion criteria were reviewed. The studies then were grouped by type, namely reviews and direct clinical trials. Each study is directly described based on the author, objectives, respondents, methods, and outputs. Meanwhile, each journal review is described based on the author, the purpose of the review, the number of studies collected, the respondents, and the variety of methods. The analysis used in this review was a comparison between studies and reviews.

DISCUSSION
This systematic review aimed to provide evidence on the benefits of breathing exercises for human health. The included studies were studies which assessed the effectiveness of breathing exercises. These interventions could be based on breathing and pursed-lip exercises, relaxation breathing exercises, and deep breathing. The result of analysis is seen in Table 1 and 2.   Breathing exercises are a series of exercises that can be performed to influence breathing patterns. It can optimize thoracoabdominal motion. It has many forms, one of which is DB which aims to increase lung ventilation. 25 In a systematic review, breathing exercises can relieve various diseases such as asthma, GERD, pain management, anxiety, COPD, stroke, CHF, gynecological cancer, lung cancer, and delirium.
Asthma is a serious public health problem. Symptoms of asthma exacerbations can be fatal and are more frequent and more serious in high-risk patients or patients with uncontrolled asthma. 15,17 In asthmatic patients, inspiratory muscle training combined with conventional therapy and a therapeutic exercise program are more effective than its separately application, hence it can increase maximum inspiratory pressure and improve forward head posture. 26 In addition, BMI breathing exercises in children with asthma have benefits, namely increasing inspiratory and expiratory muscle strength. 27 Therefore, breathing exercises are widely used for asthma management in both adults and children.
COPD can cause dyspnea and reduced lung function. 28 One of the therapies used in COPD patients is breathing exercises. It is performed in many forms such as BMI. It is effective for increasing inspiratory muscle strength, quality of life, and reducing dyspnea. 29 Breathing exercises for COPD patients can also be performed at home. In addition, deep breathing exercises are also effective for people with COPD and can reduce dyspnea. 30 For people with anxiety and depression, DB relaxation training programs are effective in reducing anxiety. 31,32 In GERD patients, breathing exercises can improve quality of life and reduce the use of acid suppressants. 33,34 Breathing exercises are also effective for pain management. Based on previous studies, breathing exercises combined with inhalation and deep expiration in pregnant women are effective in reducing pain and shortening the length of the second stage of labor. 35 In CHF patients, deep breathing exercises and active range of motion reduce systolic significant. 36 Respiratory rehabilitation exercises are thought to induce a positive effect on the respiratory muscles of stroke patients through DB and PLB exercises. 37 From previous study, it was found that breathing exercise can reduce physiological failure in gynecologic cancer patients who are undergoing therapy. Breathing exercises have a significant impact on decreasing piper fatigue scale (PFS) scores when performed for 30 minutes 4 times per day. 38 Critically ill patients in the ICU who were managed with ABCDE bundle spent 3 more days breathing unaided, reducing delirium, and easier to be mobilized during their ICU staying than patients who were treated with usual care. Therefore, breathing exercises can reduce delirium in patients in the ICU. Verification of inspiratory muscle training (IMT) effects using threshold devices in COPD patients on dyspnea, quality of life, exercise capacity, and inspiring muscle strength, and additional effects on PR-related BMI dyspnea (pulmonary rehabilitation).

studios
Unknown IMT Breathing exercises are known to have benefits in children with CP. It is also explained that children who cannot walk independently perform breathing exercises. It can strengthen the respiratory muscles and help the child's development to walk independently. This is proved by MIP, MEP, FVC, FEV1, and PEF. In children with CP who walked alone, these parameters give more significant changes than children with CP who could not walk independently. 39 The studies included in Table 1 and 2 used various breathing exercise methods on variable groups. There were studies that specifically mentioned the breathing exercise in question, some only mentioned in general terms. In the description of various studies and reviews in Table 1 and 2, DB exercises were the most used. All studies with DB methods gave positive results in the improvement of various medical problems. Therefpre, based on this review, DB exercise method is the most recommended method.
From the description, breathing exercises have many benefits for adult patients and children as well as for healthy people and even for runners. Hence, breathing exercises can be a supportive therapy to light symptoms of the disease for the patients.

SUMMARY
Breathing exercises can light some medical symptoms, both physically and psychologically. The majority of studies used DB exercises as a treatment which gave positive results due to reduced disease problems.