It is questionable whether a patient can be taught to expand localized areas of the lung while keeping other areas quiet. It is known, however, that hypoventilation does occur in certain areas of these lungs because of pain and muscle guarding after surgery.

A. Lateral costal expansion

1. This is sometimes called lateral basal expansion and may be done unilaterally or bilaterally.
2. The patient may be sitting or in a hook lying position.
3. Place your hands along the lateral aspect of the lower ribs to fix the patient’s attention to the areas which movement is to occur.
4. Ask the patient to breathe out, and feel the rib cage move downward and inward.
5. As the patient breathes out, place firm downward pressure into the ribs with the palms of your hands.
6. Just prior to inspiration, apply a quick downward and inward stretch to the chest. This places a quick stretch on the external intercostals to facilitate their contraction. These muscles move the ribs outward and upward during inspiration.
7. Tell the patient to expand the lower ribs against your hand as he or she breathes in.
8. Apply gentle manual resistance to the lower rib area to increase sensory awareness as the patient breathes in and the chest expands and ribs flare.
9. Then, again, as the patient breathes out, assist by gently squeezing the rib cage in a down ward and inward direction.
10. The patient may then be taught to perform the maneuver independently. He or She may place the hand (s) over the ribs or apply resistance using a belt.

B. Posterior basal expansion

1. Have the patient sit and lean forward on a pillow, slightly bending the hips.
2. Place your hands over the posterior aspect of the lower ribs.
3. Follow the same procedure as described above.
4. This form of segmental breathing is important for the post surgical patient who is confined to bed in a semi upright position for an extended period of time. Secretions often accumulate in the posterior segments of the lower lobes.

C. Right middle lobe or lingula expansion

1. Patient is sitting.
2. Place your hands at either the right or the left side of the patient’s chest, just below the axilla.
3. Follow the same procedure as described for lateral basal expansion.

D. Apical expansion

1. Patient in sitting position.
2. Apply pressure (usually unilaterally) below the clavicle with the fingertips.
3. This pattern is appropriate in an apical pneumothorax after a lobectomy.

Glossopharynegal Breathing

1. Glossopharynegal breathing is a means of increasing a patient’s inspiratory capacity when there is severe weakness of the muscles of inspiration. It is taught to patients who have difficulty taking in a deep breath, for example, in preparation for coughing.
2. This type of breathing pattern was originally developed to assist post polio patients with severe muscle weakness, today, if it is used at all, it is most frequently taught to patients with high spinal cord injuries who can easily develop respiratory problems.
3. Procedure
   The patient takes in several “Gulps” of air. Then the mouth is closed and the tongue pushes the air back and traps it in the pharynx. The air is then forced into the lungs when the glottis is opened. This increases the depth of the inspiration and the patient’s vital capacity.

Note: This technique is very difficult to teach and learn and will be a useful for only a limited number of patients.