RU2784605C1 - Method of breathing exercises for patients with covid-associated pneumonia - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, pulmonology, medical rehabilitation of patients with COVID-associated pneumonia. Perform a 14-day course of daily breathing exercises with biofeedback (BFB) for heart rate and saturation level (SpO₂). Each session includes a warm-up, main and final parts. Moreover, at the end of the main part, sound gymnastics exercises are carried out with the pronunciation of a sound on one exhalation when performing hand movements.

EFFECT: method provides reliable and persistent positive dynamics of heart rate and SpO₂ indicators, as well as breathing rhythm due to gradual adaptation of the patient's body to physical activity, gradual complication of exercises and gradual increase in motor density of exercises.

1 cl, 4 dwg, 1 tbl, 2 ex

Description

The invention relates to the field of medicine, pulmonology, medical rehabilitation of patients with COVID-associated pneumonia (survivors of SARS-Cov-2-associated pneumonia, COVID-AP). It can be used in medical, treatment-and-prophylactic, sanatorium-and-spa institutions.

COVID-19 (abbr. from English COronaVIrus Disease 2019) is a 2019 coronavirus infection (formerly coronavirus infection 2019-nCoV), a potentially severe acute respiratory infection caused by SARS-CoV-2 coronavirus (2019-nCoV). It is a dangerous disease that can occur both in the form of an acute respiratory viral infection of a mild course, and in a severe form (Li-Li Ren et al. 2020, doi: 10.1097/CM9.0000000000000722).

The most common symptoms of the disease include fever, fatigue and dry cough. The virus is able to infect various organs through direct infection or through the body's immune response. The most common complication is viral pneumonia, which can lead to acute respiratory distress syndrome and subsequent acute respiratory failure, when oxygen therapy and respiratory support are most often needed. Complications include multiple organ failure, septic shock, and venous thromboembolism.

From December 31, 2019 to April 2022, 490,777,296 cases of COVID-19 were reported worldwide during the pandemic, including 6,158,591 deaths (European Center for Disease Prevention and Control (ECDC)) , the number of diseases in Russia is 18,030,579 (according to the Government of the Russian Federation)

Although COVID-AP (covid pneumonia, CAP) occurs in different forms and severity, they all require rehabilitation. Existing methods of breathing exercises were created and used to treat such diseases of the respiratory system as bronchial asthma, COPD, bronchitis. At the moment, they do not provide a full-fledged safe restoration of lung function in the fight against the consequences of COVID-AP, being extremely burdensome. Thus, breathing exercises in existing complexes involve performing exercises with short, quick breaths, as well as holding the breath or exercising with forced expiration, which is unacceptable in rehabilitation after CAP, since the risk of complications increases: overstretching, microtraumatization, and collapse of the alveoli. Thus, clinical practice has shown that during rehabilitation after a new coronavirus infection, it is advisable to develop specific recovery exercises, taking into account the extremely high risk of complications as a result of breathing with resistance and severe asthenia in patients.

In this regard, we tested our own set of exercises, including both directly breathing and elements of sound (vibration) gymnastics.

Medical rehabilitation should begin as early as possible, but only after the subsidence of the main symptoms of CAP, in order to avoid forced prolonged physical inactivity, to prevent a vicious circle of asthenia, weakening of the respiratory muscles and worsening respiratory failure.

The most important for respiratory rehabilitation are the first two months after the acute period of coronavirus infection - this is the period of the "therapeutic window". Early activation has proven to improve life prognosis for patients with severe manifestations of CAP. There are a number of general principles for constructing rehabilitation stages, according to which the complications of the transferred CAP are stopped more fully and quickly:

1) a multidisciplinary approach to restorative care, starting early and continuing through the hospital stay;

2) teaching the patient and his family members to perform special exercises for the respiratory and musculoskeletal system after discharge from the medical institution;

3) continuation of rehabilitation activities on an outpatient basis in person, or through telemedicine technologies.

For patients who were on mechanical ventilation, it is important to restore the rhythm of breathing by adding exercises to the complex that can form the correct pattern of respiratory movements. Of the existing methods, only a few take into account this principle. After mechanical ventilation, patients may develop respiratory muscle weakness. As part of rehabilitation, it is required to increase the indicators of strength and strength endurance of the inspiratory muscles to ensure high-quality ventilation.

In addition, rehabilitation methods in the format of respiratory gymnastics, which mainly stimulates the auxiliary respiratory muscles, have been proven to improve the performance of external respiration by 1.5 times.

Rehabilitation after a coronavirus infection is known, including a set of breathing exercises and exercises for the upper extremity girdle, chest and lower back muscles (Danila M. CAMOZZI et al. Early rehabilitation in post-acute COVID -19 patients: data from an Italian COVID-19 Rehabilitation Unit and proposal of a treatment protocol // European Journal of Physical and Rehabilitation Medicine 2020 October; 56(5):633-41. DOI: 10.23736/S1973-9087.20.06339-X). However, as the authors themselves point out, in this case it was not possible to show the role of rehabilitation in changing specifically lung function and disability status due to the design of the crossover study.

Tina J. Wang et al. PM&R and Pulmonary Rehabilitation for COVID-19. // Am J Phys Med Rehabil. 2020 Jun 11: 10.1097/PHM.00000000000001505. / PMCID: PMC7315835. PMID: 32541352) postulates the basic principles of rehabilitation of respiratory function after covid, as well as the influence of the duration of the course and the load on the choice of exercises, incl. taking into account the values of the Borg scale.

It is also known to use yoga techniques in such patients, including its breathing exercises, as well as through telemedicine (Ka Sing Paris La et al. Breath Regulation and yogic Exercise An online Therapy for calm and Happiness (BREATH) for frontline hospital and long- term care home staff managing the COVID-19 pandemic: A structured summary of a study protocol for a feasibility study for a randomized controlled trial // Clinical Trial Trials 2020 Jul 14;21(1):648 doi: 10.1186/s13063 -020-04583-w.).

However, these well-known methods are rather complex complexes with complicated control of exercise performance using biofeedback according to heart rate.

A well-known method of post-COVID rehabilitation includes, in addition to breathing exercises, also acupuncture massage (Lulu Zha et al. Modified rehabilitation exercises for mild cases of COVID-19. Observational Study Ann Palliat Med. 2020 Sep;9(5):3100-3106. doi : 10.21037/apm-20-753. Epub 2020 Aug 10). However, this requires the direct presence of a medical specialist who knows the technique of acupuncture, which makes it difficult to widely implement this method.

According to the publication (Hatice Öner Cengiz et al. Effect of deep breathing exercise with Triflo on dyspnoea, anxiety and quality of life in patients receiving covid-19 treatment: A randomized controlled trial. // J Clin Nurs. 2021 Dec 12. doi: 10.1111 /jocn.16171.Online ahead of print.PMID: 34897869 DOI: 10.1111/jocn.16171), in patients with post-COVID syndrome, deep breathing exercises increase the saturation level (SpO2) and quality of life, help reduce dyspnea and anxiety. In addition, the length of stay in the hospital is reduced. When doing deep breathing exercises, the respiratory rate (RR) reaches normal limits in a short time, the SpO2 level rises significantly, and the quality of life of patients with COVID-19 pneumonia improves. However, there are no data on the effect of such exercises on the cardiovascular system, as well as the formation of tolerance to physical activity, for a longer period of recovery after undergoing CAP.

There is also known a method for integrative rehabilitation of patients after a new coronavirus infection (COVID-19) with damage to the upper respiratory tract (RU 2769214 C1, Kurashova O.N. et al., 03/29/2022). At the same time, normoxic barotherapy is carried out at an excess pressure of 0.15-0.35 atm with an oxygen content of up to 30% and a flow rate of 5 l/min. The exposure time is 30 minutes, the course is 8-16 procedures. Normoxic barotherapy is combined with daily walks in the natural landscape of the forest park. Stimulation of capillary blood flow and blood filling, activation of intracellular and intercellular processes is achieved. However, there is no data on the long-term positive effects obtained when using this method.

There is also known a method for the rehabilitation of patients with bronchopulmonary pathology of an infectious genesis, including a previous COVID-19 infection, at all stages of medical rehabilitation (RU 2745697 C1, FGBOU DPO RMANPO of the Ministry of Health of Russia, 30.03.2021). At the same time, compression is carried out through the system of connections between the pneumocuffs and the compression station. The operating modes of the device allow you to choose compression in pneumocuffs of 3 levels. Given the reports in the scientific literature about the need for a particularly gentle nature of the impact on the lung tissue of a patient with COVID-19, the chest compression regimen and, therefore, the patient's activity is increased gradually from the first to subsequent procedures. At the first procedure, the compression is set at the 1st level, at the 2nd procedure - at the second level, at the 3rd procedure and subsequent levels, the compression corresponds to the 3rd level. The settings of the device allow you to change the duration of the phases of compression and decompression of the chest. Impact with a low-frequency vibrator begins with the 3rd procedure. A low-frequency vibrator is installed in the projection of the legs of the diaphragm to the right and left of the spine at the level of the costal arch. The impact of the vibrator occurs synchronously with the operation of the compression station for forcing air into the system throughout the cycle of the selected duration. Before performing the procedure, the patient receives an instruction to perform - during compression through the pneumocuff, the patient must take a breath in the direction of chest compression; during a pause in the operation of the apparatus, an exhalation is performed through lips closed by a tube. Course - 10 procedures. EFFECT: method provides an effect in patients with bronchopulmonary pathology, including COVID-19, increases the functionality of the respiratory muscles with the development of maximum compensatory capabilities due to the recruitment of a larger volume of lung tissue into gas exchange, providing secondary prevention of complications of the bronchopulmonary system. However, the long-term effects of the method are not described.

A known method of medical rehabilitation of patients with viral pneumonia associated with coronavirus infection (RU 2772211 C1, Achabaeva A.B., 05/18/2022), in which, after achieving stabilization of the general condition and saturation indicators, patients are prescribed to drink warm low-mineralized mineral water 40 minutes before meals at the rate of 3-3.5 ml/kg of body weight 3 r/d; a daily walk along a path of medium difficulty with a length of at least 2600 m at a walking pace of up to 4 km/h; Exercise therapy, including breathing and physical exercises lasting 30 minutes, 12 procedures every other day; herbal medicine using a 1.5% solution of licorice root extract in the form of oxygen cocktails with a volume of 200 ml 20 minutes before meals 1 time per day, 12 servings per course of treatment, and rectal suppositories with Tambukan mud "Tambuil" 30 mg 2 times a day within 20 days. They also conduct psychotherapy sessions in small groups. The effectiveness of the treatment of patients after pneumonia caused by coronavirus infection, with a violation of the oxygen metabolic balance of the body, is increasing. However, the effects of directly administered breathing exercises in this group of patients and their impact on the long-term effects of rehabilitation have not been described.

During the period of illness, with pneumonia, it is recommended to do individually selected exercises. The patient, as a rule, has reduced mobility, there is a risk of hypodynamia, so breathing exercises benefit recovery. They are selected taking into account localization according to CT parameters: based on which part of the lungs is affected, you can select individually directed complexes. Assign breathing exercises with a wet cough, to improve sputum discharge. With a dry cough, they are ineffective and can even worsen the situation.

Respiratory gymnastics is a motor load, in which there is a change in heart rate, and it is aimed, among other things, at including additional volumes of inhaled air. With CAP, the elasticity of the bronchopulmonary system changes, so you should not resort to breathing exercises on your own, without consulting a specialist and complex treatment. During exercise, it is important to control SpO2 and pulse (HR). The work is aimed at improving drainage functions and activating the main respiratory muscles.

With SARS, if there are no bronchopulmonary complications, exercises are not needed, as well as with full recovery from pneumonia. If the patient is diagnosed with formed fibrous tissue in the lungs, then it is worth continuing to perform the exercises after the illness.

As the closest analogue of the proposed method, a well-known set of breathing exercises after a coronavirus infection can be considered (Breathing exercises for coronavirus: exercises, doctor's advice: https://style.rbc.ru/health/5fc086e69a79470b1aeff9f1, saved online 04/01/2022, https: //web.archive.org/web/20220401092601/https://style.rbc.ru/health/5fc086e69a79470b1aeff9f1). The authors believe that the goal of exercises that can be performed even at home is to cleanse the lungs of mucus and restore breathing. Gymnastics is based on deep breaths and short-term air retention. Deep breathing increases the amount of oxygen entering the lungs and the amount of carbon dioxide leaving them. At the same time, inhalation of a large amount of air through the mouth can cause irritation of the mucosa. Especially if you perform exercises in a dry, insufficiently ventilated area. At first, it is better to inhale through the nose, as this warms and humidifies the air.

It is recommended to do light gymnastics, starting from a prone position, and supplement it with breathing exercises. The latter include the alternation of deep breaths and exhalations, a short breath hold and exhalations with the pronunciation of different sounds. It is also necessary to pay attention to the training of the auxiliary muscles involved in breathing. You need to perform exercises for 3-4 weeks 2-3 times a day and only at normal body temperature.

Respiratory gymnastics does not exclude other rehabilitation appointments of a doctor: walks, a recovery diet, drug therapy and physiotherapy. Respiratory gymnastics is stopped with the appearance of dizziness, increased shortness of breath, chest pain, excessive sweating and fatigue, cardiac arrhythmia.

In particular, with well-known respiratory gymnastics, the following well-known set of exercises is used:

1. Diaphragmatic breathing. Deep breathing restores lung function, helps the nervous system to relax and recover. This deep breathing exercise is divided into phases. Gradually increase the number of repetitions and proceed to the next phase only when they perform the previous exercise without being out of breath, namely:

Phase 1: Deep breathing on the back.

The patient lies on his back, legs bent at the knees so that the feet rest on the bed. Hands lie on the stomach or wrap around the sides of the stomach. Close the lips and press the tongue to the palate. Inhale through the nose and draw air into the abdomen. On the fifth breath, they try to spread their fingers apart. Exhale slowly through the nose. Repeat deep breaths for one minute.

Phase 2: deep breathing on the abdomen. Lying on the stomach, the head is placed on the hands to allow breathing. Close the lips and press the tongue to the palate. Inhale through the nose, draw air into the abdomen. They try to focus on keeping the stomach against the mattress while breathing. Exhale slowly through the nose. Repeat deep breaths for a minute.

Phase 3: deep breathing while sitting. Sitting on the edge of the bed or on a stable chair, wrap your arms around your stomach. Close the lips and press the tongue to the palate. Inhale through the nose, draw air into the abdomen, where the hands are. They try to spread their fingers to the sides while inhaling. Exhale slowly through the nose. Repeat deep breaths for a minute.

Phase 4: deep breathing while standing. Standing straight, wrap your hands around your stomach. Close the mouth and press the tongue to the palate. Inhale through the nose, drawing air into the abdomen. They try to spread their fingers to the sides while inhaling. Exhale slowly through the nose. Repeat deep breaths for a minute.

2. Carry out the following exercises for the muscles of the body:

Yawning with a Smile - This exercise involves a deep breathing movement that helps improve coordination and strengthen the arms and shoulders. To do this, sitting on the edge of the bed or on a sturdy chair, they stretch their arms above their heads and yawn widely. Put your hands down and smile for three seconds. Repeat for one minute.

"Breathing with sound". The connection of the vocal cords during exhalation helps to increase the production of nitric oxide in the body, with the expansion of the body's blood vessels. Exercise calms and relieves stress. To do this, sitting on the edge of the bed or on a chair, they wrap their hands around their stomach. With lips closed and tongue in the sky, inhale through the nose and draw the air into the abdomen. They try to spread their fingers to the sides while inhaling. When the lungs are full, keep the lips closed and exhale through the nose, humming "hmmm." Watch how the hands go down. Repeat for one minute.

"Firewood". Perform standing. They stand on their toes, raise their hands up and clasp their fingers. They bend back and sharply lean forward and down, as if chopping wood. The exhalation should be strong and loud. Return to starting position and repeat several times.

"Skier". Feet shoulder width apart, lifting on toes. Tilt the body slightly forward, stretch the arms forward. You can imagine that the hands are holding ski poles. On exhalation, they increase the slope, move their hands down and back, springing them in this position for a couple of seconds. They return to the starting position (IP) by taking a deep diaphragmatic breath.

"Asymmetric breathing". Take short breaths and maximally long, unhurried exhalations five times longer than the inhalation. The exercise can be performed lying down, sitting or standing.

"Cat and Cow". Get on all fours. While inhaling, bend in the lower back, raising the pelvis and head up, while exhaling, round the back, lowering the pelvis and looking down. This exercise helps not only to work with breathing, but also to strengthen the muscles of the back, providing a soft comfortable stretch.

3. Breathing according to the Buteyko method.

Exercise can be performed only in the absence of obvious discomfort when breathing. The essence of the method is to provoke a short-term lack of oxygen. Inhale for two counts, then exhale for four counts, then hold your breath for five seconds.

4. "Breath of a lion." Take a comfortable sitting position. You can sit on your heels or cross your legs. They press their palms to their knees, spreading their fingers wide. Take a deep breath through the nose and open the eyes and mouth wide, sticking out the tongue, lowering its tip to the chin. During exhalation through the mouth, the muscles of the front of the throat are compressed, making a long “ha” sound. You can look up or at the tip of the nose. Repeat several times.

5. Diaphragm expansion. Lie on your back. Place a large book or stack of books on your stomach just above your navel. Direct your gaze in their direction. Inhale with your stomach to lift the books, and lower them as you exhale. The back may be slightly off the floor. Do 10-15 repetitions, rest and repeat two more times.

However, for this well-known complex, there are no data on a significant improvement and preservation of the positive effects of rehabilitation for a certain period after its completion, as well as on the risk of complications.

Taking into account the shortcomings of the listed known methods, the respiratory gymnastics offered by us was developed purposefully for patients after CAP, based on existing approaches to the restoration of respiratory function, the risk of possible complications and the clinical picture of the disease, and includes the following principles:

1. Preparation of the musculoskeletal system for further rehabilitation by performing general strengthening exercises and elements of the complex for the cervicothoracic region.

2. All exercises should smoothly move from simple to more complex.

3. Gradually increase the motor density of each lesson (reduce pauses for rest, while increasing the motor density of the lesson - the ratio of the time directly spent on performing movements during the lesson to the duration of the entire lesson).

4. Compliance with the rhythm of breathing.

5. Maintaining feedback with the patient (BFB for heart rate and SpO2).

The technical result of the proposed method is the gradual adaptation of the patient's body to physical activity, which makes it possible to complicate exercises and gradually increase the motor density of exercises (from 62.5% to 81%), achieving reliable and stable positive dynamics of heart rate and SpO2, as well as breathing rhythm.

To do this, the proposed method of breathing exercises is carried out for patients who have undergone COVID-associated pneumonia. It includes a 14-day course with daily breathing exercises using biofeedback (BFB) for heart rate and saturation level (SpO2). Each lesson includes blocks:

1) Warm-up - preparation for the main part of the gymnastics of the musculoskeletal apparatus of the neck and shoulder girdle - in the form of exercises for turning and rolling the head and rotating the shoulder girdle with free breathing, duration - 3-5 minutes.

2) The main part - the consistent implementation of a set of exercises, each of which is repeated 6 times, to stretch the muscles of the neck, pectoral muscles, train the tone of the muscles of the shoulder girdle and rotator cuff of the shoulder, back and abdomen muscles, mobility of the shoulder girdle, shoulder blades, strengthen the gluteal and thigh muscles .

At the end of the main part, sound gymnastics exercises are carried out with pronouncing a sound on one exhalation when performing hand movements, and the pronunciation of each sound - “m”, “g” and “r” is performed 2 times, with the breath resting on the diaphragm, with a cleansing exhalation after each repetition, where the cleansing exhalation is the maximum possible exhalation for the patient, at the end of which, without a pause and without straining, the patient tries to exhale the remaining air from the lungs, using the diaphragm and abdominal muscles, for which, during the cleansing exhalation, the positions of the upper limbs and body are used, compressing the chest , while saying: "V-R-U-X" with a cleansing exhalation.

The duration of the main part is 20-25 minutes.

3) The final part - lasting 5-7 minutes, in the form of exercises to restore free breathing and stretch the fascial structures of the body.

Moreover, classes are held under constant monitoring of heart rate and SpO2 indicators, and with the patient’s adaptation to the load, determined by the stability of heart rate indicators and improvement of SpO2, they reduce the rest pause between exercises, increasing the motor density of the lesson - the ratio of time directly spent on doing exercises to time the whole lesson.

At the same time, 6 repetitions of each performed exercise of the main part are carried out during the course of exercises as follows.

Initially, all 6 repetitions of each exercise are performed with the patient's free breathing.

In further classes, taking into account the tolerance of the patient, the repetition of each exercise is carried out according to the following sequential scheme of adaptation to the respiratory load:

5:1, where 5 repetitions - with free breathing, 1 repetition with an extended exhalation;

4:2, where 4 repetitions - with free breathing, 2 repetitions with an extended exhalation;

3:3, where 3 repetitions - with free breathing, 3 repetitions with an extended exhalation.

Then, according to the same scheme 5:1, 4:2, 3:3, gradually, taking into account the patient's tolerance to the load, the repetitions with an extended exhalation are replaced with repetitions with an exhalation with resistance:

5:1, where 5 repetitions - with free breathing, 1 repetition with exhalation with resistance;

4:2, where 4 repetitions - with free breathing, 2 repetitions with exhalation with resistance;

3:3, where 3 repetitions - with free breathing, 3 repetitions with exhalation with resistance.

Further, according to the same scheme, repetitions with exhalation with resistance are replaced with repetitions with inspiration from the closed position of the diaphragm - in the position of the arms and body, blocking free inspiration:

5:1, where 5 repetitions - with free breathing, 1 repetition with inspiration from the closed position of the diaphragm;

4:2, where 4 repetitions - with free breathing, 2 repetitions with inhalation from the closed position of the diaphragm;

3:3, where 3 repetitions - with free breathing, 3 repetitions with inhalation from the closed position of the diaphragm.

At the same time, the condition for each indicated replacement of exercise repetitions is the achievement of patient adaptation to the previous level of respiratory load - stable heart rate, improvement in SpO2 and exercise tolerance by the patient without subjectively unpleasant sensations when performing repetitions of each exercise.

In case of destabilization of these indicators and/or the appearance of subjectively unpleasant sensations, the next repetition of the exercise is performed at the previous level of respiratory load for this exercise - without another replacement according to the indicated scheme, until adaptation is achieved, taking into account heart rate, SpO2 and subjective tolerance.

Implementation of the method

Classes with the patient begin at the end of the acute phase of COVID-19, with stabilization of the clinical condition. It is important for the patient to learn diaphragmatic breathing to ensure high-quality ventilation of the lungs, which reduces the risk of congestion. Inhalation is performed in a calm mode through the nose, a slow elongated exhalation through the mouth, while the lips are folded into a tube.

Gymnastic warm-up necessarily includes exercises for the muscles of the neck to relieve tension from the auxiliary muscles of inspiration, such as: sternocleidomastoid muscle, anterior, middle and posterior scalene muscles, which are attached to the structures of the chest, as well as for the muscles of the lower extremities and body necessary for stable verticalization of the patient.

In order to avoid asthenization of the patient, in case of rapid fatigue, they switch to an isometric mode of operation, maintaining control of calm breathing, with alternating effects on different muscle groups, avoiding overstrain. In case of pain during exercise, the range of motion is reduced to a feeling of tension. After each exercise, a pause is made to relax and restore breathing, control heart rate and pulse oximetry. When adapting to a given load, pauses for rest are reduced, thus increasing the motor density of the lesson (the ratio of the time directly spent on performing movements during the lesson to the time of the entire lesson).

The lesson ends with elements of sound gymnastics to improve the drainage function of the bronchi. Sound (vibration) gymnastics exercises are performed without a deep breath - only on one exhalation, without tension. For a better impact, you should “lower” sounds into the thoracic region (i.e. try to pronounce them not from the vocal cords, but relying on the diaphragm: see, for example, https://ovocale.ru/opora-dihanija-paradoxalnoe-dihanie /, saved in the web archive on 10/19/2021: https://web.archive.org/web/20211019212334/https://ovocale.ru/opora-dihanija-paradoxalnoe-dihanie/). The duration of the exercise is determined by the length of the exhalation and gradually increases from session to session. After each exercise of sound gymnastics, a “cleansing exhalation” should be carried out. The elements of sound gymnastics start with the softest sound, "M", and end with the rougher "Ж" and "Р".

The load is also increased by changing the ratio of the number of movements with free breathing to repetitions of exercises with an extended exhalation, then they switch to exhalation with resistance - through slightly closed lips.

An emphasis on an extended exhalation is added to set the correct breathing rhythm and involve more lung structures in the work. The exhalation should be as complete as possible for a particular patient, in 2 counts, and at the end of the exhalation, you should try to exhale a little more, in 1 count, but without straining. When performed correctly, the abdominal muscles are connected. The maximum exhalation then implies a full-fledged passive inhalation, which contributes to the development of the respiratory muscles and the value of the vital capacity of the lungs (VC).

Each exercise is first repeated 6 times, then the first 5 repetitions are performed with free breathing, and the final repetition with an extended exhalation. Gradually, under the control of biofeedback according to heart rate and pulse oximetry data, the ratio of repetitions of exercises with free breathing and elements of the complex with an extended exhalation of 3:3 is reached. If dizziness occurs, it is recommended to continue performing all exercises, but without replacing it with an extended exhalation. As soon as dizziness stops, an extended exhalation is added again.

Upon reaching the required ratio of exercises with free breathing and elements of the complex with an extended exhalation of 3:3, a gradual replacement of repetitions of the exercise with its repetitions with exhalation with resistance, which is achieved with the help of closed teeth or lips with the pronunciation of the sound “F”, begins. The initial ratio of the number of these two types of exercises is also 5:1. The goal is to achieve a ratio of 3:3. In the event of dizziness, destabilization of heart rate and SpO2, the proportion of exhalation repetitions with resistance is replaced by exercises with an extended exhalation (i.e., there is a return to the previous phase of exercises, to which adaptation has already occurred).

You can dosedly add exercises for vertical load - aerobic elements (rolling the foot from heel to toe, walking in place, lifting the hip, overlapping the lower leg, side step). It is useful for improving blood circulation, training the cardiovascular and respiratory systems, as well as the musculoskeletal system. The axial load is dosed by the number of repetitions and is performed without the use of weights (dumbbells, elastic bands). It is important to teach the patient to control his own body and feel himself in space, which will soon restore the regime of optimal age-related physical activity. They also complicate classes by adding complex coordination exercises, where they simultaneously perform movements with arms and legs.

With successful adaptation to exercises with complicated exhalation, the elements of training the inspiratory muscles are introduced into the complex. For example, isometric exercises for the cervical-thoracic region and exercises with inspiration from the closed position of the diaphragm - when the arms and body are in positions in which free inspiration is blocked - by tilting or turning the body to the side, or placing the hands on the lateral projections of the diaphragm and / or lower chest. For emotional coloring, expansion of motor skills and a variety of activities in the classroom, you can use additional equipment: a gymnastic stick, a ball.

Exercise tolerance is controlled by a mobile pulse oximeter and heart rate measurement. The use of the modified Borg scale was not informative, since some of the trainees did not experience shortness of breath even with a significant decrease in oxygen levels.

Classes are conducted by a specialist in physiotherapy exercises both in a hospital and on an outpatient basis, through telemedicine. In the latter case, the duration of the course may vary as the patient adapts to physical activity and the symptoms of respiratory failure decrease.

The essence of the proposed method is described as follows.

Start with a warm-up (figure 1).

1) Starting position (IP) - sitting in the middle of a chair, hands with palms on hips, back straight, head straight, shoulder blades brought to the spine.

On account 1 - turn the head to the right shoulder.

2 - return to IP.

3 - turn the head to the left shoulder.

4 - return to IP.

Guidelines: fixation in each extreme position for 1 sec.

2) IP - sitting in the middle of a chair, hands with palms on hips, back straight, shoulder blades brought to the spine.

On account 1 - roll the head from the right shoulder, through the center (through the movement of the head forward and down), to the left.

2 - roll of the head from the left shoulder, through the center (through the movement of the head forward and down), to the right.

Guidelines: breathing is free, the pace is comfortable for the patient, the maximum possible amplitude for him.

3) IP - sitting in the middle of a chair, palms on hips.

At the expense of 1-8 - circular rotations of the shoulder girdle back.

At the expense of 9-16 - the same forward.

Guidelines: breathing is free, the pace is comfortable for the patient, the maximum possible amplitude for him.

Next, perform the main part of the lesson, consisting of special exercises (figure 2).

4) IP - sitting in the middle of a chair, the right arm is bent at the elbow joint in front of you, the elbow is pointing down, the right palm is on the left shoulder.

On account 1 - raise the right elbow to the forehead (inhale).

2 - returning to the PI, press the elbow on the chest (exhale).

Guidelines: the maximum possible range of motion for the patient, the movements are smooth. The back is straight, the shoulder blades are reduced to the spine, do not lean forward. Look straight ahead, do not lower your head towards the elbow.

5) IP - sitting in the middle of a chair, the left arm is bent at the elbow joint in front of you, the elbow is pointing down, the left palm is on the right shoulder.

On account 1 - raise the left elbow to the forehead (inhale).

2 - returning to the PI, press the elbow on the chest (exhale).

Guidelines: the maximum possible range of motion for the patient, the movements are smooth. The back is straight, the shoulder blades are reduced to the spine, do not lean forward. Look straight ahead, do not lower your head towards the elbow.

6) IP - sitting in the middle of a chair, arms bent at the elbows, elbows close to the body, forearms extended forward and parallel to the floor, palms parallel and open to each other.

On account 1 - take the forearms to the sides, palms open forward (exhale).

2 - return to PI (inhale).

Guidelines: fixation in each extreme position for 1 sec. We try not to tear off the elbows from the body.

7) IP - sitting, back straight, shoulder blades reduced to the spine. Arms to the sides, parallel to the floor, bent at the elbows, hands pointing forward, open palms down.

On account 1 - external rotation - the forearms and hands are lifted up perpendicular to the floor, the palms are opened forward, (exhalation), (stretching of the neck muscles that attach to the structures of the chest).

2 - return to the PI, (inhale).

3 - internal rotation - the forearms and hands are lowered down perpendicular to the floor, the palms are open backwards, (exhale).

4 - return to the PI, (inhale).

Guidelines: If possible, keep your shoulders parallel to the floor. Exhalation is even, inhalation is passive. Look ahead, do not tilt your head. In case of pain, reduce the amplitude (lower the elbows below the horizontal).

8) IP - sitting in the middle of a chair, feet are on the floor, back is straight, head is straight, shoulder blades are reduced to the spine.

Isometric foot pressure on the floor for 10 seconds.

Methodical instructions: repeat 2 times (right and left foot). Breathing is free, the degree of pressure is selected based on the ability to maintain it for 10 seconds. We maintain the vertical position of the body, avoiding tilting to the side.

9) IP - sitting in the middle of a chair, hands clasped behind the head in a castle, palms - to the head. Elbows to the sides.

On account 1 - tilt the body to the left (exhale).

2 - return to PI (inhale).

3 - tilt the body to the right (exhale).

4 - return to PI (inhale).

Guidelines: exhale without straining, passive inhale, the pace is comfortable for the patient, the maximum possible amplitude for the patient, do not move the elbows forward.

10) IP - sitting in the middle of a chair, hands in the castle behind the head, palms - to the head.

On account 1 - turn the body to the right (exhale).

2 - return to PI (inhale).

3 - turn the body to the left (exhale).

4 - return to PI (inhale).

Guidelines: exhalation without straining, passive inhalation, pace comfortable for the patient, maximum possible amplitude for the patient.

11) PI - sitting in the middle of a chair, hands on hips, palms down, back straight, shoulder blades brought to the spine.

On account 1 - pull the right thigh to the chest (exhale).

2 - return to PI (inhale).

3 - pull the left thigh to the chest (exhale).

4 - return to PI (inhale).

Guidelines: the maximum possible amplitude for the patient, the exhalation is even, not forced, the inhalation is passive. For better postural control, maintain a vertical body position, avoiding leaning to the side.

12) PI - sitting in the middle of a chair, back straight, shoulder blades brought to the spine, hands lowered behind the back and clasped in the lock, palms backwards.

On account 1 - bend your arms at the elbows, raising the hands in the lock along the spine (exhale).

2 - return to PI (inhale).

Guidelines: the maximum possible amplitude for the patient, the movements are smooth, without jerks. The back is straight, the shoulder blades are reduced to the spine, do not lean forward.

13) IP - sitting in the middle of the chair, back straight, shoulder blades brought to the spine, hands - behind the back, palms backwards, clasped into the lock and bent at the elbows as much as possible for the patient.

On account 1 - turn your elbows forward, spreading your shoulder blades as much as possible (exhale).

2 - return to PI (inhale).

Guidelines: the maximum possible amplitude for the patient, smooth movements. The back is straight, the shoulder blades are reduced to the spine, do not lean forward. Look straight ahead, do not lower your head.

14) IP - sitting, arms to the sides, parallel to the floor, bent at the elbows, hands forward, palms down.

On account 1 - left hand - external rotation (raising the arm from the elbow vertically upwards); right hand - internal rotation (lowering the arm from the elbow vertically down), simultaneously, (exhale).

2 - return to the PI, (inhale).

3 - right hand - external rotation; left hand - internal rotation, (exhale).

4 - return to the PI, (inhale).

Guidelines: fixation in each extreme position for 1 sec. Keep your shoulders parallel to the floor. Exhalation is even, inhalation is passive. Look ahead, do not tilt your head. In case of pain, reduce the amplitude (lower the elbows).

15) IP - sitting in the middle of a chair, hands behind the head are clasped into the castle, palms - to the head.

On account 1 - the right arm is straightened up, with the palm open in front, the torso is tilted to the left (exhalation).

2 - return to PI (inhale).

3 - the left arm is straightened up, with the palm open in front, the torso is tilted to the right (exhalation).

4 - return to PI (inhale).

Guidelines: exhalation without straining, passive inhalation, pace comfortable for the patient, maximum possible range of motion for the patient.

16) IP - sitting in the middle of a chair, hands in the lock behind the head, palms - to the head.

On account 1 - turn the body to the right, stretch and open the right hand in the direction of the turn, look at it (exhale), the left hand remains behind the head.

2 - return to PI (inhale).

3 - turn the body to the left, stretch and open the left hand in the direction of the turn, look at it (exhale), the right hand remains behind the head.

4 - return to PI (inhale).

Guidelines: exhalation without straining, passive inhalation, pace comfortable for the patient, maximum possible range of motion for the patient.

17) IP - sitting in the middle of a chair, hands - palms on the hips of the same name and give resistance, preventing you from raising the corresponding leg.

On account 1 - pull the right thigh to the chest (exhale), preventing this with the corresponding hand.

2 - return to PI (inhale).

3 - pull the left thigh to the chest (exhale), preventing this with the corresponding hand.

4 - return to PI (inhale).

Guidelines: exhalation is even, not forced, inhalation is passive. For better postural control, maintain a vertical body position, avoiding leaning to the side.

18) IP - sitting in the middle of a chair, the back is straight, the head is straight, the shoulder blades are reduced to the spine, hands are on the belt, elbows are to the sides.

At the expense of 1-3 - the elbows spring forward towards each other (exhale). 4-6 - elbows spring towards each other backwards (inhale).

Guidelines: the maximum possible range of motion for the patient, the movements are smooth. The back is straight, the shoulder blades are reduced to the spine, do not lean forward. Look straight ahead, do not lower your head.

19) IP - sitting in the middle of a chair, hands folded in a "window" in front of you: the right palm covers the left elbow joint, the left palm - the right one. Forearms at collarbone level, parallel to the floor.

On account 1 - we take the right shoulder with folded forearms to the right, in the same plane with the body (exhale).

2 - return to PI (inhale).

3 - we take the left shoulder with folded forearms to the left, in the same plane with the body (exhale).

4 - return to PI (inhale).

Guidelines: exhale evenly, inhale passively. Look forward, do not tilt your head, do not twist your body. In case of pain, reduce the range of motion.

20) IP - sitting in the middle of the chair, fingers touch the shoulders of the same name, elbows - at the side zones of the chest.

On account 1 - connect the elbows in front at chest level (exhale).

2 - spread your arms to the sides, stretch your elbows to each other backwards (inhale).

Guidelines: the maximum possible amplitude for the patient, smooth movements. The back is straight, the shoulder blades are reduced to the spine, do not lean forward. Look straight ahead, do not tilt your head.

21) IP - sitting in the middle of a chair, hands in the lock behind the head, palms - to the head.

On account 1 - turn to the side while tilting the body forward, for which purpose raise the right thigh and touch it with the left elbow (exhale).

2 - return to PI (inhale).

3 - turn to the other side while tilting the body forward, for which raise the left thigh and touch it with the right elbow (exhale).

4 - return to PI (inhale).

Guidelines: exhale without straining, passive inhale, the pace is comfortable for the patient.

Main part: special sound gymnastics exercises (fig.3 )

22) IP - sitting on a chair, the back is straight, the shoulder blades are reduced to the spine. Hands raised up, palms forward.

Then the hands are lowered through the sides, continuously pronouncing the sound "M" with the maximum possible volume for the patient and at the patient's maximum possible exhalation.

The exercise of "sound" (vibration) gymnastics is performed without a deep breath and on one exhalation, without tension. For a better impact, sounds should be “lowered” into the thoracic region (that is, we pronounce with support from the diaphragm, and not just from the vocal cords). The duration of the exercise is determined by the length of the exhalation. You need 2 repetitions, with a "cleansing exhalation" and restoration of breathing between sets.

Cleansing exhalation

23) IP - sitting on a chair, the back is straight, the shoulder blades are reduced to the spine. Hands in the castle at chest level, palms forward, elbows to the sides, forearms parallel to the floor.

Sharply straighten your arms forward, saying: “V-R-U-X” (or, instead, with a cleansing exhalation, you can say “O-O-X-X-X”, or “A-A-X-X-X” , or "U-U-X-X-X").

24) IP - sitting on a chair, the back is straight, the shoulder blades are brought to the spine, arms are straight to the sides, palms are open downwards.

On the account 1-8: describe circles back with straight arms, continuously pronouncing the sound “Ж”. With tolerance - not at the expense, but with the maximum possible volume at the maximum possible duration of exhalation for the patient.

The exercise of sound (vibration) gymnastics is performed without a deep breath and on one exhalation, without tension. For a better effect, you should “lower” the sounds into the thoracic region. The duration of the exercise is determined by the length of the exhalation. You need 2 repetitions, with a "cleansing exhalation" and restoration of breathing between sets.

Cleansing exhalation

25) Repeat the cleansing exhalation according to paragraph 23 with the pronunciation of “V-R-U-X” (or the other combinations of sounds indicated above).

26) IP - sitting on a chair, the back is straight, the shoulder blades are brought to the spine, the right arm is straightened vertically upwards, the left arm is straight extended to the side.

At the expense of 1-8, the position of the hands is changed through the sides (the right hand goes down to the side, the left one goes up and back), while continuously pronouncing the sound "P". With good tolerance - not at the expense, but with the maximum possible volume at the maximum possible duration of exhalation for the patient.

The exercise of sound (vibration) gymnastics is performed without a deep breath and on one exhalation, without tension. For a better effect, you should “lower” the sounds into the thoracic region. The duration of the exercise is determined by the length of the exhalation. You need 2 repetitions, with a "cleansing exhalation" and restoration of breathing between sets.

Cleansing exhalation

27) Repeat the cleansing exhalation according to paragraph 23 with the pronunciation of "V-R-U-X" (or other of the above combinations of sounds).

The final part (Fig.4)

28) PI - sitting, back straight, head straight, shoulder blades brought to the spine.

On account 1-4: tilt the head forward, touch the jugular notch with the chin, hold the position for 1 second.

5-8 - return to IP.

Methodical instructions: repeat 1 time, breathing is free. Try to relax.

29) PI - sitting in the middle of a chair, back straight, shoulder blades brought to the spine, arms folded in a "window" under the chest: while the right palm covers the left elbow joint, the left palm - the right one.

On account 1 - raise your arms up, forearms above your head.

2 - return to IP.

Guidelines: breathing is free, the maximum possible amplitude for the patient, movements are smooth, without jerks. The back is straight, the head is straight, the shoulder blades are reduced to the spine, do not bend in the lower back.

30) PI - sitting, back straight, head straight, shoulder blades brought to the spine, palms resting on the corresponding hips.

At the expense of 1-2 - tilt the head forward, touch the jugular notch with the chin.

3-6 - on the exhale: roll head down, like a "snowball" - roll forehead as low as possible, towards the navel (i.e. twist the head and upper chest around the transverse axis of the body).

Methodical instructions: repeat 1 time, breathing is free. Try to relax.

The exercises presented in the complex above (figure 1) are, in fact, exemplary. The exercise therapy specialist will understand that they can be replaced with equivalent ones, taking into account the observance of the above general principles for the use of breathing exercises in patients with previous CAP. Complexes of similar exercises are given, for example, in the methodological recommendations of our authors "Methodology of breathing exercises for patients who have had COVID-associated pneumonia" (approved at a meeting of the Educational Center of the Federal State Budgetary Institution "NMIC RK" of the Ministry of Health of Russia on February 14, 2022, protocol No. 2, Publishing House "Bibliographer ”, M., 2022, 48 p., ISBN 978-5-907063-76-1).

The developed program of breathing exercises is effective and can be recommended for practical use in patients who have had pneumonia, including CAP, patients with COPD, bronchial asthma, chronic heart failure of the 1st degree. (CHF 1 st.), both in the conditions of inpatient stay in medical rehabilitation centers or sanatorium-resort institutions, and during classes using telemedicine technologies or outpatient treatment.

The results of using the method.

This technique was tested on the basis of the National Medical Research Center of the Republic of Kazakhstan of the Ministry of Health of Russia as part of the implementation of the medical rehabilitation program using an interactive platform for remote rehabilitation of patients with COVID-19 and formed the basis of the COVIDREHAB telemedicine platform (covidrehab.online).

The study involved 30 people, including 14 women (46.66%) and 16 men (53.33%). All the subjects experienced difficulties in self-service, noted an increase in weakness from minimal physical activity, including verticalization. The course consisted of 14 daily breathing exercises. Classes included a gradual increase in intensity as the patient adapted to the loads. The transition to a more difficult level of respiratory load was performed only in the case of stabilization of SpO2 and heart rate and no complaints associated with the intensity of the exercise complex. During training, the heart rate was not allowed to rise to the anaerobic power zones and the saturation fell by more than 3% of the initial level. If shortness of breath occurred, an additional pause was performed using diaphragmatic breathing exercises.

To evaluate the effectiveness of this technique, we used measurements of heart rate (HR), respiratory rate (RR) and SpO2 (Aiqura AD-805 pulse oximeter, made in China) before, during and after the course. In addition, the standard Borg Scale was used to assess the patient's exercise tolerance.

Table 1 presents statistical data on the dynamics of heart rate, saturation (SpO2) and respiratory rate (RR). Statistical analysis was performed using the StatTech v. 2.5.6 (developer - Stattech LLC, Russia). Quantitative data were described using the median (Me) and the lower and upper quartiles (Q1–Q3). When comparing the indicators, the Wilcoxon test was used.

As a result of the course of respiratory gymnastics from the side of the cardiovascular system due to the gradual complication of repetitions of exercises - from free breathing to breathing with an extended exhalation, then with resistance on exhalation and, finally, with inspiration from the closed position of the diaphragm (with this position of the hands and body , in which there is some compression of the diaphragm, blocking a free breath - for example, when tilting, turning the body, placing the hands on the lower parts of the chest), with the transition to each more complex level of respiratory load according to the scheme: 5:1, 4:2 and 3:3 - there was a gradual adaptation to physical activity. This, in turn, made it possible to increase the motor density of training (from 62.5% to 81%). Reliable positive dynamics of heart rate and SpO2 indicators was determined, in connection with which it was accepted to use them directly as biofeedback indicators.

The breathing exercises developed by us contributed to the activation of the auxiliary inspiratory muscles (sternocleidomastoid, anterior, middle and posterior scalene muscles, pectoralis major and minor, lower fibers of the serratus anterior and latissimus dorsi). Also, the rhythmicity of breathing was influenced by the activation of the auxiliary muscles of exhalation (the rectus abdominis, external oblique, internal oblique and transverse abdominal muscles), as well as the lower fibers of the iliocostal muscle, the posterior inferior serratus muscle and the square muscle of the lower back.

Table 1. Analysis of the dynamics of physiological parameters

Indicators Before treatment After treatment p heart rate 87.00
[75.50; 97.75] 80.50
[70.00; 84.75] < 0.001 _SpO2 93.00
[90.25; 95.00] 98.00
[96.25; 98.75] < 0.001 BH 20.50
[19.00; 23.00] 18.00
[17.00; 18.00] < 0.001

The formation of the correct pattern of the respiratory act was reflected in a decrease in the rate of respiratory rate, the absence of complaints of shortness of breath and respiratory failure.

At the end of the course of breathing exercises, the indicators of subjective well-being of exercise tolerance, assessed by the Scale of individual perception of the intensity of the Borg load, in all patients significantly changed in the range from 13-14 points to 9-11 points. However, the use of Borg scale indicators as indicators of biofeedback directly in the course of the classes themselves was not informative.

In groups of patients involved in online and offline, i.e. through remote communication and directly in person in the gym, there were no statistically significant differences in the studied indicators.

Thus, it can be concluded that the developed program of breathing exercises is effective and can be recommended for practical use in patients after CAP, both under conditions of inpatient stay in medical rehabilitation centers or sanatorium-and-spa institutions, and during classes using telemedicine technologies.

Clinical examples.

1. Patient A., 59 years old. Condition after bilateral COVID-associated pneumonia, of moderate severity. Percentage of lung involvement: 40% (CT-2).

Complaints: persisting shortness of breath during physical exertion (when walking), poor performance, general weakness, headache.

Indicators before the start of the course:

SpO2 = 94%,

Heart rate = 96 beats / min,

RR = 21 dd/min.

At the end of the course - the normalization of these indicators. Shortness of breath, tachycardia stopped.

At the control examination after 6 months, the patient notes positive results, no complaints, there are no changes in the lungs according to CT data, the indicators of spirometry, bicycle ergometry, pulse oximetry are stable.

2. Patient T., 62 years old. Condition after suffering bilateral coronavirus pneumonia, severe, respiratory failure of the 2nd degree. Percentage of lung involvement: 80% (CT-4).

Complaints: shortness of breath at rest, poor performance, severe general weakness, dizziness, headache, low blood pressure. Before the start of the course, the following levels of indicators of the functions of the cardiovascular and respiratory systems take place:

SpO2 = 91%,

Heart rate = 110 bpm,

RR = 26 dd/min.

At the end of the course, there is an improvement in these indicators, a decrease in the number of complaints. At the follow-up examination after 6 months, the patient notes the preservation of positive results, shortness of breath occurs only with long walking, working capacity has increased, there are no fibrotic changes in the lungs according to CT, spirometry, bicycle ergometry, and pulse oximetry are stable.

Claims (23)

A method of breathing exercises for patients who have undergone COVID-associated pneumonia, characterized in that it includes a 14-day course of daily breathing exercises using biofeedback (BFB) for heart rate and saturation level (SpO ₂ ), and each session includes blocks: 1) warm-up - preparation for the main part of the gymnastics of the musculoskeletal apparatus of the neck and shoulder girdle - in the form of exercises for turning and rolling the head and rotating the shoulder girdle with free breathing, duration - 3-5 minutes of training, 2) the main part - the consistent implementation of a set of exercises, each of which is repeated 6 times, for stretching the muscles of the neck, pectoral muscles, training the tone of the muscles of the shoulder girdle and rotator cuff of the shoulder, back and abdomen muscles, mobility of the shoulder girdle, shoulder blades, strengthening the gluteal and thigh muscles , at the end of the main part, sound gymnastics exercises are carried out with pronouncing a sound on one exhalation when performing hand movements, and the pronunciation of each sound - “m”, “g” and “r” is performed 2 times, with the breath resting on the diaphragm, with a cleansing exhalation after each repetition, where the cleansing exhalation is the maximum possible exhalation for the patient, at the end of which, without a pause and without straining, the patient tries to exhale the remaining air from the lungs, using the diaphragm and abdominal muscles, for which, during the cleansing exhalation, the positions of the upper limbs and body are used, compressing the chest , while saying: "V-R-U-X" with a cleansing exhalation, duration of the main part - 20-25 minutes; 3) the final part - lasting 5-7 minutes, in the form of exercises to restore free breathing and stretch the fascial structures of the body; moreover, classes are held under constant monitoring of heart rate and SpO ₂ indicators, and with the patient's adaptation to the load, determined by the stability of heart rate indicators and improvement of SpO ₂ , they reduce the rest pause between exercises, increasing the motor density of the lesson - the ratio of time directly spent on doing exercises, by the time of the lesson, at the same time, 6 repetitions of each performed exercise of the main part are carried out during the course of exercises as follows: - first, all 6 repetitions of each exercise are performed with the patient's free breathing, - in further classes, taking into account the tolerance of the patient, the repetition of each exercise is carried out according to the following sequential scheme of adaptation to the respiratory load: 5:1, where 5 repetitions - with free breathing, 1 repetition with an extended exhalation; 4:2, where 4 repetitions - with free breathing, 2 repetitions with an extended exhalation; 3:3, where 3 repetitions - with free breathing, 3 repetitions with an extended exhalation; - then, according to the same scheme 5:1, 4:2, 3:3, gradually, taking into account the patient's tolerance to the load, replace repetitions with an extended exhalation for repetitions with an exhalation with resistance: 5:1, where 5 repetitions - with free breathing, 1 repetition with exhalation with resistance; 4:2, where 4 repetitions - with free breathing, 2 repetitions with exhalation with resistance; 3:3, where 3 repetitions - with free breathing, 3 repetitions with exhalation with resistance; - then, according to the same scheme, repetitions with exhalation with resistance are replaced with repetitions with inhalation from the closed position of the diaphragm - in the position of the arms and body, blocking free inspiration: 5:1, where 5 repetitions - with free breathing, 1 repetition with inspiration from the closed position of the diaphragm; 4:2, where 4 repetitions - with free breathing, 2 repetitions with inhalation from the closed position of the diaphragm; 3:3, where 3 repetitions - with free breathing, 3 repetitions with inhalation from the closed position of the diaphragm; at the same time, the condition for each indicated replacement of exercise repetitions is the achievement of patient adaptation to the previous level of respiratory load - stable heart rate, improvement of SpO ₂ and exercise tolerance by the patient without subjectively unpleasant sensations when performing repetitions of each exercise, and in case of destabilization of these indicators and/or the appearance of subjectively unpleasant sensations, the next repetition of the exercise is performed at the previous level of respiratory load for this exercise - without another replacement according to the indicated scheme, until adaptation is achieved, taking into account heart rate, SpO ₂ and subjective tolerance.

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