Method for rehabilitation of external respiratory system in patients with chronic heart failure

Abstract

FIELD: cardiology.SUBSTANCE: used as a component of the first stage of cardiac rehabilitation in patients with chronic heart failure (CHF), as well as an auxiliary component at all stages of cardiac rehabilitation. Warm-up exercises are performed – stretching exercises and movements in the joints of the upper body, followed by a basic set of breathing exercises lasting from 15 to 30 minutes, at least once a day, at least 5 days a week, for at least 8 weeks. At the first stage, the main set of exercises includes four exercises performed in sequence: abdominal breathing, chest breathing, breathing involving the shoulder muscles, breathing slowing. The first three exercises are performed for 5–10 breathing cycles with an interval between exercises of at least 1 minute, the fourth exercise contains 5–15 cycles, where each cycle includes an inhalation through the first nostril, followed by an exhalation and inhalation through the second nostril, then an exhalation through the first nostril . In the second and subsequent stages, the main set of exercises includes two exercises performed sequentially: an exercise for full breathing and an exercise for slowing down breathing. The full breathing exercise involves sequentially performing abdominal breathing, chest breathing, and breathing with the involvement of the shoulder muscles throughout one inhalation. The exhalation is performed in reverse order. The number of cycles of the full breathing exercise at the second stage is 15–20. The duration of each stage is at least 2 weeks, where at each subsequent stage, starting from the second one, the duration of the exercises performed in the main complex is increased by increasing the number of exercise cycles. Also the duration of inhalation and exhalation is increased when performing exercises to slow down breathing. The method improves the biomechanics of breathing: increases the depth of breathing, reduces the frequency of respiratory movements, increases the efficiency of breathing and reduces the activity of the inspiratory metaboreflex.EFFECT: exercise tolerance in patients with CHF improves.3 cl, 6 dwg, 3 ex

Description

[0001] Field of technology to which the invention relates

[0002] The invention relates to medicine, namely to cardiology, and can be used as a component of the first stage of cardiac rehabilitation in patients with chronic heart failure (CHF), as well as an auxiliary component at all stages of cardiac rehabilitation.

[0003] Technology Level

[0004] Cardiac rehabilitation (CR) is a complex of coordinated medical, physical, psychological, pedagogical and social measures aimed at the most complete restoration of health, psychological status and working capacity of patients with cardiovascular diseases (Bubnova M.G., Aronov D.M. Cardiac rehabilitation: stages, principles and international classification of functioning (ICF). Preventive medicine. 2020; 23 (5): 40-49.) Currently, all patients with clinically stable CHF are recommended to be included in structured comprehensive cardiac rehabilitation programs in order to reduce disease symptoms, increase physical performance, improve functional capabilities, quality of life, psychological and social functioning. Cardiac rehabilitation is represented by three stages, within which the patient is routed.According to the 2024 Russian clinical guidelines, the physical rehabilitation program should include a set of therapeutic exercises with breathing exercises, inspiratory muscle training, regular dynamic physical activity of moderate intensity, interval training, and low / moderate-intensity strength training. (Galyavich A.S., Tereshchenko S.N., Uskach T.M., et al. Chronic heart failure. Clinical guidelines 2024. Russian Journal of Cardiology. 2024; 29(11):6162).

[0005] Meanwhile, the interaction between the cardiovascular and respiratory systems is key in the development of physical disability in CHF. CHF is characterized by mechanical and neurogenic respiratory impairments, which reduce the effectiveness of ventilation and gas exchange in the lungs during exercise. Limited tidal volume expansion (restriction) and high respiratory drive lead to premature cessation of exercise due to shortness of breath. Deterioration of respiratory function increases metabolic stress, reduces the efficiency of oxygen exchange, and further limits physical activity. At the cellular level, signs of mitochondrial dysfunction, decreased capillary density, a switch to glycolytic (fast-fatiguing) fibers, and increased activity of proteolytic pathways are observed in the respiratory muscles. This makes the respiratory muscles less resilient to exercise and accelerates their fatigue, especially under conditions of hypoperfusion and metabolic stress.Patients with chronic heart failure are characterized by unique pathological respiratory biomechanics, which worsen as the disease progresses. These abnormalities can be most fully analyzed using cardiorespiratory exercise testing (exercise testing with gas analysis (CTGA)), which is the "gold standard" for studying functional impairments in patients with CHF and allows for the most comprehensive characterization of both respiratory biomechanics and gas exchange parameters during exercise (Galyavich A.S., Tereshchenko S.N., Uskach T.M., et al. Chronic Heart Failure. Clinical Guidelines 2024. Russian Journal of Cardiology. 2024; 29(11):6162). When conducting CRNT in patients with CHF, minute ventilation increases during exercise, mainly due to an increase in respiratory rate, while the depth of breathing (determined by the tidal volume on exhalation) increases to a much lesser extent, i.e.The normal sequence of mechanisms increasing ventilation is disrupted. Biomechanics (respiratory rate and depth) are regulated by the functional respiratory control system (FRCS) through its influence on the respiratory muscles. The FRCS aims to regulate ventilation so that the work of breathing (WOB) (the mechanical work performed by the respiratory muscles during spontaneous breathing, which depends on the respiratory rate and the resistance overcome) remains at the lowest possible level. Increased WOB is associated with both an increase in respiratory rate and a decrease in lung and chest wall compliance. Causes of increased resistive WOB in patients with CHF include decreased airway and lung tissue compliance due to pulmonary hypertension, pulmonary congestion, the onset / increase of bronchial tone during exercise, and an age-related decrease in chest wall excursion.Furthermore, shortening of expiration leads to dynamic overinflation of the lung tissue, which further increases the elastic component of inspiratory work. Thus, frequent, shallow breathing is an adaptive response to the decreased compliance of the lung tissue and airways, as well as the increased work of breathing, characteristic of patients with CHF. Under these circumstances, tachypnea becomes the only available mechanism for maintaining the required ventilation volume without rapidly exhausting the respiratory muscles. Higher work of breathing leads to an increased "energetic cost" of respiration, and blood flow to the skeletal muscles is reduced to meet the needs of the respiratory muscles, which serve an organ that performs a vital function in the body. This occurs even at submaximal exertion, especially in cases of respiratory muscle myopathy.Competition for cardiac output contributes to a deterioration in exercise tolerance and additional activation of the metaboreflex due to an increase in the concentration of lactate and other metabolic products in the working muscles (Begrambekova, Yu.L. Remodeling of the external respiratory system in chronic heart failure - a pathogenesis factor and therapeutic target / Yu.L. Begrambekova / / Cardiology. - 2025. - Vol. 65, No. 1. - P. 41-49).

[0006] Russian clinical guidelines describe respiratory rehabilitation as static and dynamic breathing exercises that should be performed at all stages of cardiac rehabilitation, active breathing techniques, and training of the respiratory muscles (primarily the inspiratory muscles) using breathing simulators, starting from stage 1 of cardiac rehabilitation (Galyavich A.S., Tereshchenko S.N., Uskach T.M. et al. Chronic heart failure. Clinical guidelines 2024. Russian journal of cardiology. 2024; 29 (11): 6162). The guidelines indicate the possibility of using breathing training without the use of breathing simulators, but there is no description of methods for conducting respiratory muscle training without the use of breathing simulators.

[0007] Targeted impact on the respiratory muscles and the biomechanics of breathing can improve ventilation parameters - increase the depth and decrease the frequency of breathing, reduce the activity of the inspiratory metaboreflex, reduce the severity of shortness of breath and increase exercise tolerance. The prior art includes methods for training respiratory muscles using commercially available breathing simulators for the rehabilitation of patients with CHF I-IV FC according to the NYHA classification (see, for example; RU 2405608 C2, Arutyunov G.P., Kolesnikova E.A., Rylova A.K., Method for the rehabilitation of patients with acute myocardial infarction and concomitant chronic heart failure; Gianfranco Parati et al., Device-Guided Paced Breathing in the Home Setting, Effects on Exercise Capacity, Pulmonary and Ventricular Function in Patients With Chronic Heart Failure: A Pilot Study, Circulation: Heart Failure, 2008, No. 1, p. 178-183, Fernandez-Rubio H., Becerro-De-bengoa-vallejo R., Rodríguez-Sanz D. et al.Inspiratory muscle training in patients with heart failure / / Journal of Clinical Medicine. - 2020. - Vol. 9, No. 6), including various training regimens, both in inpatient and outpatient settings.

[0008] The closest approach to the present invention is a method for the rehabilitation of patients with acute myocardial infarction and concomitant chronic heart failure (RU 2405608 C2). The method involves prescribing standard therapy using prolonged-release nitrates, calcium antagonists, beta-blockers, and direct anticoagulants.On days 3-5 of the treatment, additional training of the respiratory muscles begins using the Threshold IMT and Threshold PEP simulators, which allow for creating resistance during inhalation and exhalation, respectively. In this case, the starting resistance to inhalation is set at 9 cm of water column, and to exhalation at 5 cm of water column; every third to fifth training session, the resistance of both simulators is increased by 2 cm of water column; training on the simulators is carried out twice a day daily and consists of 4 cycles consisting of a four-time repeated sequence of inhalation lasting 4-5 s, exhalation lasting 5-6 s, and a pause; the cycles are separated by a 2-minute rest.

[0009] However, the known method is based on the use of commercial training devices, which must be purchased by patients themselves. These devices have a limited lifespan. Cheaper models of breathing devices have a weak point—the membrane—which can fail (tear off) within 1-2 months of use. Furthermore, after use, the device must be cleaned hygienically to prevent upper and lower respiratory tract infections, as saliva and mucus that enter the device after use create a favorable environment for microbial growth. Another disadvantage of the known method is the inability to target different respiratory muscle groups and the lack of control over breathing rate and rhythm, which reduces the effectiveness of the therapy.

[0010] Thus, the technical challenge is to overcome the shortcomings of existing approaches by developing a method for rehabilitating the external respiratory system in patients with chronic heart failure through interventions with the respiratory muscles (RM). This approach allows not only for training its strength, as occurs with respiratory training devices, but also for influencing the rhythm and frequency of breathing, thereby reducing the hyperactivity of the carotid chemoreceptors and alleviating the severity of dyspnea. The need to influence not so much the strength of the respiratory muscles, but rather their endurance and the restoration of respiratory biomechanics in general, is supported by the fact that measuring RM strength at rest provides little information regarding the predictive performance of the respiratory muscles under load.

[0011] Disclosure of the essence of the invention

[0012] The technical result of the proposed method consists in the rehabilitation of the respiratory muscles of patients with CHF through the use of breathing exercises that do not require additional instrumental support.

[0013] The invention aims to improve the biomechanics of breathing: increasing its depth, reducing the frequency of respiratory movements, increasing respiratory efficiency, and reducing the activity of the inspiratory metaboreflex. These effects improve exercise tolerance in patients with CHF.

[0014] The technical result is achieved by a method for rehabilitation of the external respiratory system in patients with chronic heart failure, including performing warm-up exercises for at least 5 minutes - stretching exercises and movements in the joints of the upper body, followed by performing a basic set of breathing exercises (training of the respiratory muscles) lasting from 15 to 30 minutes, lasting from 15 to 30 minutes, at least once a day, at least 5 days a week, for at least 8 weeks,

[0015] at the first stage, the main set of exercises includes four exercises performed sequentially: an abdominal breathing exercise, a chest breathing exercise, a breathing exercise involving the muscles of the shoulder girdle (with the sequential involvement of all groups of the respiratory muscles in the breathing process: the diaphragm, intercostal muscles, muscles of the shoulder girdle), an exercise to slow down breathing;all exercises are performed in a sitting position on a chair, while the abdominal breathing exercise is performed in such a way that the stomach rises on inhalation and falls on exhalation, the chest breathing exercise is performed in such a way that on inhalation the chest expands, moving to the sides and upward, and on exhalation it contracts, the breathing exercise involving the muscles of the shoulder girdle is performed in such a way that on inhalation the collarbones move upward and on exhalation they move downward, the first three exercises are performed for 5-10 breathing cycles with an interval between exercises of at least 1 minute, the fourth exercise contains 5-15 breathing cycles, where each cycle includes inhalation through the first nostril, exhalation and subsequent inhalation through the second nostril, and subsequent exhalation through the first nostril;

[0016] at the second and subsequent stages, the main set of exercises includes two sequentially performed exercises: an exercise for full breathing and an exercise for slowing down breathing; the exercise for full breathing includes the sequential performance of abdominal breathing, chest breathing and breathing with the involvement of the shoulder girdle muscles during one inhalation (with the sequential involvement of all groups of respiratory muscles in the breathing process: diaphragm, intercostal muscles, shoulder girdle muscles), exhalation is performed in the reverse order, the number of cycles of the exercise for full breathing at the second stage is 15-20, and the exercise for slowing down breathing is performed with an increase in the duration of inhalation and exhalation - by 2 counts every 2 weeks;

[0017] The duration of each stage is at least 2 weeks, and at each subsequent stage, starting from the second, the duration of the exercises performed in the main complex is increased by increasing the number of exercise cycles, as well as increasing the duration of inhalation and exhalation when performing exercises to slow down breathing.

[0018] After 8 weeks of performing a set of breathing exercises, the patient's functional state is assessed, and then the exercises of the main set are performed at least 3 times a week on a regular basis.

[0019] Improving the effectiveness of rehabilitation in patients with chronic heart failure is achieved through a sequential, multi-stage core exercise program aimed at improving respiratory biomechanics—increasing the depth of breathing and reducing the respiratory rate. These changes, in turn, lead to a reduction in physiological dead space, an increase in the area of ​​ventilated alveoli, and improved ventilation efficiency. These changes are recorded during exercise testing. Improvements are seen in both respiratory biomechanics and gas exchange parameters, as well as exercise tolerance. A significant increase in respiratory muscle strength is also recorded. Improved exercise tolerance is also observed during submaximal exercise tests (6-minute walk distance), as well as an improvement in the patients' psychoemotional state.These changes lead to a reduction in shortness of breath and heaviness in the legs during physical activity. The effect is achieved by performing the exercises at least 5 times a week for at least 8 weeks. The effect increases with increasing frequency and duration (more than 8 weeks).

[0020] Brief description of drawings

[0021] The invention is explained by illustrative materials, where figures 1-3 demonstrate warm-up exercises - stretching exercises and movements in the joints of the upper body: figure 1 shows rotational movements in the shoulder joints, figure 2 - stretching of the intercostal muscles with interlaced arms, figure 3 - stretching of the intercostal muscles in the frontal plane; figures 4-6 demonstrate the performance of breathing exercises: figure 4 - an abdominal breathing exercise, figure 5 - a chest breathing exercise, figure 6 - a technique for slowing down respiratory movements.

[0022] Implementation of the invention

[0023] Before starting breathing exercises using the proposed method, the patient is assessed for contraindications. The list of contraindications is standard for cardiac rehabilitation and respiratory system rehabilitation. These are the following diseases and conditions: myocardial infarction, ACS, heart surgery, percutaneous coronary intervention or coronary artery bypass grafting performed less than 3 months before randomization; unstable or refractory angina; constrictive pericarditis; premature ventricular excitation syndrome; the need for percutaneous coronary intervention or coronary artery bypass grafting in the near future; blood pressure less than 90 / 60 mmHg and more than 160 / 110 mmHg; mental, physical and other reasons that do not allow you to adequately assess your condition and perform the exercises correctly.

[0024] The proposed breathing exercise program can serve as a complement to the patient's prescribed medication and other non-pharmacological interventions. This method of respiratory rehabilitation involves performing breathing exercises, the duration and difficulty of which gradually increase over 8-10 weeks. The exercises can then be performed regularly 3-5 times per week to maintain the achieved effect.

[0025] The goal of these exercises is to master the technique of sequentially engaging all respiratory muscle groups in the breathing process: the diaphragm, intercostal muscles, abdominal muscles, and shoulder girdle muscles. Individual exercises are aimed at gradually slowing the number of breaths per minute and increasing their depth.

[0026] The exercises begin with a 5-minute warm-up of the shoulder girdle and chest muscles. The warm-up exercises are shown in Figs. 1-3.

[0027] Exercise 1 (Fig. 1). Rotational movements of the shoulder joints. Starting position: feet shoulder-width apart, hands close to the shoulders. Perform the exercise slowly and with the maximum range of motion possible. As the arms are raised, bent at the elbows, the shoulder blades rise. As they are lowered, the shoulder blades descend and move closer together. Perform 5 forward circular movements and 5 backward circular movements.

[0028] Exercise 2 (Fig. 2). Intercostal muscle stretch in the lateral projection. The intercostal muscle stretch is performed with the arms interlaced. To do this, the arms are positioned so that the shoulder is perpendicular to the torso and the forearm is parallel to the torso, with the angle between the shoulder and forearm being approximately 90 degrees. Then the elbow of one arm is placed on the elbow of the other arm. If possible, the hands are interlaced, with the fingers of the lower hand placed on the palm of the upper hand. If crossing the arms is difficult for the patient, the fingers of the lower hand are left on the back of the upper hand. Then, on an inhale, the arms are moved upward, on an exhale, they are moved downward. Do 5 repetitions. Then, switch arms and repeat the exercise. Do 5 repetitions. This exercise should not be performed in patients with a history of upper limb injuries or in the presence of implantable devices.

[0029] Exercise 3 (Fig. 3). Stretching the intercostal muscles in the frontal projection. With your arm raised, slowly bend to the side opposite your raised arm, doing 5 repetitions, then repeating the exercise bending to the opposite side – 5 repetitions.

[0030] All exercises are performed with maximum amplitude and synchronized with slow breathing.

[0031] After completing the warm-up, move on to the main exercise routine, which in the first stage includes abdominal, thoracic, and clavicular (involving the shoulder girdle) breathing exercises, as well as an exercise to slow down breathing. This stage lasts at least two weeks or at least 10 sessions (at least five sessions per week).

[0032] Abdominal breathing.

[0033] The exercise is performed in a sitting position with a straight back. For 5-10 breaths, the patient is instructed to breathe so that the abdomen rises on inhalation and falls on exhalation. This means that on inhalation, the anterior abdominal wall moves forward, while the diaphragm descends. On exhalation, the anterior abdominal wall moves toward the spine. At the beginning of the exercise, to control the movement of the anterior abdominal wall, the patient is asked to place a hand on the abdomen—both palms are placed on the abdomen near the navel. The exercise is completed with calm breathing for approximately 1 minute.

[0034] Chest breathing.

[0035] The exercise is performed in a sitting position with a straight back. For 5-10 breaths, the patient is instructed to breathe so that on inhalation, the chest, along with the palms, expands, moving laterally and upward, and on exhalation, it contracts. To check the correctness of the exercise, the patient is advised to place their palms on the sides of the chest on the lower ribs, directly under the breastbone, and notice how the hands move apart on inhalation and come together on exhalation. Finish the exercise with calm breathing for approximately 1 minute.

[0036] Breathing with the involvement of the shoulder girdle muscles.

[0037] The exercise is performed in a sitting position with a straight back. For 5-10 breaths, the patient is instructed to breathe so that the collarbones move upward on inhalation and downward on exhalation. To check the correctness of the exercise, the patient is advised to place their palms on the collarbones. The exercise is completed with calm breathing for approximately 1 minute.

[0038] Slowing of respiratory movements (or slowing of breathing).

[0039] Alternate right and left nostril breathing technique. The exercise begins with the left nostril. Closing the right nostril, the patient takes a slow, deep breath in through the left nostril, then closes the left nostril and exhales through the right nostril, then inhales through that nostril. Then, closing the right nostril and exhaling through the left nostril and then inhales through that nostril. During this sequence, the patient is asked to silently count to 6 on the inhale and to 8 on the exhale. The sequence of using the right or left nostril for breathing changes after inhalation. One cycle includes inhaling through the first nostril, exhaling and then inhaling through the second nostril, and then exhaling through the first nostril, which is performed 5 to 10 times. It is recommended to complete the cycle (regardless of the number of repetitions).When performing this exercise, the duration of your breath naturally increases, as you breathe through only one nostril throughout the entire exercise. Therefore, it takes longer to fill your airways. Finish the exercise with calm breathing through both nostrils for 1 minute.

[0040] In the second stage of the basic exercise program—after two weeks of training in the described regimen (stage one)—the already mastered variations of individual breathing exercises (abdominal, thoracic, and clavicular) are replaced with full-body breathing exercises. Full-body breathing involves sequentially performing abdominal breathing, thoracic breathing, and shoulder girdle muscle breathing throughout a single inhalation. This involves consistently engaging all respiratory muscle groups in the breathing process: the diaphragm, intercostal muscles, and shoulder girdle muscles. Thus, during inhalation, the patient sequentially pushes the anterior abdominal wall forward, then expands the rib cage and lifts the clavicles in a continuous motion. The full inhalation cycle is complete. Exhalation is performed by the patient in the reverse order.

[0041] Starting with stage 2, and if the training is well tolerated, it is recommended to gradually increase the duration of the core exercises by increasing the number of repetitions by 5 every 2 weeks. When practicing slow breathing, it is recommended to increase the duration of inhalation and exhalation by 2 counts every 2 weeks. Thus, if the patient inhaled to a count of 6 and exhaled to a count of 8 for the first two weeks, then in the next stage, the patient inhales to a count of 8 and exhales to a count of 10. The duration of inhalation and exhalation is increased every 2 weeks by 2 counts of inhalation and exhalation, respectively.

[0042] The implementation of the proposed rehabilitation method is presented in the following clinical examples.

[0043] Example 1. Patient B., 80 years old. Diagnosis on admission to hospital: IHD: Postinfarction cardiosclerosis, grade 1 aortic valve insufficiency, grade 1 tricuspid valve insufficiency. Heart rhythm disturbances: frequent ventricular extrasystoles. Complete left bundle branch block. Implantation of a cardiac resynchronization device with cardioverter-defibrillator function on August 28, 2019. Stage 3 hypertension, stage III. Chronic heart failure stage II B, FC 3, ejection fraction (EF) - 47%. Complaints of shortness of breath with minor physical exertion, general weakness, fatigue, depression. The patient underwent a comprehensive functional examination, including measurement of respiratory muscle strength, cardiorespiratory exercise testing, and a 6-minute walk test, as well as a questionnaire using the Hospital Anxiety and Depression Scale (HADS).

[0044] Examination data. Respiratory muscle strength at rest is significantly reduced: maximum inspiratory pressure is 42 cm H2O (39% of the age-sex norm), maximum expiratory pressure is 52 cm H2O (48.3% of the age-sex norm). Exercise tolerance is reduced during the CRNT. VO2 пик = 12.5 ml / kg / min (57.3% of the age-sex norm). Severe ventilation disorders. A pattern of frequent shallow breathing and insufficient increase in tidal and minute volume during exercise are recorded. Tidal volume (VT) at peak exercise is 1.13 l. (48% of the age-sex norm); Minute volume at peak exercise is 34 l / min (73% of the age-sex norm), VCO2 пик = 0.788 (48% of the age-sex norm) with a paradoxical increase after the end of the load. The distance in the 6-minute walk test is 325 meters. Points on the HADS scale are -12.

[0045] The patient was advised to perform breathing exercises according to the proposed method. After stabilizing his condition in the hospital, the patient began performing breathing exercises according to the proposed method.

[0046] The exercises were performed twice a day, morning and evening. Before starting the breathing exercises, the patient performed a 5-minute warm-up of the shoulder girdle and chest muscles. The patient performed shoulder rotations and stretched the intercostal muscles in the lateral and frontal projections. Then, the patient began the main set of exercises. The patient assumed a sitting position on a chair and performed abdominal breathing. To check the correctness of the exercises, the patient placed their palms on the stomach near the navel. For 5 breathing cycles, the patient breathed so that on inhalation the stomach rose and on exhalation it fell. Then the patient performed chest breathing. For 5 breathing cycles, the patient breathed so that on inhalation the chest, along with the palms, expanded, moving laterally and upward, and on exhalation it contracted. To check the correctness of the exercise, the patient was advised to place their palms on the sides of the chest on the lower ribs, directly under the breastbone.The patient then moved on to mastering the technique of engaging the shoulder girdle muscles in breathing. This was also done in a sitting position with a straight back. For five breathing cycles, the patient breathed so that the collarbones moved upward on inhalation and downward on exhalation. To check the correctness of the exercise, the patient was advised to place their fingers on the collarbones. Each exercise concluded with calm breathing for 1 minute. The patient then moved on to practicing slowing down their breathing. The patient placed the thumb of their left hand on the left wing of their nose and pressed it to the bridge, blocking the airflow. Having closed the left nostril, the patient slowly inhaled through the right nostril. Then, using the second finger of their right hand, the patient closed the right nostril and opened the left. They exhaled and inhaled through the left nostril, and then, pressing the left nostril with their finger and opening the right nostril, exhaled through the right nostril. This sequence constituted one breathing cycle.The patient was instructed to silently count to 6 on each inhalation and to 8 on each exhalation. The patient performed this cycle 10 times. The exercise concluded with calm breathing for 1 minute.

[0047] The patient performed exercises for 3 days before hospital discharge and then continued training for 8 weeks at home. Over the course of 8 weeks, the patient gradually increased the number of repetitions (by 5 repetitions every 2 weeks) and the duration of inhalation (by 2 counts every 2 weeks). At home, he performed the exercises once a day. After 8 weeks, the patient underwent a comprehensive functional assessment, including respiratory muscle strength measurement, cardiorespiratory exercise testing, a 6-minute walk test, and the Hospital Anxiety and Depression Scale (HADS).

[0048] Repeat examination data. There was an increase in respiratory muscle strength at rest: maximum inspiratory pressure of 61 cm H2O (70% of the age-sex norm), maximum expiratory pressure of 78 cm H2O (63.2% of the age-sex norm). Exercise tolerance improved during the CRNT. VO2 пик = 14.4 ml / kg / min (66% of the age-sex norm). Severe ventilation disorders. A pattern of frequent shallow breathing and insufficient increase in tidal and minute volumes during exercise are recorded. Tidal volume (VT) at peak exercise is 1.15 l. (49% of the age-sex norm); Minute volume at peak exercise is 36 l / min (77% of the age-sex norm), VCO2 пик= 0.884 (54% of the age-sex norm) with a paradoxical increase after the end of the exercise. The distance in the 6-minute walk test was 350 meters. There was a significant improvement in the psychoemotional state. The HADS score was -2. The patient noted a decrease in shortness of breath and improved exercise tolerance. Continued breathing exercises are recommended.

[0049] Example 2. Patient E., 78 years old. Diagnosis: coronary artery disease: angina pectoris FC 2, hypertension grade 3 stage III, persistent atrial fibrillation. Chronic heart failure stage II, FC 3, ejection fraction (EF) = 48%. NT-proBNP - 2680 pg / ml. Complaints of shortness of breath with minor physical exertion, general weakness, and rapid fatigue. After stabilization of the patient's condition in the hospital, a comprehensive functional examination was performed, including measurement of respiratory muscle strength, cardiorespiratory exercise testing and a 6-minute walk test, as well as a questionnaire using the Hospital Anxiety and Depression Scale (HADS).

[0050] Examination data. Resting respiratory muscle strength is above the age-sex norm: maximum inspiratory pressure is 96 cm H2O (150.2% of the age-sex norm), maximum expiratory pressure is 102 cm H2O (159% of the age-sex norm). During the CRNT, the patient did not achieve the required load level, interrupting the exercises due to severe shortness of breath. After 1 minute of testing, the respiratory rate reached 33 breaths per minute (127 of the age-sex norm), and a paradoxical decrease in the depth of breathing occurred (rest 0.3 l, maximum load 0.27 d). The distance in the 6-minute walk test was 310 meters. The HADS score was -12.

[0051] The patient was recommended to perform breathing exercises according to the method proposed by the authors. Written and video instructions were provided. Due to her high initial respiratory muscle strength, she was asked to begin training with 10 breathing movements for each muscle group.

[0052] The exercises were performed twice a day, morning and evening. Before starting the breathing exercises, the patient performed a 5-minute warm-up of the shoulder girdle and chest muscles. The patient performed shoulder rotations and intercostal muscle stretches in the lateral and frontal projections. Then, the patient began the main set of exercises. The patient assumed a sitting position on a chair and performed abdominal breathing. To ensure the exercises were performed correctly, the palms were placed on the abdomen near the navel. For 10 breathing cycles, the patient breathed so that on inhalation the abdomen rose and on exhalation it fell. Then the patient performed chest breathing. For 10 breathing cycles, the patient breathed so that on inhalation the chest, along with the palms, expanded, moving laterally and upward, and on exhalation it contracted.To check the correctness of the exercise, the patient was instructed to place her palms on the sides of her chest, directly under her breastbone, on her lower ribs. She then moved on to mastering the technique of engaging the shoulder girdle muscles in her breathing. This was also done while sitting with a straight back. For 10 breaths, the patient breathed so that her collarbones moved upward on inhalation and downward on exhalation. To check the correctness of the exercise, the patient was instructed to place her fingers on her collarbones. The exercise concluded with calm breathing for 1 minute.

[0053] The patient then moved on to breathing slowing exercises. She placed the thumb of her left hand on the left side of her nose and pressed it against the bridge of her nose, blocking the airflow. With her left nostril closed, she slowly inhaled through her right nostril. Then, using the second finger of her right hand, she closed her right nostril and opened the left. She exhaled and inhaled through the left nostril, and then, pressing her left nostril with her finger and opening the right nostril, exhaled through the right nostril. This sequence constituted one breathing cycle. The patient was advised to silently count to 6 on each inhalation and to 8 on each exhalation. The patient performed this cycle 15 times. The exercise concluded with calm breathing for 1 minute.

[0054] The patient performed the exercises for 2 days before hospital discharge and then continued training for 12 weeks at home. Over the 12 weeks, the number of repetitions was gradually increased (by 5 repetitions every 2 weeks) and the inspiratory duration was increased (by 4 counts every 2 weeks). The patient performed the exercises twice daily. After 12 weeks, the patient underwent a repeat comprehensive functional assessment, including respiratory muscle strength measurement, cardiorespiratory exercise testing, a 6-minute walk test, and the Hospital Anxiety and Depression Scale (HADS).

[0055] Repeat examination data. There was an increase in respiratory muscle strength: maximum inspiratory pressure was 103 cm H2O (170.5% of the age-sex norm), maximum expiratory pressure was 108 cm H2O (169% of the age-sex norm). Exercise tolerance improved during the CRNT. VO2 пик= 16.1 ml / kg / min (127% of the age-sex norm). Tidal volume (VT) at peak load is 1.46 l. (97% of the age-sex norm); Minute volume at peak load is 50 l / min (117% of the age-sex norm), VCO2 пик = 1.57 (119% of the age-sex norm). The 6-minute walk test distance was 370 meters. There was a significant improvement in her psychoemotional state. The HADS score was -2. The patient noted a decrease in shortness of breath, improved exercise tolerance, and decreased anxiety. Continuing breathing exercises and incorporating moderate-pace walking are recommended.

[0056] Example 3. Patient L., 82 years old. Diagnosis. Primary: IHD: PCI with stenting of the circumflex artery with Resolute Integrity 3.5 × 22 mm drug-eluting stents, Resolute Integrity 3.5 × 22 mm from March 18, 2024. Hypertension stage III, grade 3, very high risk. Impaired fasting glucose. NC 2a stage II FC (NYHA). CKD C3a (SCF 57.84 ml / min / 1.73 m 2). Permanent form of atrial fibrillation, complaints of shortness of breath with minor physical exertion, general weakness, rapid fatigue.

[0057] After stabilization of the patient's condition in the hospital, a comprehensive functional examination was performed, including measurement of respiratory muscle strength, cardiorespiratory exercise testing and a 6-minute walk test, as well as a questionnaire using the Hospital Anxiety and Depression Scale (HADS).

[0058] Examination data. Respiratory muscle strength at rest is slightly reduced: maximum inspiratory pressure = 63 cm H2O (73.3% of the age-sex norm), maximum expiratory pressure = 102 cm H2O (95% of the age-sex norm). During the CRNT: exercise tolerance is moderately reduced. VO2 index пик= 14.9 ml / kg / min (74% of the age-sex norm). Severe ventilation disturbances are recorded during exercise. A pattern of frequent shallow breathing, insufficient increase in tidal and minute volume during exercise are recorded. Tidal volume (VT) at peak exercise = 1.07 l. (48% of the age-sex norm); Minute volume at peak exercise 38 l / min (82% of the age-sex norm), VСO2 пик = 1.036 (67% of the age-sex norm). Distance in the 6-minute walk test = 425 meters. Points on the HADS scale = 8.

[0059] The patient was recommended to perform breathing exercises according to the method proposed by the authors. Written and video instructions were provided. After the training session, the patient continued to perform the exercises independently. The exercises were performed once a day in the evening. Before starting the breathing exercises, the patient performed a 5-minute warm-up of the shoulder girdle and chest muscles, which included shoulder rotations and stretching the intercostal muscles in lateral and frontal projections. The patient then began the main set of exercises. The patient assumed a sitting position on a chair and performed abdominal breathing. To ensure the exercises were performed correctly, the palms of the hands were placed on the abdomen near the navel. For 10 breathing cycles, the patient breathed so that the abdomen rose on inhalation and fell on exhalation. The patient then performed chest breathing.For 10 breathing cycles, the patient breathed so that on inhalation, the chest, along with the palms, expanded, moving laterally and upward, and on exhalation, it contracted. To check the correctness of the exercise, the patient was advised to place their palms on the sides of the chest, on the lower ribs, directly under the breastbone. The patient then moved on to mastering the technique of engaging the shoulder girdle muscles in breathing. This was also done while sitting with a straight back. For 10 breathing cycles, the patient breathed so that on inhalation, the collarbones moved upward, and on exhalation, they moved downward. To check the correctness of the exercise, the patient was advised to place her fingers on the collarbones. The exercise concluded with calm breathing for 1 minute.

[0060] The patient then moved on to breathing slowing exercises. During this exercise, the patient placed the thumb of their left hand on the left side of their nose and pressed it against the bridge of their nose, blocking the airflow. With the left nostril closed, they inhaled slowly through the right nostril. Then, with the second finger of their right hand, they closed the right nostril and opened the left. They exhaled and inhaled through the left nostril, and then, pressing the left nostril with their finger and opening the right nostril, exhaled through the right nostril. The patient was advised to silently count to 6 on each inhalation and to 8 on each exhalation. The patient repeated this cycle five times. The exercise concluded with calm breathing for 1 minute.

[0061] The patient performed exercise for 2 days before hospital discharge and then continued training for 8 weeks at home. The patient gradually increased the number of repetitions (by 3 repetitions every 2 weeks) and increased the inspiratory duration (by 4 counts every 2 weeks). The patient performed the exercises once a day for 10 weeks. After 10 weeks, the patient underwent a comprehensive functional assessment, including respiratory muscle strength measurement, cardiorespiratory exercise testing, a 6-minute walk test, and the Hospital Anxiety and Depression Scale (HADS).

[0062] At follow-up examination, the patient showed a significant increase in respiratory muscle strength: maximum inspiratory pressure = 82 (95.4% of the age-sex norm), maximum expiratory pressure = 128 (119.2% of the age-sex norm). During the CRNT, exercise tolerance improved. VO2 пик= 17.0 ml / kg / min (84% of the age-sex norm). Positive dynamics of ventilatory parameters. Increased tidal volume at peak load VT = 1.19 l. (53% of the age-sex norm); Minute volume at peak load 44 l / min (96% of the age-sex norm). Increased oxygen production VCO2 пик = 1.097 (71% of the age-sex norm). The 6-minute walk test distance increased to 385 meters. The patient noted increased endurance and noted that when repeating the test, he did not experience significant fatigue or a feeling of heaviness in his legs. Continuing breathing exercises and incorporating moderate-paced walking are recommended.

Claims

1. A method for rehabilitation of the external respiratory system in patients with chronic heart failure, including performing warm-up exercises - stretching exercises and movements in the joints of the upper body, followed by performing a basic set of breathing exercises lasting from 15 to 30 minutes, at least once a day, at least 5 days a week, for at least 8 weeks, In this case, at the first stage, the main set of exercises includes four exercises performed sequentially: an abdominal breathing exercise, a chest breathing exercise, a breathing exercise involving the muscles of the shoulder girdle, with the sequential involvement of all groups of the respiratory muscles in the breathing process - the diaphragm, intercostal muscles and muscles of the shoulder girdle, an exercise to slow down breathing;all exercises are performed in a sitting position on a chair, while the abdominal breathing exercise is performed in such a way that the stomach rises on inhalation and falls on exhalation, the chest breathing exercise is performed in such a way that on inhalation the chest expands, moving to the sides and upward, and on exhalation it contracts, the breathing exercise involving the muscles of the shoulder girdle is performed in such a way that on inhalation the collarbones move upward and on exhalation they move downward, the first three exercises are performed for 5-10 breathing cycles with an interval between exercises of at least 1 minute, the fourth exercise contains 5-15 cycles, where each cycle includes inhalation through the first nostril, subsequent exhalation and inhalation through the second nostril, then exhalation through the first nostril,; In the second and subsequent stages, the basic set of exercises includes two exercises performed sequentially: an exercise for full breathing and an exercise for slowing down breathing; the exercise for full breathing includes the sequential performance of abdominal breathing, chest breathing and breathing with the involvement of the muscles of the shoulder girdle during one inhalation, with the sequential involvement in the breathing process of all groups of the respiratory muscles - the diaphragm, intercostal muscles, muscles of the shoulder girdle, exhalation is performed in the reverse order, the number of cycles of the exercise for full breathing in the second stage is 15-20, Moreover, the duration of each stage is at least 2 weeks, where at each subsequent stage, starting from the second, the duration of the exercises performed in the main complex is increased by increasing the number of exercise cycles, as well as increasing the duration of inhalation and exhalation when performing exercises to slow down breathing.

2. The method according to paragraph 1, characterized in that after 8 weeks of performing a set of breathing exercises, the functional state of the patient is assessed, then the exercises of the main set are performed at least 3 times a week on an ongoing basis.

3. The method according to paragraph 1, characterized in that the exercise to slow down breathing in the second and subsequent stages is performed with an increase in the duration of inhalation and exhalation - by 2 counts every 2 weeks.

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