Pulmonary Rehab Programs and Breathing Exercises That Can Help Improve COPD

If you have a chronic breathing problem, a physical therapy program may seem like the last thing you would want to do. After all, how could exercise ever help to improve breathlessness? 

Pulmonary rehabilitation is a science-backed, highly effective way to improve symptoms in people with long-term breathing problems. Even people with severe shortness of breath can take part and benefit. 

What is pulmonary rehabilitation?

Pulmonary rehab (PR) is a supervised outpatient treatment program. It’s scientifically proven to improve symptoms and quality of life for people with COPD and other long-term lung diseases. 

Pulmonary rehabilitation is a structured program that involves: 

• Learning how to manage medications and symptoms

• Endurance and strength training

• Breath training

• Psychological counseling

• Help to stop smoking

• Nutrition advice

• Social support

PR programs vary in how they’re structured and run. The program doesn’t replace your treatment with inhalers and other medications. But, together with your medications, PR can improve the way you feel and how well your treatment helps you. 

Who qualifies for pulmonary rehabilitation?

Chronic obstructive pulmonary disease (COPD) is the main reason why people get referred to pulmonary rehab. 

But PR can help people with other chronic lung conditions, too, like:

• Asthma

• Sarcoidosis

• Lung fibrosis

• Pulmonary hypertension

• Bronchiectasis

• Cystic fibrosis

• Lung cancer

• Long COVID

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So, if you have any of these conditions, and you’re struggling with breathlessness, PR may be an option for you. 

You can find out more about pulmonary rehab programs near you from the American Thoracic Society’s Live Better pulmonary rehabilitation directory. You’ll need a referral from your primary care provider or respiratory specialist. Even then, it’s possible you may have to join a waitlist and/or travel a considerable distance to attend a program.

What to expect if you join a pulmonary rehab program for COPD

Pulmonary rehab programs typically take place in an outpatient department. This might be in a hospital or clinic, including Veterans Administration (VA) hospitals. 

Pulmonary rehab programs are usually led by a physical therapist, respiratory physician, or a trained respiratory nurse. Before you start the program, or at your first session, your care team will carry out baseline tests to find out more about you and your health. 

Your pulmonary rehab assessment will typically include: 

• Your medical history 

• Your symptoms

• Your medications 

• Your home setup

• Your mental health

• Your support network

• Your diet

• Lung-function testing

• Exercise testing, usually a 6-minute walk test

• Blood tests

With this information, your team will make sure you have a PR plan that suits your needs and goals. Enrolling in a PR program requires commitment. You have to attend regularly and complete the program to get the most benefit from it.

How long is a typical pulmonary rehabilitation program for COPD?

Most PR programs require you to attend once or twice a week, for between 8 to 12 weeks. This can be a real commitment, especially if the PR program you’re attending is far from where you live, and if you need help getting there and back. If you can make it happen, the results are worth it. 

Pulmonary rehab breathing exercises

Regular breathing exercises can help improve the symptoms of breathlessness by: 

• Strengthening the muscles involved in breathing

• Increasing the amount of air you’re able to take in and breathe out with each breath

• Working through the feelings of anxiety that come with feeling short of breath

Here are five breathing exercises to try at home. You can practice these wherever you are, without needing any special equipment. The more you practice, the easier and more effective these exercises will feel.

1. Pursed-lip breathing

Pursed lip breathing improves airflow, slows breathing rate, and reduces shortness of breath. You can practice it every day. It’s also a helpful one to try during physically demanding activities, like walking upstairs. 

Follow these steps:

• Inhale slowly through your nose (about 2 counts).

• Purse your lips (like blowing out a candle).

• Exhale slowly through pursed lips (about 4 counts)

2. Diaphragmatic (belly) breathing

Belly breathing strengthens the diaphragm, improves oxygenation, and takes the pressure off your chest breathing muscles. It also stimulates the vagus nerve, which sends signals to the brain to promote calmness, a slower heart rate, and lower stress hormones. It’s a good one to practice every day when you’re relaxed, so that you can tap into it during moments of breathlessness and anxiety.

Here’s how to do it:

• Sit or lie down.

• Place one hand on your chest and one on your belly.

• Inhale deeply through your nose — your belly should rise more than your chest.

• Exhale slowly through pursed lips — your belly should fall.

3. Coordinated breathing

This helps to prevent breath-holding during physical activity. Time your breath with movement — like a stretch or walking — to practice staying in control of your breath.

This is how to do it:

• Inhale before starting an activity (such as lifting or bending).

• Exhale through pursed lips during the effort.

4. Active cycle of breathing technique (ACBT) with huff coughing

Active cycle of breathing technique (ACBT) with huff coughing helps clear mucus in people with chest congestion. It works best if you repeat the cycle a few times. But be sure not to overdo it. Rest between each cycle to avoid fatigue.

ACBT includes three stages:

Stage 1: Breathing control

• Sit or lie comfortably with relaxed shoulders.

• Breathe gently in through your nose and out through your mouth.

• Let your belly rise and fall with each breath.

• Continue for 1 to 2 minutes.

Stage 2: Deep breathing

• Take a slow, deep breath in through your nose.

• Hold it for 3 to 5 seconds. Then exhale gently through your mouth.

• Repeat several times to loosen mucus.

Stage 3: Huff coughing

• Take a slightly deeper breath than usual.

• With your mouth in an “O” shape, exhale with a strong “huff” — like you’re fogging a mirror.

• Use your belly muscles to push the air out.

• If mucus moves up, cough or take a sharper huff to clear it. Avoid huffing too forcefully.

5. Box breathing (square breathing) 

This one is not specific to COPD, but it’s helpful for anxiety. It calms the nervous system, and helps to control panic during breathlessness.

Follow this sequence: 

• Inhale for 4 counts.

• Hold for 4 counts.

• Exhale for 4 counts.

• Hold for 4 counts.

• Repeat.

How does pulmonary rehab improve lung function in COPD patients?

PR programs improve exercise ability and lung function mainly through mind, behavior, and body training:

• Psychological coaching and peer support: This part of a PR program can improve the fear and loss of control that can come with having a lifelong lung condition and feeling short of breath. 

• Disease, medication, and nutrition education: This part of the program helps people improve symptoms by teaching them how and when to self-treat, how and what to eat, and how to conserve energy.

• Physical coaching and training: This part of the program helps to build muscle strength and endurance. Strength training is centered on the muscles needed to breathe, as well as those needed to exercise. The stronger your breathing muscles, the better your lung function will be. Not only that, but your cough and swallow will get stronger.

By treating the whole person, PR programs can help people with COPD to develop:

• More strength

• Better fitness

• Fewer symptoms

• Improved mood

• Better overall health

How exercise helps people with COPD

Regular exercise is beneficial to everyone, regardless of age or health. For people with COPD, there are specific benefits which feed into each other and improve overall health. 

These benefits include:

• Helping the body use oxygen more effectively 

• Improved energy levels

• Increased lean muscle mass, which improves metabolism and overall health

• Stronger heart and lung muscles, which improves shortness of breath

• Improved mood, including mental health disorders, like anxiety and depression

• Better quality sleep

• Better self-esteem

• Promoting more social interaction, which helps reduce feelings of isolation

What is the difference between pulmonary rehab and physical therapy?

Pulmonary rehab programs include physical therapy and are often run by physical therapists. But there’s more to a PR program than physical therapy. Though PR includes physical therapy, this type of physical therapy is specific to the needs of people with chronic breathing problems.

Unlike physical therapy, PR programs also include:

• Education

• Psychological support

• Coaching

• Help with quitting smoking

• Group support

• Nutrition advice

How much does pulmonary rehab cost, and is it typically covered by insurance?

How much pulmonary rehab costs for you depends on where you live, what program you attend, and your insurance coverage. Some insurance plans and Medicare will cover pulmonary rehabilitation for COPD and other lung conditions, if you meet certain criteria.

Tips and tricks to improve your COPD symptoms on your own

Unable to join a pulmonary rehab program? Or, maybe there’s a long wait time? Below are some evidence-based lifestyle changes you can make on your own:

• Quit smoking. If you smoke, the most important part of any treatment plan is to try to quit or cut back. No matter how advanced your disease is, and no matter how many times you may have tried to quit before, it’s never too late to try. Stopping smoking slows the progression of COPD. It also reduces risk of heart disease, stroke, and lung cancer. 

• Stay up to date on vaccines. Vaccines for flu, COVID, and pneumonia can help prevent serious chest infections.

• Pay attention to what you eat. Some people with severe breathing problems aren’t able to eat enough because they’re too breathless. Weight loss and malnutrition can make symptoms worse and put you at more risk of chest infections. And, too much weight can also make breathing symptoms worse. Work with a dietitian or nutritionist to make more tactical food choices. 

• Keep well hydrated. Staying well hydrated when you have a chronic cough helps to moisten a dry mouth. It also keeps chest mucus thinner and easier to cough up. If you have heart trouble in addition to your lung condition, check with your medical team about whether you need to limit your fluid intake. 

• Exercise regularly. All three forms of exercise — exercise for flexibility, cardiovascular and aerobic exercise, and resistance training — help people with COPD. For flexibility, try stretching and yoga. For cardiovascular and aerobic exercise, try walking, gentle jogging, biking, or swimming. And build strength with squats and light weights. To get started, work with a trainer or follow online videos. (For more guidance on developing your own exercise program, see the British Lung Foundation and the COPD Foundation’s online resources and videos.) 

• Practice breathing exercises. Work the breathing exercises mentioned above into your daily routine. These help to strengthen your lungs and improve feelings of breathlessness and anxiety.

• Stay socially and mentally active. Engage with friends, hobbies, music, nature, or creative activities to support emotional well-being and respiratory health. 

• Keep up with medical checkups. Make time for regular checkups with your healthcare team to monitor symptoms and overall health, as well as review inhalers and other treatments. Most people with lung disease should see their lung specialist every few months. 

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Written by:

Sophie Vergnaud, MD

Sophie Vergnaud, MD, is the Senior Medical Director for GoodRx Health. A pulmonologist and hospitalist, she practiced and taught clinical medicine at hospitals in London for a decade before entering a career in health education and technology.

Reviewed by:

Mandy Armitage, MD

Mandy Armitage, MD, has combined clinical medicine with her passion for education and content development for many years. She served as medical director for the health technology companies HealthLoop (now Get Well) and Doximity.

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