B re a t h i n g E x e rc i s e s an d

Inspiratory Muscle
Tr a i n i n g i n H e a r t Fa i l u re
Lawrence P. Cahalin, PhD, PT, CCSa,*,
Ross A. Arena, PhD, PTb

KEYWORDS

Functional capacity
Respiratory muscle weakness
Rehabilitation
Exercise training

KEY POINTS

Because of the intimate and linked functional and compensatory relationships it is often difficult to
identify the primary determinant limiting exercise in heart failure (HF).

Respiratory contributions have been shown to limit exercise in patients with HF due to abnormal-
ities in ventilation, perfusion, or both ventilation and perfusion.

Breathing exercises and inspiratory muscle training seem to have substantial potential to improve
exercise and functional performance in HF and should be considered as key components of a reha-
bilitation program in this patient population.

INTRODUCTION elevated pulmonary vascular resistance

Respiratory contributions have been shown to limit
exercise in patients with heart failure (HF). The
manner by which the respiratory system limits exer-
cise is due to abnormalities in ventilation, perfusion,
or both ventilation and perfusion.1–16 The key fac-
tors limiting ventilation in HF include pulmonary
edema, loss of elastic recoil of the lungs, ascites,
and inspiratory muscle weakness.1–7 Thus, the ab-
normalities in ventilation in HF are mostly restrictive
in origin, producing a ventilatory response during
exercise in HF that is characterized by: (1)
decreased tidal volume, end-tidal carbon dioxide,
peak oxygen consumption (VO2), and tidal volume
to ventilation ratio (VT/VE); and (2) increased respi-
ratory rate, VE, peak dead space ventilation to tidal
volume ratio (VD/VT), ventilation to VO2 ratio (VE/
VO2), and the VE/carbon dioxide consumption
(VE/VCO2) slope.7–9 The key factors limiting perfu-
sion in HF include poor right ventricular perfor-
mance, elevated pulmonary artery pressure, and
(PVR).2,8,9,14 Ventilation-perfusion abnormalities in
HF are due to these factors in addition to several
other potential factors, including ventricular asyn-
chrony, cardiac arrhythmias, and loss of viable
and elastic lung tissue, as in advanced HF. All of
these factors contribute to a ventilation-perfusion
mismatch of varying degrees.1–15 The purpose of
this article is to demonstrate how breathing
exercises (BE) and inspiratory muscle training
(IMT) have the potential to improve many of
these abnormalities in ventilation, perfusion, and
ventilation-perfusion matching. The rationale for
BE and IMT in HF is provided, followed by an exten-
sive review of the literature of BE and IMT in HF. The
role of BE and IMT in HF is expanded to patients
with pulmonary hypertension (PH) to highlight (1)
the manner by which the pulmonary vasculature af-
fects respiratory performance, and (2) the potential
that both BE and IMT have on improving the pulmo-
nary vasculature and pathophysiology of HF.
heartfailure.theclinics.com

a
Department of Physical Therapy, Leonard M. Miller School of Medicine, University of Miami, Miami, 5915
Ponce de Leon Boulevard, Coral Gables, FL 33146-2435, USA; b Department of Physical Therapy, College of
Applied Health Sciences, University of Illinois at Chicago, 1919 West Taylor Street, Room 459, Chicago, IL
60612, USA
* Corresponding author. Department of Physical Therapy, Leonard M. Miller School of Medicine, University of
Miami, 5915 Ponce de Leon Boulevard, Fifth Floor, Coral Gables, FL 33146-2435.
E-mail address: l.cahalin@miami.edu

Heart Failure Clin 11 (2015) 149–172

http://dx.doi.org/10.1016/j.hfc.2014.09.002
1551-7136/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.