Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Respiratory muscle training and resting in COPD

Bartolome R Celli, MD
Section Editor
James K Stoller, MD, MS
Deputy Editor
Helen Hollingsworth, MD


The respiratory muscles constitute a vital component of the respiratory pump. Their contraction during part of the breathing cycle changes the anatomic configuration of the thorax and displaces its components, so that air moves into and out of the gas exchanging portion of the lungs [1-3]. The importance of the respiratory musculature in chronic obstructive pulmonary disease (COPD) is underscored by diaphragmatic structural changes which render patients more resistant to fatigue, including an increased quantity of slow twitch fibers and slow isomers of myosin light chains, tropomyosin, and troponins [4,5].

The effect of training and resting the respiratory muscles in patients with COPD will be presented here. An overview of the management of stable COPD is discussed separately. (See "Management of stable chronic obstructive pulmonary disease".)


A number of studies have demonstrated that respiratory muscle strength and endurance can be increased with specific training, similar to skeletal muscle training [6-9]. A sufficient stimulus, such as greater than 30 percent of maximal force, is needed for training to occur.

Since reduced inspiratory muscle strength is evident in patients with chronic obstructive pulmonary disease (COPD), considerable efforts have been made to define the role of respiratory muscle training in this setting. Theoretically, an increase in inspiratory muscle strength (and perhaps endurance) could result in improved respiratory muscle function. However, this may only be relevant when patients must handle inspiratory loads that are greater than baseline, such as during an acute exacerbation.

Inspiratory muscle training improved the six minute walk distance and reduced dyspnea in a study that compared expiratory, inspiratory, and combined training [10]. In a systematic review and meta-analysis (32 trials), inspiratory muscle training improved inspiratory muscle strength, endurance time, 6 or 12 minute walk distance, and also reduced dyspnea [7]. On the other hand, a systematic review indicates that expiratory muscle training will improve expiratory muscle forces, but not the six minute walk distance or dyspnea in patients with COPD [11]. More data are needed to clarify the possible role of expiratory muscle training on clinical outcomes.

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: May 24, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Roussos C, Macklem PT. The respiratory muscles. N Engl J Med 1982; 307:786.
  2. Rochester DF. The diaphragm: contractile properties and fatigue. J Clin Invest 1985; 75:1397.
  3. Celli BR. Respiratory muscle function. Clin Chest Med 1986; 7:567.
  4. Levine S, Kaiser L, Leferovich J, Tikunov B. Cellular adaptations in the diaphragm in chronic obstructive pulmonary disease. N Engl J Med 1997; 337:1799.
  5. Testelmans D, Crul T, Maes K, et al. Atrophy and hypertrophy signalling in the diaphragm of patients with COPD. Eur Respir J 2010; 35:549.
  6. Leith DE, Bradley M. Ventilatory muscle strength and endurance training. J Appl Physiol 1976; 41:508.
  7. Gosselink R, De Vos J, van den Heuvel SP, et al. Impact of inspiratory muscle training in patients with COPD: what is the evidence? Eur Respir J 2011; 37:416.
  8. Hill K, Jenkins SC, Philippe DL, et al. High-intensity inspiratory muscle training in COPD. Eur Respir J 2006; 27:1119.
  9. Dellweg D, Reissig K, Hoehn E, et al. Inspiratory muscle training during rehabilitation in successfully weaned hypercapnic patients with COPD. Respir Med 2017; 123:116.
  10. Weiner P, Magadle R, Beckerman M, et al. Comparison of specific expiratory, inspiratory, and combined muscle training programs in COPD. Chest 2003; 124:1357.
  11. Neves LF, Reis MH, Plentz RD, et al. Expiratory and expiratory plus inspiratory muscle training improves respiratory muscle strength in subjects with COPD: systematic review. Respir Care 2014; 59:1381.
  12. Reid, WD, Warren, CP. Ventilatory muscle strength and endurance training in elderly subjects and patients with chronic airflow limitation: a pilot study. Physiol Canada 1984; 36:305.
  13. Larson JL, Kim MJ, Sharp JT, Larson DA. Inspiratory muscle training with a pressure threshold breathing device in patients with chronic obstructive pulmonary disease. Am Rev Respir Dis 1988; 138:689.
  14. Harver A, Mahler DA, Daubenspeck JA. Targeted inspiratory muscle training improves respiratory muscle function and reduces dyspnea in patients with chronic obstructive pulmonary disease. Ann Intern Med 1989; 111:117.
  15. Belman MJ, Shadmehr R. Targeted resistive ventilatory muscle training in chronic obstructive pulmonary disease. J Appl Physiol (1985) 1988; 65:2726.
  16. Noseda A, Carpiaux JP, Vandeput W, et al. Resistive inspiratory muscle training and exercise performance in COPD patients. A comparative study with conventional breathing retraining. Bull Eur Physiopathol Respir 1987; 23:457.
  17. Weiner P, Azgad Y, Ganam R. Inspiratory muscle training combined with general exercise reconditioning in patients with COPD. Chest 1992; 102:1351.
  18. Belman MJ, Mittman C. Ventilatory muscle training improves exercise capacity in chronic obstructive pulmonary disease patients. Am Rev Respir Dis 1980; 121:273.
  19. Wanke T, Formanek D, Lahrmann H, et al. Effects of combined inspiratory muscle and cycle ergometer training on exercise performance in patients with COPD. Eur Respir J 1994; 7:2205.
  20. Lisboa C, Muñoz V, Beroiza T, et al. Inspiratory muscle training in chronic airflow limitation: comparison of two different training loads with a threshold device. Eur Respir J 1994; 7:1266.
  21. Ramirez-Sarmiento A, Orozco-Levi M, Guell R, et al. Inspiratory muscle training in patients with chronic obstructive pulmonary disease: structural adaptation and physiologic outcomes. Am J Respir Crit Care Med 2002; 166:1491.
  22. Condessa RL, Brauner JS, Saul AL, et al. Inspiratory muscle training did not accelerate weaning from mechanical ventilation but did improve tidal volume and maximal respiratory pressures: a randomised trial. J Physiother 2013; 59:101.
  23. Ries AL, Moser KM. Comparison of isocapnic hyperventilation and walking exercise training at home in pulmonary rehabilitation. Chest 1986; 90:285.
  24. Levine S, Weiser P, Gillen J. Evaluation of a ventilatory muscle endurance training program in the rehabilitation of patients with chronic obstructive pulmonary disease. Am Rev Respir Dis 1986; 133:400.
  25. Koppers RJ, Vos PJ, Boot CR, Folgering HT. Exercise performance improves in patients with COPD due to respiratory muscle endurance training. Chest 2006; 129:886.
  26. Westerdahl E, Urell C, Jonsson M, et al. Deep breathing exercises performed 2 months following cardiac surgery: a randomized controlled trial. J Cardiopulm Rehabil Prev 2014; 34:34.
  27. Celli B, Lee H, Criner G, et al. Controlled trial of external negative pressure ventilation in patients with severe chronic airflow obstruction. Am Rev Respir Dis 1989; 140:1251.
  28. Brochard L, Isabey D, Piquet J, et al. Reversal of acute exacerbations of chronic obstructive lung disease by inspiratory assistance with a face mask. N Engl J Med 1990; 323:1523.
  29. Kramer N, Meyer TJ, Meharg J, et al. Randomized, prospective trial of noninvasive positive pressure ventilation in acute respiratory failure. Am J Respir Crit Care Med 1995; 151:1799.
  30. Bott J, Carroll MP, Conway JH, et al. Randomised controlled trial of nasal ventilation in acute ventilatory failure due to chronic obstructive airways disease. Lancet 1993; 341:1555.
  31. Brochard L, Wysocki M, Lofaso F, et al. Face. Face mask inspiratory positive airway pressure (IPAP) for acute exacerbation of chronic respiratory insufficiency . A randomized study. Am Rev Respir Dis 1993; 147:984.
  32. Hill NS. Noninvasive ventilation for chronic obstructive pulmonary disease. Respir Care 2004; 49:72.
  33. Zibrak JD, Hill NS, Federman EC, et al. Evaluation of intermittent long-term negative-pressure ventilation in patients with severe chronic obstructive pulmonary disease. Am Rev Respir Dis 1988; 138:1515.
  34. Shapiro SH, Ernst P, Gray-Donald K, et al. Effect of negative pressure ventilation in severe chronic obstructive pulmonary disease. Lancet 1992; 340:1425.
  35. Strumpf DA, Millman RP, Carlisle CC, et al. Nocturnal positive-pressure ventilation via nasal mask in patients with severe chronic obstructive pulmonary disease. Am Rev Respir Dis 1991; 144:1234.
  36. Casanova C, Celli BR, Tost L, et al. Long-term controlled trial of nocturnal nasal positive pressure ventilation in patients with severe COPD. Chest 2000; 118:1582.
  37. Clini E, Sturani C, Rossi A, et al. The Italian multicentre study on noninvasive ventilation in chronic obstructive pulmonary disease patients. Eur Respir J 2002; 20:529.
  38. COPD Working Group. Noninvasive positive pressure ventilation for chronic respiratory failure patients with stable chronic obstructive pulmonary disease (COPD): an evidence-based analysis. Ont Health Technol Assess Ser 2012; 12:1.
  39. Struik FM, Sprooten RT, Kerstjens HA, et al. Nocturnal non-invasive ventilation in COPD patients with prolonged hypercapnia after ventilatory support for acute respiratory failure: a randomised, controlled, parallel-group study. Thorax 2014; 69:826.
  40. Köhnlein T, Windisch W, Köhler D, et al. Non-invasive positive pressure ventilation for the treatment of severe stable chronic obstructive pulmonary disease: a prospective, multicentre, randomised, controlled clinical trial. Lancet Respir Med 2014; 2:698.
  41. Duiverman ML, Maagh P, Magnet FS, et al. Impact of High-Intensity-NIV on the heart in stable COPD: a randomised cross-over pilot study. Respir Res 2017; 18:76.