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A Guide to Monitoring Respiration

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DOI: 10.5298/1081-5937-47.1.02

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 Biofeedback
Volume 47, Issue 1, pp. 6–11
DOI: 10.5298/1081-5937-47.1.02
Research Article
A Guide to Monitoring Respiration
Christopher Gilbert, PhD
Osher Center for Integrative Medicine, University of California, San Francisco, CA
Keywords: biofeedback, breath training, capnometry, hyperventilation, oximetry
Professionals can monitor respiration using six biofeedback
modalities: strain gauges, surface electromyography,
capnometers, oximeters, inspirometers, and feedback ther-
mometers. This article emphasizes the importance of the
breathing rhythm, describes how to effectively use each
modality, and explains how to minimize contamination by
artifacts that masquerade as respiratory activity.
Consider: How many ways are there to monitor breathing
with biofeedback devices?
Answer: AT LEAST air temperature, muscle tension,
torso circumference, color shifts in blood, percent of
exhaled carbon dioxide (CO2), and inhalation strength.
Some of these modalities are less direct than others, but
each method can follow breathing, breath by breath, and
report what’s happening. Like heart rate and electroen-
cephalogram, breathing is rhythmic and cyclical, and that is
a large part of the information needed.
Breathing is as subject to conscious control as any
voluntary skeletal muscle activity. Since autonomic mea-
sures like heart rate, hand temperature, or galvanic skin
response provide less conscious feedback, conscious mastery
of these functions often requires more training. Yet,
breathing can proceed without any conscious control—like
a horse who knows the way. There is continual input from
emotional centers, so that the two systems sometimes
compete for control of breathing. People can learn to
control breathing indirectly by altering the emotional
input, or else manipulate it directly and usually receive an
‘‘upstream’’ effect on the emotional state (see Figure 1).
Strain Gauges: Body Circumference
Bands around the abdomen or chest are used to measure
changes in circumference caused by breathing activity. This
method uses changes in electrical resistance in a transducer
Spring 2019 | Biofeedback
to convert stretching in the band into a signal. It is good for
determining rate of breathing, volume, pauses, ratio of
inhalation to exhalation time, and the slopes of inhalation
and exhalation. One gauge is good, but two are better. A
pair of strain gauges can easily differentiate abdominal from
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ÓAssociation for Applied Psychophysiology & Biofeedback
www.aapb.org
chest breathing and show the relative amounts of each
(Figure 2).
Possible Artifacts
Placement is important, especially preventing slippage of
the bands on the body. The measure of breathing volume
depends on which part of the body is changing volume. A
too-tight band may restrict natural breathing and a too-
loose band may miss small changes.
Thresholds can be set for rate, breathing volume, and the
ratio of chest to abdominal breathing. An on-screen
template or breath pacer can be used as a guide to the
desired optimal breathing pattern. Finally, a strain gauge
can provide feedback for a person learning to exhale slowly
with breathing muscles rather than from the lips (‘‘pursed
lips’’).
Abdominal Placement
Belly shapes and contours vary, but the best placement is
usually above the navel in a zone that expands with
inhalation. Thin clothing can remain, but thick sweaters or
jackets reduce the accuracy of the data. Since a potentially
major artifact is slippage of the band (either upward or
downward), the band’s position can be maintained by
taping or pinning it to the clothing.
Changes due to emotional shifts can be observed, similar
to galvanic skin response, heart rate, or any other
biofeedback signal (see Figure 2).
Surface Electromyography: Muscle Activity
Each breath begins with muscle activity. Suction must be
created somewhere in the upper body in order to create a
low-pressure space to be filled with fresh air. Although the
position of the lungs is fixed, different lung regions can be
induced to expand so that air rushes in.
Muscle feedback for breathing is most often used to
monitor neck and shoulder muscles. Chest (thoracic)
breathing is common during stress, but can become a
habit, or perhaps the stress response becomes a habit. One

Figure 1. Five ways to monitor breathing.
cannot breathe primarily into the chest without using the
muscles that expand the chest.
Monitoring breathing muscles shows where work is
being done, at what point in the cycle, and allows
comparison of various muscle groups (Peper et al., 2008).
It also shows rate and regularity of breathing and changes
in volume. There is usually a strong cardiac artifact that
does not appear when using other monitoring methods.
Scalene muscles attach to the cervical spine and to the
upper ribs, three on each side. These muscles can be located
easily by palpation: Breathing into the upper chest tightens
them, which is often visible as well. Abdominal breathing
causes little to no activity in the scalenes unless the breath
is deep. The sternomastoid muscles usually parallel the
action of scalenes, lift the sternum, and can also be
monitored (see Figures 3 and 4).
The trapezius muscles assist with chest expansion, and in
some people are chronically tense, which usually correlates
with chest breathing. They can be accessed at the rear neck
and top of the shoulder, slightly dorsal to the muscle’s crest.
If the electrodes are spaced more widely, activity from
deeper neck muscles will contribute more to the signal.
Gilbert
Artifacts
Cardiac activity is most evident with a wide-band amplifier
setting and will ride on top of the muscle tension. Keeping
smoothing low will make the cardiac signal more visible,
easier to identify.
Values from any muscle monitoring will be influenced
by variations in subcutaneous fat, so this limits comparison
from person to person. More insulation means a weaker
electromyography signal.
Capnometry: CO2 Feedback
The amount of CO2 in the blood is important for
maintaining normal functioning of many systems, includ-
ing regulation of blood pH and blood vessel diameter. Using
a device to monitor the proportion of CO2 in exhaled air is
more complex than most other breathing measures, but
reveals abnormalities in breathing that result in either
Biofeedback | Spring 2019
excessively high or low CO2 levels in the blood. CO2
content in air measured from the nostrils correlates closely
with CO2 in the blood (‘‘partial pressure’’ of CO2).
A capnometer uses an air pump to create mild suction.
Exhaled air is pulled through a sampling tube into an
7
 Guide to Monitoring Respiration
Figure 2. Strain gauges to monitor thoracic and abdominal breathing.
analyzing component, which quickly yields a number
representing the percentage of CO2 in each air sample.
The feedback is given either in changes in the waveform or
in a number that represents the percentage of CO2 breath
by breath. A measurement of 36 mmHg (36 torr)
corresponds to about 5% CO2 in exhaled air. Readings
below 25 mmHg indicate severe overbreathing, 25–30
mmHg indicates moderate-to-severe overbreathing, and
30–35 mmHg shows mild-to-moderate overbreathing
(Khazan, 2013).
This breath-by-breath information provides quick feed-
back about changes in breathing rate and volume, allowing
the patient to optimize the breathing so that there is a good
match between CO2 produced (by the body) and CO2
exhaled. Though it is a waste gas, CO2—on its way to the
lungs to be exhaled—regulates blood vessel diameter and
also the release of oxygen from the hemoglobin molecule.
Spring 2019 | Biofeedback
Anxiety states often include irregular breathing, and
commonly the breathing is excessive, so that CO2 drops.
This causes several transient symptoms, including rapid
heart rate, smooth muscle vasoconstriction (blood vessels,
gastrointestinal, bronchioles) and reduced cerebral cortex
8
Figure 3. Scalene muscles, cervical spine, and ribs. Major accessory breathing
muscles. Lift first two ribs upward to expand chest. Easily monitored by
surface electromyography—access above clavicle between trapezius and
sternomastoid (clavicle not shown here).
circulation. Habitual hyperventilation can be hard to detect
except with a capnometer, but can lead to many chronic
problems (see Figure 5).
Artifacts
Capnometers usually display a waveform so that the user
can check for validity. Kinks, obstructions, or shifts in
position of the breathing tube are easily detected this way.
Some have built-in alarms or alerts announcing obstruc-
tion in the sampling tube, or excess moisture. Either single
tubes at the nostril or a nasal cannula can be used, but
shifting the position of the sampling apparatus can give
false readings. Without a face mask to collect the exhaled
air, using a nasal tube requires exhalation through the
nose; intermittent mouth-breathing will lead to a less
accurate sample.
Detecting and evaluating hyperventilation is the main
application of capnometry for biofeedback. Seeing infor-
mation about breath-to-breath CO2 content facilitates quick

Figure 4. Sensor placement for scalene muscles.
adjustments in breathing rate and volume in order to
maintain optimal end-tidal CO2 and thus blood content
around 5%.
Medical Caution
Various medical conditions can elevate or depress the end-
tidal level, so it is premature to assume that low CO2
indicates respiratory alkalosis—hyperventilation—until
other possible reasons are considered. Capnometers some-
times come with oximeters built in, using finger sensors,
giving valuable information about blood oxygen saturation.
Oximetry: Oxygen Saturation
An instrument to estimate blood oxygen saturation can be
pocket-sized, battery powered, and priced below $100.
Oximeters are clipped to a finger or toe and compare the
ratio of two colors—wavelengths of red and blue in the
blood—to determine how much of the blood’s hemoglobin
Gilbert
is carrying oxygen. Oximeters are especially useful when
training breathing control to counteract or eliminate
hyperventilation, because when breathing exceeds the
body’s needs, the amount of oxygen in the blood (PaO2)
rises from a normative 95%–98% toward 100% (meaning
less oxygen is being released to the tissues). Another
advantage is simply to demonstrate to a person anxious
about suffocating or showing excessive ‘‘air hunger’’ that
the blood is carrying plenty of oxygen (Gilbert, 2016).
Oximetry can detect dangerously low saturation, (in the
mid-80s or lower). That in turn could explain low CO2
readings associated with overbreathing—in that case the
excessive breathing could be life-saving. High-altitude
breathing, for example, promotes hyperventilation as
necessary compensation for oxygen-thin air. Lung disease
such as emphysema or cardiac or circulatory insufficiency
could create the equivalent of high altitude and force more
vigorous breathing that could not be distinguished from
hyperventilating due to anxiety.
Artifacts
Cold fingers can reduce the amount of blood flow and make
it hard to obtain a clear signal. An oximeter is slow to
respond because of the oxygen reserve in the bloodstream,
but is still sensitive to changes in CO2. Uneven pulse
pressure from excessive beat-to-beat variability can make
interpretation of values less valid.
Inspirometer
This device is plastic, low-cost, and powered only by the
breath (see Figure 6). An inspirometer (incentive spirom-
eter) is normally given to those recovering from chest
surgery, especially lung surgery, or any other procedure
that may compromise breathing activity. Pulling air deeply
into the lungs helps prevent fluid and mucus accumulation
and pneumonia. An inspirometer is also helpful for
showing patients that engaging the diaphragm brings in
more air, more easily, than chest breathing.
A user inhales slowly and fully through a mouthpiece
and a piston rises in a calibrated tube. A marker is set for a
particular goal—perhaps 3,000 milliliters—and the person
tries to inhale enough to pull up (with suction) the piston to
that mark. Over a few days of periodic practice, the
diaphragm muscle gets stronger and the performance
improves.
Biofeedback | Spring 2019
Apart from surgical recovery, using an inspirometer is
also helpful for directly increasing the strength of the
diaphragm. This is sometimes needed when a person has
formed breathing habits that neglect diaphragmatic activity.
The diaphragm can lose strength from disuse just like any
9
 Guide to Monitoring Respiration
Figure 5. Sample CO2 waveforms.
other muscle. An incentive inspirometer also helps to
compensate to a degree for chronic obstructive pulmonary
disease. Stronger breathing muscles tend to create more
suction on the inhale and open the alveoli more fully to air
exchange.
Strengthening of the diaphragm is also used by athletic
trainers. Performance in any sport that benefits from sharp,
full inhalation might improve when the diaphragm is
operating at full strength. Inspiratory muscle trainers (such
as POWERBreathe or Medline’s Threshold Inspiratory
Muscle Trainer) are marketed as a method to improve
breathing muscle strength. Instead of simply measuring
volume of air inhaled, these inspirometers are adjustable by
a valve that alters resistance to the inhalation, as if
Spring 2019 | Biofeedback
breathing through a smaller opening.
Temperature at the Nostril
If you want a quick feedback display to monitor breathing
frequency and regularity, temperature of air at the nostril is
10
a good choice. Air leaving the lungs is usually warmer than
air entering, and monitoring this change can serve as
biofeedback. The variation in temperature is usually 28–58
F, depending on ambient temperature and breathing speed.
Room air should not be too warm; a range of 708–758 F is
fine. The magnitude of temperature change is not very
important compared with the regular variation that
indicates the phase of breathing. This can be enhanced by
including audio feedback with the signal, allowing eyes-
closed practice. Adjusting the range (vertical scale) to
maximize the fluctuating signal gives clear feedback of
changes in breathing rate, volume, and regularity. It is
insensitive to which muscles are doing the breathing, to the
relative dominance of chest or abdomen, and to cardiac
artifact.
Thermistor response needs to be fast: 1–2 seconds. A
low-cost ‘‘stress thermometer’’ that updates its digital
display every 4–5 seconds is not adequate.
 Gilbert

Conclusion
In conclusion, clinicians can enhance breathing assessment
and training using complementary biofeedback modalities.
Inexpensive noninvasive instruments like an oximeter can
increase the safety of breathing training by identifying
compensatory hyperventilation in response to an underly-
ing disorder. They can help clients adjust their breathing to
treat symptoms and achieve optimal performance. Finally,
they can demonstrate the value of breathing within the
body’s healthy limits.

References
Gilbert, C. (2016). Pulse oximetry and breathing training. In D.
Moss & F. Shaffer (Eds.), Foundations of heart rate variability
biofeedback: A book of readings (pp. 59–62). Wheat Ridge, CO:
AAPB.
Khazan, I. Z. (2013). The clinical handbook of biofeedback: A step-
by-step guide for training and practice with mindfulness.
Chichester, West Sussex, UK: John Wiley & Sons.
Peper, E., Gibney, K. H., Tylova, H., Harvey, R., & Combatalade,
D. (2008). Biofeedback mastery: An experiential teaching and
self-training manual. Wheat Ridge, CO: AAPB.

Figure 6. Incentive spirometer or inspirometer. High value, low cost (under $10).
Graphic Ó Pavel Skopets/Shutterstock. ‘‘POWERbreathe’’ explanation and video:
https://player.vimeo.com/video/48362259?title¼0&portrait¼0&autoplay¼1. In-
centive spirometer instruction video (Kaiser Permanente): www.youtube.com/
watch?v¼-O-Zawtb32o

Christopher Gilbert
The tip of the thermistor should be placed in the stream
of air into and out of the nostril. The sensor must not touch
flesh because that will change the temperature registered; Correspondence: Christopher Gilbert, PhD, UCSF Osher Center for
Integrative Medicine, 1545 Divisadero St., No 819, San Francisco,
use rolled-up tissue or parts of a cotton ball as insulating
CA 94115, email: cgilbert1@outlook.com.
spacers. Taping the lead to the upper lip works well as long
as the tip does not touch skin. For brief monitoring, the
patient can simply hold the lead so that it catches the
exhaled stream of air.
Biofeedback | Spring 2019

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