It has been well established that rhythmic (or controlled) breathing can be an effective non-pharmacologic technique for reducing procedure-related pain and anxiety. Controlled breathing can lower heart rates and promote vasodilation. (Tollison, 2002) Bubbles and pinwheels are frequently used to demonstrate controlled breathing techniques for toddlers and preschoolers. For school-age children, drawing an analogy to blowing out birthday candles is a common way to elicit the proper technique during relatively brief stressful experiences like immunizations or blood draws. However, sustaining this coping mechanism for longer periods of time, either when coupled with sedation medications or when used solely with other non-pharmacological techniques, requires a more thoughtful approach.
When considering rhythmic breathing techniques, it is important to develop an individualized coping plan for the patient that is appropriate from a developmental and procedural perspective. When at all possible, rehearse the breathing technique so the patient can feel comfortable with the mechanism. Though controlled breathing certainly can be used when the patient is in the midst of a procedure; it is more effective when the technique is introduced before the painful stimuli. The longer a child has to develop a sense of mastery, the better chance they have of successfully implementing a coping plan. If the procedure is scheduled, the patient and their family can even rehearse various rhythmic breathing techniques in the days leading up to the appointment. As is the case with developing any new skill, practice is required.
When implementing a rhythmic breathing technique, it is important that the primary support person (caregiver, child life specialist, nurse, etc.) participate, demonstrating the technique along with the patient. And, as with most coping techniques intended to promote relaxation, it is most effective when implemented with One Voice methodology.
If the patient prefers to keep their eyes open while implementing rhythmic breathing, various visual cues can be used. Box Breathing (or Square Breathing) uses visual cues and imagery to promote breathing patterns, using a four count pattern. Children can trace the outline of a square, as they inhale, pause and exhale. Lazy 8 Breathing also employs a tracing technique. Starting in the center, children will take a deep breath in, tracing one side of the figure. As they cross back over the center, they will exhale slowly. A similar strategy is Five Count Breathing which can be implemented by having the patient trace the fingers of a hand, inhaling as they move up one side of the finger, pausing at the tip of the fingernail, and then exhaling as they move down the other side. This method is also known as Star Breathing. If the patient’s vision is obstructed or if they simply prefer to keep their eyes closed, a visualization of a five-pointed star can be substituted for the finger tracing method.
Guided imagery can also be used to promote relaxation and controlled breathing. This technique encourages children to bring a pleasant scene to mind, incorporating as many senses as possible. Using a calm, soothing tone of voice, the facilitator will begin to describe a place (real or imagined) where the patient feels safe and secure. Descriptive language is used so that the patient feels immersed in the experience. Thinking about the scene will promote relaxation, which will slow the breathing. Cues can also be inserted into the script to further encourage controlled breathing. For example, as the facilitator is describing a tranquil beach scene, they can encourage the patient to match their breathing to the roll of the ocean tide. This technique can be particularly effective when the patient is receiving nitrous oxide. Sometimes, patients can have “dreams” while receiving this medication, which may be quite vivid. When guided imagery is utilized to promote rhythmic breathing, the patient may be more likely to have a pleasant dream.
If a designated support person is not available to guide the patient through imagery or rhythmic breathing techniques, technology may also be used to promote positive coping. Apps with nature sounds or guided meditation scripts are plentiful and can be effective.
Additional information:
http://kidsrelaxation.com/uncategorized/the-deep-breath-box-square-breathing/
https://omazingkidsllc.com/2013/10/05/five-count-breathing-visual-support/
http://www.readysetrelax.com/Relax.htmlhttp://www.readysetrelax.com/Relax.html
Apps:
https://appgrooves.com/ios/1003758958/relax-deep-breath/joseph-tsui/
https://appgrooves.com/android/ipnossoft.rma.free/relax-melodies-sleep-sounds/ipnos-software/
Tollison, C. D. (2002). Practical pain management. Philadelphia: Lippincott Williams & Wilkins.
