September 2017: Respiratory Compromise



Content courtesy of the National Swimming Pool Foundation.

Recent publications which show how water works for respiratory compromise.

For many years, the pool was considered verboten for some respiratory compromised client. However, vertical (read: upright) exercise in water has been shown to be as safe -- or even safer -- than its land-based counterparts under many conditions.
Not only is pulmonary compromise no longer considered a contraindication, therapists are intentionally placing their respiratory patients in the pool. Why? Because immersion in graded pressurized environment (i.e., the pool) can provide a progressive pulmonary challenge unlike any other.

It's amazing to think of how the human body deals with pressure - even out of water. At sea level, there are 14.7 pounds of air (1 Atmosphere) pressing against every square inch of the human body. This means that before a person immerses even one toe, each inch on his body is pounded by 14.7 pounds of molecules. As divers put it, we should be crushed to death!

However, inside our bodies are molecules that push back with an equal - or even greater - force. For instance, every time your heart pumps, it creates a pressure on your arterial vessels of approximately 120 mm. Even when the heart rests, there remains an intrinsic outward pressure of approximately 80 mm. You may know this more commonly as blood pressure (the normative 120/80 used as the example).

So what happens when we enter the pool? The pressure pushing inward on our bodies increases as depth increases. Even the casual swimmer instinctively recognizes the power of pressure as ear pain whenever diving down to the bottom of the pool. Scuba divers experience this to a much greater extent, doubling the amount of pressure from 1 Atmosphere to 2 Atmospheres of pressure within the first 34 feet of a dive.

This hydrostatic pressure drives fluid to the large vessels of the lungs (creating a 60-percent increase in the work of breathing) and creates a mechanical barrier to ribcage expansion. All before the first exercise is performed. With the proper instruction, the resulting pressure gradient can be used to create an amazing therapeutic training effect. How?

Read the articles below and find out!


Agopian, A. J., Lupo, P. J., Canfield, M. a., & Mitchell, L. E. (2013). Swimming pool use and birth defect risk. American Adams, S., Hutton, S., Janszen, A., Rawson, R., Sisk, C., Stenger, S., … Adams, S., Hutton, S., Janszen, A., Rawson, R., Sisk, C., Stenger, S., & Ennis, B. (2016). Effects of an Individualized Aquatic Therapy Program on Respiratory Muscle Function in Adolescents with Muscular Dystrophy. Archives of Physical Medicine and Rehabilitation, 97(10), e130–e131. 

Albarello, M. J., Pelegrini, M. C. De, Mohr, F., Strassburger, S. Z., & Winkelmann, E. R. (2014). The hydrotherapy in respiratory function of the Down Syndrome bearer. Journal of the Health Sciences Institute, 32(3), 286–289. Retrieved from 

Anastasia, S., & Evangelia, K. (2016). The Effects of Aquatic Exercise on Functional Capacity and Health-related Quality of Life in Hemodialysis Patients. Journal of Clinical & Experimental Nephrology, 1(3), 1–6. Retrieved from

Andrade, A. (2014). Influence of Different Levels of Immersion in Water on the Pulmonary Function and Respiratory Muscle Pressure in Healthy Individuals: Observational Study. Physiotherapy Research International, 19(3), 140–146. Retrieved from

Atabek, H. Ç. (2017). The effects of swimming training on selected strength and respiratory function variables in pre-pubertal children. Original Article Journal of Athletic Performance and Nutrition, 4(1), 17–33. Retrieved from

Azizi, A., Mahdavinejad, R., Allah, A., Tizabi, T., Mazreno, A. B., Nodoushan, I. S., & Behdoust, M. R. (2012). The effect of 8 weeks specific corrective exercise in water and land. Sport Science, 5(2), 62–65.
Bove, A. A. (2016). Pulmonary Aspects of Exercise and Sports. Methodist DeBakey Cardiovascular Journal, 12(2), 93–7.

Chia, K. S., Wong, P. K., Faux, S., McLachlan, C. S., & Kotlyar, E. (2017). The Benefit of Exercise Training in Pulmonary Hypertension: a Clinical Review. Internal Medicine Journal, 47(4), 361–369.

Cuesta-Vargas, A. (2012). Aquatic Physiotherapy: A Much Used and Little Studied Treatment Modality. Journal of Novel Physiotherapy, 2(6), 120–121.

De Souto Araujo, Z. T., De Miranda Silva Nogueira, P. A., Cabral, E. E. A., De Paula Dos Santos, L., Da Silva, I. S., & Ferreira, G. M. H. (2012). Effectiveness of low-intensity aquatic exercise on COPD: A randomized clinical trial. Respiratory Medicine, 106(11), 1535–1543.

Dionne, A., Leone, M., Andrich, D., & Pérusse, L. (2017). Acute breathing patterns in healthy and heart disease participants during cycling at different levels of immersion. Respiratory Physiology & Neurobiology, 235, 1–7. Retrieved from

Felten-Barentsz, K. M., Haans, A. J. C., Slutsky, A. S., Heunks, L. M. A., & van der Hoeven, J. G. (2015). Feasibility and safety of hydrotherapy in critically ill ventilated patients. American Journal of Respiratory and Critical Care Medicine, 191(4), 476–7.

Guille, S. (2016). Aquatic Physiotherapy in the Inpatient Setting. Aquatic Physical Therapy Group.

Hildenbrand, K., Freson, T. S., Barbosa-, C., Nordio, S., Becker, B. E., & Miller, A. J. (2011). The Impact of an Aquatic Exercise Protocol on Physiologic Measures within an Asthmatic Population.pdf. International Journal of Aquatic Research and Education, 5, 378–388. Retrieved from

Jack, S., West, M., & Grocott, M. P. W. (2011). Perioperative exercise training in elderly subjects. Best Practice and Research: Clinical Anaesthesiology, 25(3), 461–472.

Jung, J. J. J., Chung, E. E., Kim, K., Lee, B.-H. H., & Lee, J. (2014). The effects of aquatic exercise on pulmonary function in patients with spinal cord injury. Journal of Physical Therapy Science, 26(5), 707–9.

Junyoul, C., Taeil, K., & Jungmin, P. (2017). Effects of Aquatic Training on the Job Related Physical Fitness and Pulmonary Function on Fire Fighters in Korea. International Journal of Crisis & Safety, 2, 1–8. Retrieved from

Martín-Valero, R., Cuesta-Vargas, A. I. I., & Labajos-Manzanares, M. (2011). Effectiveness of hydrotherapy in people with chronic obstructive pulmonary disease. Rehabilitacion, 45(4), 335–343.

Martin-valero, R., Cuesta-Vargas, A. I., & Labajos-Manzanares, M. T. (2012). Evidence-based review of hydrotherapy studies on chronic obstructive pulmonary disease patients. International Journal of Aquatic Research and Education, 6(3), 235–248. Retrieved from

Martín-Valero, R., Cuesta-Vargas, A. I., & Labajos-Manzanares, M. T. (2012). Types of physical exercise training for COPD patients. Chronic Obstructive Pulmonary Disease-Current Concepts and Practice. Retrieved from

McNamara J, R., Alison A, J., McKeough J, Z., McNamara, R. J., Alison, J. & McKeough, Z. J. (2011). Water-based exercise in chronic obstructive pulmonary disease. Physical Therapy Reviews, 16(1), 25–30.

McNamara, R. J., McKeough, Z. J., McKenzie, D. K., & Alison, J. A. (2012). Water-based exercise in COPD with physical co-morbidities: a randomised controlled trial. European Respiratory Journal, 41(6), 1284–1291.

McNamara, R. J., McKeough, Z. J., McKenzie, D. K., & Alison, J. A. (2013). Water-based exercise training for chronic obstructive pulmonary disease. The Cochrane Database of Systematic Reviews, 12, CD008290.

McNamara, R., McKeough, Z., McKenzie, D., & Alison, J. (2015). Acceptability of the aquatic environment for exercise training by people with chronic obstructive pulmonary disease with physical comorbidities: Additional results from. Physiotherapy, 101(2), 187–92. 

Nolasco, R., Moreira, L. D. F., Bocalini, D. S., Fronza, F. C. A. O., Marin, R. V., Lazaretti-Castro, M., … Lazaretti-Castro, M. (2016). Effects of vitamin D supplementation on pulmonary function in postmenopausal women following an aquatic exercise program. Archives of Endocrinology and Metabolism, Epub ahead of print.

Olamazadeh, S., Taghian, F., Barakatain, M., & Rahnama, N. (2014). Effects of aquatic exercises on selected physiological variables in panic disorder patients. Gazzetta Medica Italiana Archivio per Le Scienze Mediche, 173(4), 185–195.

Şas, S., Toprak Celeney, Ş., & Özer Kaya, D. (2016). The effects of balneotherapy on acute, process-related, and cumulative peripheral cardiac responses and pulmonary functions in patients with musculoskeletal disorders. Turkish Journal of Medicinal Sciences, 46(6), 1700–1706.

Tito, C., & Burton Hess, J. (2017). Aquatic Therapy for a Patient with Postural Orthostatic Tachycardia Syndrome: a Case Report Recommended Citation Aquatic Therapy for a Patient with Postural Orthostatic Tachycardia Syndrome: a Case Report. Internet Journal of Allied Health Sciences and Practice Jul, 15(3), 1–11. Retrieved from

Yamashina, Y., Yokoyama, H., Naghavi, N., Hirasawa, Y., Takeda, R., Ota, A., … Okazaki, K. (2016). Forced respiration during the deeper water immersion causes the greater inspiratory muscle fatigue in healthy young men. Journal of Physical Therapy Science, 28(2), 412–418.

Yang, H. (2015). Effects of Underwater Treadmill Gait Training on Gait, Balance, and Pulmonary Function in Stroke Patients. Daejeon University. Retrieved from