Aquatic Health Benefits Bulletin

NSPF provides a monthly Aquatic Health Benefits Bulletin (AHBB), each focusing on a different topic area: athletes and non-impaired, cardiopulmonary & systemic, neurological & cognitive musculoskeletal, pediatric, and women's health. The monthly posts include 300-500 vignettes written in laymen's terms and the corresponding scientific references. The bibliography is organized by a certain topic area with links to publications that are available online. The AHBB is a great resource for the pool and spa industry influencers who want to help build demand for pools, spas, and aquatic facilities by promoting the benefits of water immersion and activity. It is also a perfect way for aquatic leaders to help promote healthier living and reduce drownings.


November 2018: Aquatics & Respiratory Compromise



Content courtesy of the National Swimming Pool Foundation


Immersion in water creates a dramatic cascade of effects on the human body. The rib cage is compressed inward, the diaphragm is shoved inward and upward, and the blood that was pooling down in the legs resettles northward – into the chest – making for a huge change in the work of respiration. In fact, immersion in neck-deep water can result in a 60% increase in the work of breathing – and this is all before exercising a single muscle. 

Even healthy people have a drop in their vital capacity and a huge increase in airway resistance when standing in a pool. Imagine the patient with pulmonary or respiratory compromise! Surely, you would think that the pool is an intolerable environment for exercise for patients with emphysema or asthma. 

Not true!

Despite the massive changes which occur with immersion, research has shown that there is no significant increase in acute respiratory attacks or other negative reactions with immersion. What’s more, when patients with respiratory difficulties exercise in water, wonderful things can occur.

During immersion, the muscles which allow patients to breathe are challenged in a nearly perfect way. Some researchers think that one of the reasons this is possible is that – with immersion – patients receive an effect somewhat similar to the “lean forward” posture that many people with respiratory illnesses assume. Patients who feel that they cannot catch their breath need only step into shallower water for this discomfort to be alleviated. In fact, it is possible to find the perfect “sweet spot” in the pool which permits a challenging respiratory program without distress. 

Of course, there is always risk with aquatic exercise. Individuals who exercise in an indoor pool need to make sure that the air quality is good (a bad sign? eye irritation, coughing, a strong “bleach” smell). Respiratory inhalers need to be brought onto the pool deck, in case they are needed in a hurry. It is even possible for people to use their oxygen in the pool; the oxygen tanks only need to be secured and the tubing long enough to permit freedom. There are floats made for portable oxygen tanks for individuals who wish to walk or swim laps, unencumbered by long swaths of tubing. 

The jury remains out on whether water-based exercise is more effective than land-based exercise, but it appears to be at least as effective and, more importantly, feasible and safe. It is indeed a “sweet spot” for the patient who cannot – or will not – exercise on land.


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{_}jul-set/V32{_}n3{_}2014{_}p286a289.pdf

Alberton, C., & Pinto, S. (2014). Maximal and Ventilatory Thresholds Cardiorespiratory Responses to Three Water Aerobic Exercises Compared With Treadmill on Land. The Journal of Strength and Conditioning Research, Retrieved from

Alberton, C. L. C., Pinto, S. S. S., Gorski, T., Antunes, A. H., Finatto, P., Cadore, E. L., … Kruel, L. F. M. (2016). Rating of perceived exertion in maximal incremental tests during head-out water-based aerobic exercises. Journal of Sports Sciences, 13(18), 1–8.

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

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

Felcar, J., Probst, V., de Carvalho, D., Merli, M. F., Mesquita, R., Vidotto, L. S., & Pitta, F. (2018). Effects of exercise training in water and on land in patients with COPD: a randomised clinical trial. Physiotherapy, Epub ahead of print. 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.

Felten-Barentsz, K., Oorsouw, R. van, … A. H.-J. of C., & 2018, undefined. (2018). Patient views regarding the impact of hydrotherapy on critically ill ventilated patients: A qualitative exploration study. Elsevier. Retrieved from

Freitas, L., Araujo, M., & Ferreira, J. (2018). Effects of cardio respiratory heated water-based training in an adult after heart transplantation. Int Phys Med Rehab J, 3(2), 167–173.

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. International Journal of Aquatic Research and Education, 5(4), 378–388. Retrieved from

Jakaitis, F., dos Santos, D. G., Abrantes, C. V, Gusman, S., & Bifulco, S. C. (2012). Role of physical therapy of aquatic fitness in stroke patients. Revista Neurociencias, 20(2), 204–209. Retrieved from 20 02/651 original.pdf\n

Jarad, N. A., Powell, T., & Smith, E. (2010). Evaluation of a novel sputum clearance technique--hydro-acoustic therapy (HAT) in adult patients with cystic fibrosis: a feasibility study. Chronic Respiratory Disease, 7(4), 217–227. article.

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

Kumar, M., & Thompson, P. D. (2018). A literature review of immersion pulmonary edema. The Physician and Sportsmedicine, 1–4.

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.

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.

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

McNamara, R. J., Alison, J. A., McKenzie, D. K., & McKeough, Z. J. (2010). Water-based exercise improves exercise capacity in people with COPD with physical co-morbid conditions. Respirology, 15, A24--ato. Retrieved from

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. R., McKeough, Z. J. Z. Z. J., McKenzie, D. K. D. D. K., & Alison, J. a. 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.

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.

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.

Ozdemir, E. P., Solak, O., Fidan, F., Demirdal, U. S., Evcik, D., Unlu, M., & Kavuncu, V. (2010). The Effect of Water-Based Pulmonary Rehabilitation on Anxiety and Quality of Life in Chronic Pulmonary Obstructive Disease Patients. Turkiye Klinikleri Tip Bilimleri Dergisi, 30(3), 880–887. article.

Porter, K. M., Hoglund, C. A., & Henry, S. (2018). The Difference in Efficiency and Pulmonary Function While Performing Cycle Ergometry on Land and in Water. International Journal of Undergraduate Research and Creative Activities, 10(10), 1.

Sackett, J. R., Schlader, Z. J., Cruz, C., Hostler, D., & Johnson, B. D. (2018). The effect of water immersion and acute hypercapnia on ventilatory sensitivity and cerebrovascular reactivity. Physiological Reports, 6(20), e13901.

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.

Seys, S., Feyen, L., & Keirsbilck, S. (2015). An outbreak of swimming-pool related respiratory symptoms: An elusive source of trichloramine in a municipal indoor swimming pool. International Journal of Hygiene and Environmental Health, 218(4), pp. 386-391. Retrieved from

Shead D, Aswegen HV. Hydrotherapy in the management of chronic obstructive pulmonary disease: a qualitative systematic review. Physical Therapy Reviews. 2012 Oct 1;17(5):271-83. Retrieved from

Shei, R.-J. (2018). Respiratory Muscle Training and Aquatic Sports Performance. Journal of Sports Science and Medicine, pp. 161–162. Retrieved from

Smith, R., Ormerod, J., Sabharwal, N., & Kipps, C. (2018). Swimming-induced pulmonary edema: current perspectives. Open Access Journal of Sports Medicine, Volume 9, 131–137.

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

Vasant, V., & Shetty, P. (2018). Comparative Study on Naturopathic Treatments Cold and Hot Spinal Bath on Autonomic and Respiratory Variables in Healthy Volunteers. IAETSD Journal for Advanced Research in Applied Sciences, 5(7), 72–84. Retrieved from

Wegner, S., Thomas, P., & James, C. (2017). Hydrotherapy for the long term ventilated patient: A case study and implications for practice. Australian Critical Care, Epub ahead of print.

Yamashina, Y., & Yokoyama, H. (2015). Treadmill walking in water induces greater respiratory muscle fatigue than treadmill walking on land in healthy young men. The Journal of Physiological Sciences, 66(3), pp 257–264. 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