Episode 31: Stack-Stack-Stack Breathing

The goal is to learn , inspire and bring cardiopalm to the forefront of conversation . Thanks for joining me today and let's get after it . Hello , hello and welcome to another episode of Talking All Things Cardiopulm . I am your host , Dr . Rachele Burriesci . Before we dive in today , just a message from our sponsor , Jane .

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Jane's promise to you is to be transparent with their rates and unlimited support from a team that truly cares . So thank you again , jane , for your support and sponsorship . Before we get started today , I figured I'd give you some life updates , because today's just been a wild one and my week isn't my normal routine week .

Not everyone who's listening follows me on Instagram , so you might not see my everyday sort of routine , but we are not in it today . So if you've listened to my earlier podcast , I'm very traditional .

I think it's really important to carry on family traditions , and not even as a point , but there's this inside feeling that it needs to happen , and so something that my family has done since I was about five , six years old is make sauce , and so my mom is Austrian she's first generation Austrian and my dad is Sicilian .

My mom was always the outsider in the family because she wasn't Sicilian , and it was very important to marry someone who's Sicilian or marry someone who is Austrian . Same story repeats how many years later . Anyway , she learned how to speak their dialect , just to kind of be in the know .

But she was never privy to learning how to do things , because they didn't allow it to happen . But I was very close with my cousin , and my cousin's side of the family is Northern Italian , and I would go there every weekend , you know , just to hang out in Brooklyn with her family .

And I learned at five or six years old how to make sauce and run sauce day with my cousin's family , and then I came home and I helped my mom and dad recreate that episode . It was like five or six . So I just like think about these things and I'm like wow , like I've been doing this for a really long time and it's it's a team , it's a team process .

It is definitely not a solo show . You definitely need people to help run this day and I have integrated Nikki into this tradition . So when we were in Michigan , we were in an apartment and I was just so tired of doctoring canned puree and I can make a decent sauce with the puree . I don't buy jarred sauce .

Fun fact about me I've never in my entire life had Chef Boyardee or Raghu or Prego , like it's just , it's a no right and it's not because it's because I didn't need to ever . We always had fresh sauce and so the flavor of those canned processed sauces just I want nothing to do with it . I couldn't be completely honest with you .

So I learned how to make a decent puree out of the canned stuff , and I mean literally like I buy the tomato puree with nothing in it and then I doctor it and I have to let that thing cook for a good amount of time for it to have some love and feel in it . And one day I told Nikki I was like you know what I ? Just I miss my sauce .

We had been probably gone for a few years at that point and I was like we need to do this , like it's time . So it really wasn't that hard to find tomatoes and so when you make sauce you make it with rum and tomatoes . Other people may do other things , but that's like standard and they have to be like ripe , ready to go , bright red , not over , right .

You don't want them to be rotten and if they're under , like your sauce isn't going to have flavor . So we happened to come across like a farm stand in Michigan and they had buckets of tomatoes and so like we figured out what a bushel would be like and we were like all right , we're doing this . It was a hot mess Academy .

Like don't , let me try to fool you on this . This episode I would like every wish in your life that you could be recording in the background and then rewatch it . This was one of those episodes that I would definitely want to rewatch .

So we didn't have a small apartment but we didn't have a big apartment and our kitchen was a galley kitchen with a tiny stove against a wall , so I mean for burner , but , like you know , apartment style size and no outside water , which is a big deal .

And so I had to figure out how to clean the tomatoes in this apartment and so , like there's a whole process , right , like you clean the tomatoes , you boil the tomatoes , then you press the sauce or peel it if you do peel tomatoes and then you jar it , and then you have to boil the jars , and so that all takes a lot of time .

And when you're doing it on a stove top with four burners , you really could only get two pots at best , and those pots aren't significant in size . So that day we had we were cleaning tomatoes in the bathtub .

We had a second bathroom in that apartment and it had a tub , which we obviously never used in this place , but we used it for tomato day , and so we were like washing tomatoes in the bathtub , in the sink , we had tomatoes everywhere , and then we were boiling jars until three o'clock in the morning , and then we went to work the next day and what I'm going

to say next is sawstay is no joke . It is not for the fickle . Like you're in it and you're in it for good , and the next day you're going to feel like absolute shit . Like I'm not even going to lie to you . You need a recovery day . So now we plan a little bit better . There is no working .

So with up to six , two , one and three in this big box Ready the day after sauce day , you need legit recovery because it's an all day process . So when we moved to Kansas City , I was like , okay , like we got to do this the right way . Now we need big girl equipment . And we moved in 2017 . We didn't make sauce until 2020 .

And I still had some leftover . I must have made it like 2016 or something . So like it held us over for a bit of time and then 2020 happened and I was like , all right , we're out of sauce again . I'm tired of the canned stuff . Like we got to do this .

So you know , like COVID was a hot mess with getting goods and I was like , well , we're not doing anything anyway , so let's do sauce day . And so we started looking for , like all the equipment my family upgraded over the years , right , like we used to do it on a stove top , we used to do it in the basement it was .

We used to have a hand crank press , like I was five years old pressing tomatoes , just like you know , circling through for hours on end and the basement looked like a war scene every time . And it was a . It just takes so long because you don't have enough space and your equipment's not big enough .

So anyway , we finally got the equipment , and so I am literally Googling cauldron size pots I mean all of anything to get me a big pot . Couldn't find it , couldn't find it . Finally , king Cooker to the rescue . We got two giant cauldron pots . They're still not as big as my parents have , but good enough , and they're outside .

So they need outside burners and it's just a better experience because you don't have to then clean the walls of your house when you're done . Great , got all the equipment going . I did not realize how difficult it was to find tomatoes .

So part of it was COVID and then part of it was Kansas is in like zone eight , eight , nine I believe , and apparently Roma's isn't like that big here , so getting bushels isn't a thing . And everyone was like , oh , I have a whole bunch of Roma's , you want some ? I'm like , okay , I really appreciate the offer , but I'm talking bushels .

A bushel is a 50 pound crate . I'm gonna do 10 bushels , so typically in the Midwest they sell them by the half bushel . So I'm like looking for 18 to 20 boxes of tomatoes at this point . And restaurant Depot changed their policy during COVID to allow outside non-members to buy , and the day that I went to buy tomatoes they retracted that .

So I'm standing there . I'm like I just need tomatoes , let me buy tomatoes , I'll pay cash like whatever you need . I think they sold me two boxes . They would not sell me 20 . So then I was like on the hunt . I was like this isn't gonna happen , hot mess .

So I finally found this place in city market , small little grocery store and the guy was like , yeah , I can help you out . So I got my tomatoes . They weren't great . They were under . They were a little orange . They were . My sauce was not as red as it normally was . Whatever , it lasted me about two and a half years . So here we are , 2023 .

I'm like we're out of sauce . I can't do it anymore , let's go . So now I have a tomato guy and I called this week to ask him does he have tomatoes yet ? So here's the thing like Roma has usually come out last week in August , first two weeks of September , it just depends on the growing season .

Now I have a garden so I'm like watching the tomatoes coming out . Now I'm like all right , it's this week or next week . This week works better because if we do sauce on Thursday we have a day off on Friday . If we do it next week we can do it . But it's gonna be a hot mess , mostly for Nikki on Thursday . So I call the guy . He looks .

He's like I got 30 . I got 30 boxes . I should have enough for you . But he said but they're ripe . I was like I want ripe , like gamey last year . Last time was like orange , so I'm excited . But I asked him I'm like it's not over , right ? He's like no , no , it's not over , they're just really ripe .

They're ready to go , which is great because I'm gonna make them like tomorrow . So I called him on Tuesday . I'm gonna pick him up on Wednesday . Thursday they get cooked .

There's not a big window on this game , so I show up today Sorry , this is long winded , but this is like just happened and it's just a you know sequence of events where I feel like I'm on the Truman show and I've had this feeling many times in my life where I just feel like at any moment someone's gonna pop out and just be like gotcha Gonna be totally

pumped . No one ever pops out . I don't know what's happening , but no one ever pops out . So I show up , the girl is behind the counter , tells me my guy isn't there , but they knew I was coming . So she's like no problem . She tells her husband go get me 20 boxes . Great , meet me outside , pull the car around . It's wonderful .

I get the card to the pull-up thing . This guy comes out with this palette . I think there's like 50 boxes on this palette . I'm like what is happening ? This doesn't look the same as last year in the sense of like how many ? And he basically told me whatever you want is yours . And I was like oh .

So she did give me a good price and I asked her you know , point blank , are they over ? Are they bad ? She's like no , they're not bad , mufa . So I'm gonna teach you a word . Today is wordy Wednesday . Mufa is , I think , slang , italian or Sicilian . That means molded . I look at the top 10 and they all have white fuzzy . I'm like God , shit .

So I'm like I don't know man , like what am I doing with this ? I'm not putting all of these boxes in like I'll probably get close , but it's leaking it , they're like bursting . I had my , you know , so he's . I said can I get a box ? And like pick through it . So he did . He got me some crates and he picked with me for about almost an hour I think .

And I mean I'm like punching holes through these tomatoes . I think I got close to my number , but the whole time I'm thinking at what point does this person pop out and be like just kidding , here's your , here's your actual 18 boxes of tomatoes Person ever popped up , got the tomatoes loaded , got them in the house . Their intent , control , environment .

And now we pray , we put all the good juju in the universe that they last until tomorrow , because I don't know what I'm going to get . So please give me sauce juju . I'm definitely going to need it this year . All right , I know that was a long story , but I'm in sauce world and this is like you know , it's kind of like the garden right .

When you want a certain outcome , you have to take responsibility for the process . And this process is no joke . And I have people all the time ask me like , oh , how do you make this ? Like teach me how to make it . And I'm like , listen , I'm going to make a whole bunch . If you want some , I'll give you a couple of jars .

No , no , no , I want to learn , I get it and I'm happy to teach , but this is like an undertaking . Could you do it on a smaller level ? Yes , but even on a smaller level it's going to be a big ordeal , a big mess and if you're not using the right equipment it's just going to take you all day . So little little . You know what

I ? What I basically have to say from the process is , if you expect that outcome , enjoy the process or at least take the process head on . Take the process head on because you know it's a lot of steps . You got to do it in a systematic way and you have to put in the work and I think that's some .

That's just like an important wrap around to everything in life and PT and school , in business . You want this outcome , you want to pass the test . You want to do great on the practical . You want to nail your a fill . You want to know , you want to be an expert . You want to get your certification . You want to X , y , z .

You want to be a successful business person . You want an outcome . But , boy , and I'm going to tell you from a business perspective , you better be ready to put on your big girl and boy pants and get after it , because sometimes you really have to dig in and you have to take the things that just don't go your way . And you got to make it work anyway .

I could have turned around and said you know what these tomatoes are bad , I'm done , I'm out of here and maybe that would have been the right decision and try again next week . But I'm ready now and if I try again next week it's just going to delay the process and you know what ? Next week they might be under .

And so this is what I was dealt and I'm diving in and I'm going to deal with it and I'm going to take it with whatever comes my way . And so here we are , we're ready to go for saw state tomorrow . More to come on that last little personal update . My wife does listen to the podcast , I think .

Still I don't know we're so many and she may have given up , but if she is listening , this weekend is our sixth wedding anniversary , so we got married September 9th 2017 . We had a ton of huge life changes that year and so we've been here in Kansas married for six years . So she is my partner in crime .

She puts up with all of my crazy Italian traditions , my Thanksgiving traditions , all the DIY projects I can throw at her , and she does it with grace and skill and calm , and I love her dearly . So happy anniversary , love . All right . So today we're actually going to talk about something . If you're still with me , here we go Stacked .

Breathing is a technique I want to talk about because I don't think a lot of people use this technique , but it can be very impactful for certain populations and I'm also going to be honest with you . Sometimes it's too tricky for patients to use , and so you might try it and be like you know what that's not working and you try something different .

Actually just happened to me recently try this technique . She was kind of like the perfect person to try it with . She just was having a really hard time coordinating and she just couldn't get the groove .

Sometimes you have to take a break , sometimes you have to walk away from it , sometimes you have to just throw it to the wayside and sometimes you have to come back and sometimes when you come back to it , you get that impact that you're trying to make . So what is stacked breathing ?

Stacked breathing is a technique that you use to basically help your patient increase title volume in a stacked way , meaning you're going to take consecutive breaths without letting go to build your title volume .

So this technique from like a testing perspective so students listen up If you were to ask for , like the quintessential patient to use stacked breathing with , you're going to use it with your patients who are post-surgery For instance , your cardiothoracic , your sternotomies , your thoracotomies , your clam shells and your abdominal incisions because these patients are painful

and when you have pain you tend to hypoventilate and when you hypoventilate you end up with that electasis and all sorts of issues . So it's super important to get these patients to breathe , but sometimes you need buying it and stacked breathing is a great technique to get you there . So it's multi-fold , okay .

So I'm going to just go through how I teach my patients how to do stacked breathing and then we'll kind of extrapolate on other patients we can use it with and all the good stuff . So stacked breathing typically is three breaths stacked without letting go . So you have to take three consecutive breaths without letting go . But you build as you do it .

So the way I teach my patients is I want you to breathe in through your nose and take a small breath , medium breath , large breath without letting go , and then exhale . And for most patients I don't cue the exhale . It's relaxed , it's going to happen anyway . The goal for this patient is to get a bigger inhale . So the exhale isn't your priority .

The inhale is Now . When you have a patient with a sternotomy and they have at electasis , your first initial thought may be to just do an inspiratory hold . In theory that would work great . But if your patient goes in hard and fast and tries to take a deep breath in and it hurts , you probably just lost some trust .

So stacked breathing is that technique that helps you kind of bridge the gap . It helps build trust and helps you accomplish a bigger tidal volume in a consecutive sort of way . I do have to say that I've noticed that my patients that have chest tubes have a really hard time with both stacked breathing or inspiratory holds in general .

So don't expect big breaths per stack . I usually use hand gestures and I say the words and give them the hand gestures and show them at the same time . The caveat is , if I'm talking , I can't hold in between each breath .

So the most important thing about a stacked breathing technique is that you're actually holding between each step up Okay , so you're progressively getting bigger and bigger . So I always use the hand gestures .

I have put two hands together and I say small , medium , large , and so my hands are moving out gradually and I have them hold at the top and then exhale , and I don't give any cues on exhales . As I've progressed in my career and I've said this before I do a lot of combo techniques .

Now , from a student perspective , I don't like to do that because it's just too confusing . Stacked breathing is stacked breathing . Persilve breathing is persilve breathing . Inspiratory holds is inspiratory holds .

When you get out in your career and you're working with a patient who has COPD and a sternotomy and you want to pair and marry those things together , please do From a test perspective , from a student perspective , from a learning perspective . Even my mentees that are studying for CCS .

I keep it separate because they're separate techniques and you don't want to muddy the waters when you're trying to answer questions about a specific thing . So stacked breathing gets you to a larger tidal volume in a progressive kind of way and it takes the fear out of it . And sometimes it's small , small , small , and that's okay .

The goal is for the patient to build confidence , build the size of the breath and coordinate so you can use stacked breathing for patients that have uncoordinated breathing patterns .

And I did this with a recent patient and she just had a really hard time wait for it to coordinate it because it's multi-step and the hardest part for a lot of patients is the hold in between the breaths . So essentially I got her to breathe , breathe , breathe and then she exhaled . It wasn't exactly what I wanted .

We walked away from it for a while and then came back and the second go around . She did much better . So sometimes you just have to be patient , give a different cue , give a different hand gesture .

Maybe tactile cues can be better and if they're getting frustrated , back off for a minute because that's not going to help the anxiety , the breathing pattern , all of that . And I told her because she was short of breath . She had a really small tidal volume .

We were trying to increase breath size a little bit and I said you know , this is the first time you've ever done this in your whole life and you're 85 . So it's a new skill . It's going to take some time to learn it , and so remember that right . These patients have never heard these instructions before .

They may be medicated , they may be coming out of anesthesia , they may be in pain , they're on pain meds . You know , the list is endless . Take your time , don't rush it . Try different cues . Also , feel what's right for you . I always tell my students , I tell my mentees , how I say something is not the only way .

I always tell you how I do it so that you can repeat it and then put in your own words , because how I say something sure as hell might not be how you say it , so make sure to make it your own . The other population that this is really good for are patients that have pain and specifically could be someone who has rib fractures .

So patients with rib fractures . Really , there's actually a number of things you can do with them . Bestacked breathing is one of them , and the reason is is because you're not having them breathe aggressively in to get the large title volume which they need .

You're doing it incrementally to get them there and so they're eventually going to get to the same amount of title volume or inspiratory reserve volume . But they're not going to do it fast and it's going to be a step increase and so therefore it can be more tolerable .

Rib fractures are difficult I haven't had one but they're painful , right From what I am seeing from my patient population . That hurts and so you're asking them to inhale , which is literally gonna put pressure and movement potentially at that rib fracture . So tread lightly , start with stacked and if they can only get two of three breaths , start there . Right .

Textbook says three patient could do two . It doesn't mean it's wrong , it just means they're not there yet . So back off , do two and then eventually you might have to really make that first breath really small to then get a small second breath and then maybe a slightly larger third breath . Two medium sized breaths isn't bad either , right Like ?

The objective is the same , the end goal is the same . So don't get hung up on definitions and specifics . It matters for testing if they were to ask you like patient performs a breathing exercise where they increase their breath with three consecutive breaths and a pass of exhale . That would be stacked breathing . So post-op pain , rib pain .

The other big one is atelectasis , so very similar to an inspiratory hold . It's going to create that hold to pop open the aviolite . So they worked very similarly as an inspiratory hold with the gradual increase in size of breath . So atelectasis , being on the list , can maybe get a bigger inhale than if you just take one in . Everybody's different .

You have to see what works for them . If stacked breathing is messing them up , sometimes I just get rid of it . I'll try an inspiratory hold , small or medium , and then I'll have them increase from there . Sometimes I'll start with two stacks , sometimes they get to three but they're really small .

You just gotta kind of play with it and see what your patient does right , if it makes them more anxious back off , if it builds the confidence and you can see the confidence build in your patient , try it again , try to increase those incremental steps until they're where you need them to be . The last one is an ineffective cough .

So both inspiratory hold and stacked breathing are very beneficial in using as an exercise , essentially to train the cough . So when we cough we have four phases of that cough . We have inhale , glottoclosure , abdominal contraction and expulsion , and inspiratory hold or stacked breathing hits two to three of those techniques Usually two depends on what you're doing .

On exhale , the cool thing about the stacked breathing is the coordination and a lot of times patients who have difficulty coughing or a weak cough really just have poor coordination of the whole system . So stacked breathing works on phase one , helps you increase size of your inhale .

It also works on glottoclosure because you're practicing hold , hold , hold , hold at the top exhale , unless you threw in something else at the expulsion part . That's as far as it's gonna help train with your cough . But that coordination piece is so clutch for so many patients , especially our patients with neurologic disorder .

They tend to have weakness , decreased inhale size and poor coordination and when you have poor coordination this is a great technique to train that coordination . Inhale , hold , cough it's actually interesting to just ask people to cough Like it's not something that you typically do on command .

You do it because you have to cough and a lot of patients have a hard time coughing on command and sometimes that's why right Like they're like I can't do it just because you told me to do it and that's fair . But then there , when you're watching it happen , what's that word ? When you're watching it happen , what is that word I want to say ?

Instinctually , you fill in the blank for me . When they cough just because they have to , there's a word that I want that's lost somewhere up in the brain and You're watching it and they're losing power because they don't have the coordination . That's when you have to tune in to well , how can we get them to coordinate ?

And so I'm back to the same two breathing exercises stacked breathing or or Inspiratory homes . The last Population that you could potentially use this with is restrictive lung disease . But this is a big caveat . With restrictive lung disease , you have decreased title line to decrease total lung capacity . You have lesser ability to expand the lungs .

Stacked breathing is nice because you can try to get them to push that limit and then the exhale is going to happen to whatever they did on inhale , which is really nice . But it depends on what is causing the restrictive lung disease and it also depends on that person . Sometimes that stacked breath may make them more anxious , maybe it doesn't .

So just another population to throw in there for stacked breathing . I have used it quite a few times , some patients really like it and you can actually get a bit more , and some patients it just doesn't work . So it's not , it's not a definite , but it's definitely give it a try and see what happens .

So to recap , stacked breathing is a breathing exercise where you're taking three inhales consecutively without letting go . Exhale is passive . We're going to typically use this with our post-op Painful patients or just your post-op patient period . So cardiothoracic abdominal surgeries Really do well with this technique .

Your patients that have pain for whatever reason , in the chest region a common example is rib fracture your patients that have atelectasis and they're just having a really hard time increasing tidal volume . Stacked breathing is a great technique . And then , if we're helping to train the cough , it has Multi-purpose . It's going to hit the phase one , increasing inhale .

It's going to train glottal closure that hold multiple times in that one sequence and it's going to help with coordination , and coordination is some coordination to sometimes the key to having a more successful cough . And then , lastly , I'm going to add this one on is restrictive lung disease .

This can , especially if your restrictive lung disease is musculoskeletal in nature , like your very kyphotic patients , patients with scoliosis , same thing , rib fracture it can really help them get there and sort of Create a stretching effect for your patients that have fibrosis or scarring . It might help , but it also might make them more anxious .

So you're just going to have to tread lightly and try it out . If they can only get two stacked breaths , good , then work from there and then increase each stack to eventually get one big one . So the progression essentially gets you to an inspiratory hold .

So very similar in how they can help really pop open the aviolai , increased tidal volume , train glottal closure , and so super effective with our painful patients . All right , that's a quick one for you . Today I am going to go back and get soft , stay rolling and if you are following me on Instagram , you'll see all the pictures and videos .

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I hope you all have a wonderful rest of your day and whatever you have to do , I get after it . Thank you , thank you , thank you .