2. Begin with the easiest resistances by rotating both hubs where each #1 setting aligns with the bold arrow at the top of the Breather.

3. Inhale deeply and forcefully, approximately 2 to 3 seconds, feeling your stomach slightly expand. Pause approximately 1 second; then exhale forcefully within 3 to 4 seconds, feeling your stomach muscles contract. NOTE A: Secure the mouthpiece with your lips, not your teeth. Bitting down on the mouthpiece may cause undue jaw pressure or an inadequate seal. NOTE B: Swallow normally, and if necessary, remove the Breather from your mouth to prevent a build up of saliva in it. NOTE C: Holding the nose closed or using nose clips may cause an uncomfortable sensation in the sinuses or ear canals. However, it may initially be necessary to feel proper airflow into the lungs and to prevent nose breathing.
NOTE D: You should be hearing a strong, audible flow of air while using the Breather. Effective training requires a fairly intense level of effort, but not to the point of exhaustion. The vigorous sound of your breathing in and out is the audio feedback incentive to breathe deeply and correctly while inhaling and exhaling through your Breather.

4. Use the optional adaptor only as instructed. (See illustration on reverse side.) NOTE: If using supplemental oxygen, it is naturally entrained into the lungs; therefore, the adaptor is usually not necessary.

5. Choose one of the following training techniques best suited to you. NOTE: Technique One is the most commonly followed.

Technique One: Inhale and exhale approximately 6 - 10 times per minute as in step #3. (This is one set.) Relax 1⁄2 - one minute. Limit daily training the first week to 5 - 6 sets. Gradually increase training to
10 - 20 sets. NOTE A: Since resistance training of the respiratory muscles is compared to lifting arm or leg weights, this technique may be the easiest to follow as this is the most familiar style of resistance training. NOTE B: A slight variation of this step is to increase the time of each set up to 5 minutes per set, increasing to 4 - 6 sets daily. However, proceed cautiously because every breath may not be as productive as the standard one minute set.

Technique Two: Limit daily training the first week to 10 - 15 minutes, gradually increasing training to 20 - 30 minutes daily.

Technique Three: This technique is for secretion clearance and may be performed during or after training, or anytime you may feel congested. It incorporates the principle of positive expiratory pressure (PEP) therapy via exhalation resistance. Breathe 1 minute forcefully through the Breather. Perform 2 to 3 "huff cough" maneuvers as follows.
NOTE A: Hold bent arms close to sides - hands in loose fists position pulled toward chest. While inhaling deeply, raise elbows up and out; then, forcefully flap arms up and down as you exhale 2 to 3 smaller bursts of air creating a huffing sound. NOTE B: This form of coughing is more effective and less tiring. NOTE C: If still congested, use the Breather for more "one minute" intervals, allowing adequate time for huff coughing.

6. After maintaining your training level for approximately one week, increase the settings from #1 to #2. NOTE A: The hubs rotate independently from each other; your inhalation setting may be different than the exhalation setting. NOTE B: As inspiratory resistance is increased, inhalation should still be forcefully maintained taking 2 to 3 seconds to inhale; exhalation should still take 3 to 4 seconds. NOTE C: If you are puffing your checks during exhalation, the setting may be too high. Simply decrease to the previous setting. NOTE D: As you increase resistances, it may be necessary to resume training in less sets or amount of time, gradually increasing training.

7. Continue increasing the resistances by simply trying them.
NOTE A: Maximum resistance is #5 for inhalation and #4 for exhalation. NOTE B: For maximum benefit, it is often not necessary to train at maximum resistances, even for an athlete. NOTE C: If you have an incentive spirometer (IS), you may use it as a measuring aid to check your weekly progress. NOTE D: While IS encourages deep breathing, there is minimal inspiratory resistance and no exhalation resistance which is absolutely necessary for maximum therapy.

Additional Tips For Resistive Breathing Training

1. Try to maintain diaphragmatic breathing throughout your training. NOTE A: By placing one hand on the upper portion of the stomach in order to feel it expanding is a good way to detect proper breathing. NOTE B: A semi-reclined position is also helpful for proper breathing.

2. The training load (resistance) is easy to determine; it's the inspiratory resistance that, on a few but not all inspirations, causes an inward movement of the stomach - an observation easily felt by the user and seen by the eye. The stomach should be expanding during inspiration; if not, do not further increase resistance until your muscles become stronger.

3. When training is initially started, you may feel light-headed. This feeling is normal and will quickly subside. Some people also yawn or sigh during training due to the opening of smaller airways in the lungs.

4. Training may also trigger some coughing which may be caused from mucus in the airways. This is good for coughing helps to clear the lungs.

5. After surgery, the Breather may be used in place of incentive spirometry as often as every hour while awake, decreasing to four times daily. This helps to clear the airways and to expand the lungs.

6. Train on a daily basis for it usually takes 2 - 4 weeks to begin feeling results. Training is a lifetime commitment. Respiratory muscles, as all other muscles, lose strength should you stop training.

7. If you experience shortness of breath or that "panicking feeling," simply inhale and exhale comfortably through the Breather's easiest settings of numbers 1 and not forcefully as in training. Often it takes less than a minute for your breathing to become easier, under control. NOTE: The Breather is not a substitute for metered dose inhalers.

Optional Manometer Readings (Practitioner's Instructions)

1. Suggested resistance range goal values:
Inhalation Resistance: -5 to -30 cmH2O.
Exhalation Resistance: +5 to +30 cmH2O.
(Greater resistances may be attained; however, studies reveal im- provement within these ranges. Resistances may also increase as strength and endurance increases.)
2. Any small incremental inspiratory/expiratory manometer may be used. NOTE: If a manometer is not used, the training load (resistance) is easy to determine. See number 2 in Additional Tips above.

Caution: If you experience shortness of breath, increased heart rate, or any respiratory problems during or after training, notify your health care professional. Resume your training with his or her approval.