Table 2:

Themes and subthemes

Theme 1: Process of learning self-regulated breathing
Subtheme	Quotes
Real-time Biofeedback is a Powerful Learning Tool: There’s Something Very Immediate About This Breathing	I could look at the graph and the graph would tell me how I’m doing, and how far apart the waves are. The further apart and the higher they were, the more successful I was in doing the breathing. And when I first started, the graph only went up half-way. And most of the time, after I learned different breathing techniques, it would almost come up to the top….I probably would consider that the most important part of the intervention. How it had this even flow – it was rewarding for me to be able to see that. It just gave me this visual of what I am capable of doing – deep and high – being able to use my airways. The airways now make sense to me …. I felt this sense of relief … it just made me think as I’m looking at those numbers that I am feeling in control. You’re seeing the screen and you see the breathing level at the same time.… Those lines help to control your breathing to a certain level as you see the needle goes up and down and keep a steady pattern and an even pattern.
Motivational Interviewing: A Process of Discovering It For Myself	She created situations where I would discover what I was doing myself rather than pointing it out. I was really rediscovering it in myself…. As a teacher, she was very thoughtful, very analytical, very cautious about what she would say, and non-judgmental. There was some real personal touch there, real personal care, and very encouraging. There was a lot of sort of personal attention… in terms of somebody actually mapping your progress and knowing you as a patient… Much of the wellness factor should be about positivity and encouragement, especially with breathing for some reason…. It’s just so important to hear positive words of encouragement. She would constantly check in on how I was feeling or what I thought about something.
Home Program and mHealth: Easy to Do and Takes a While to Integrate	It’s a matter of unlearning bad habits. So, if I normally did shallow breathing – which apparently, I did – it takes a while to integrate. When I’m walking and I catch myself, if my tongue isn’t in the right position, I still remind myself because it takes a little while to get used to doing it right. And it’s easy enough for somebody, once the sessions are over, to follow through on. You know, it doesn’t mean that once you end the sessions, that’s the end of the exercises. There’s enough for you to take home with you and follow them at home… No matter where you are you can put the exercises into effect because they’re nothing strenuous; there’s no equipment that you need. It is still a work in progress. My numbers were a little higher, but my biggest problem is getting it together when I exert. I have to pace myself better, maybe go slower, and remember, but sometimes it gets all thrown out the window when I am walking. I am trying to focus on what I have learned and incorporate it into my daily life but that takes some doing.
Theme 2: Mechanisms of a mind-body intervention
Interoception of breathing: A New Way of Being	Sometimes when I get upset, I notice that my breathing gets agitated again. But I noticed I get upset if I get nervous. I start getting palpitations and, sometimes the wheezing acts up. … But with the exercises, it helps take your mind off of things. It’s helped me a lot with my anxiety. The breathing exercises and the pursed breathing have helped me quite a bit…. It made me aware of when I’m rushing, and I stop and say take a deep breath and why am I rushing? It’s just not necessary. It helped me to slow down with all my routines during the day. Every once in a while, I’ll catch myself. If I’m walking upstairs, I’ll remind myself to take a breath before I start (to exhale as I’m going up). It’s almost like standing outside of yourself and watching yourself do it, because you’re creating new habits and trying to coordinate everything.
Cognitive Re-appraisal: A Fresh Outlook on My Life – It’s Become Manageable	I was really thinking like I was doomed in the beginning. This has given me a fresh outlook on my life…. We think these things and they’re not correct…. I was really thinking that life was basically over for me. I wasn’t breathing properly. I was holding in and holding back. I don’t know why I thought I was saving energy or oxygen by the shallow breathing. I thought if I just didn’t move around too much, if I didn’t breathe too hard, that would be better for me… so I can live longer. And that’s just not the case…. I’m able to walk. I wasn’t walking before. I wasn’t thinking about walking. I was like, oh no, that’s going to take too much energy. I better not do that. Let me just go to work and come home and just sit down, and not move around. And then I was avoiding stairs. I’m not avoiding stairs. I’m not avoiding walking. I’m not avoiding anything. I’m planning to travel. You know these are things I wasn’t planning on before CALM Breathing. [I gained] some sense of confidence and positivity, optimism that I can manage, that this is going to be manageable with these techniques that I have now. But it’s been a real turning point for me and before I wasn’t sure that I could manage. It’s become manageable. I think being in touch with your body and being in touch with your breathing is really so important to prevent the downslide. It is psychosomatic and much more. Getting mind in touch with body, I totally believe in that. I just feel it was a gift. …. I mean, it’s kind of emotional and a very doable realization that I have the power to somewhat heal myself through breathing and breathing exercises that I was not aware that would empower me so much…. What I mean by that is it changed my thinking about COPD and me having this disease. I didn’t have to open my mouth and knew I could breathe my way out of this without opening my mouth, and I did. You know I used to go into a panic breathing before and I am sure I would gasp. But I could control it, I could actually control it.
Motivation: Understanding the Benefit	What motivated me would be doing certain exercises, and then while I’m doing them, I’m looking at the graph and seeing how it improved. So that was an incentive for me to go home and do it because I know that it’s helping. …The graph – the biofeedback – was really motivating. I don’t miss a day even if it’s just walking and humming. …. I wanted to help myself because I wasn’t finding help any other way and that’s what prompted me. That was very important and for me and it turned out very well… I was willing to take the challenge. Rather than just say, oh God, I’m too tired to do anything, too short of breath, I’ll do the exercise. That’s a consciousness. When I’m in the middle of being engaged in something and I’m losing the ability to breathe at a maximum rate, that I know I can reach, I will use those exercises and, I say go from 92 to 95. It’ll go up definitively and I’ll feel better…. I’m very proud of myself. It was important for me to continue the exercises even when I wasn’t in the sessions. And it’s helped…like I said, it’s helped with the breathing; it’s helped mentally…. I put my best foot forward to do this program. I found within a short period of time that, mentally and physically, the wheezing – the breathing – was getting better. I really give it my full concentration because I can really see a difference right now.
Optimized Breathing Biomechanics and Physiology: It’s How I Use the Breath I Have– I’m Breathing Slower and Calmer	Because when you’re breathing up around your neck rather than with your lungs, my breathing becomes very rapid that way. And the other problem was slowing my breathing down…. It made me aware that I can do activities … in a calmer manner, with slower breathing. My particular problem was shallow breathing and breathing from the top of my chest rather than deep breathing…. Just being aware of that, and trying to breathe from the diaphragm, like a singer, and widen my ribs was essential. I like all the exercises but especially the one I breathe in with my nose and breathe out with my mouth because it makes me relax. I mean when I am short of breath and I’m working, I do these five or six times, and I feel better. Yeah, I used to walk with my mouth open all the time now I consciously don’t. I started to learn how to breathe out. My tongue automatically went to the roof of my mouth, behind the top of my teeth, which is obviously where it is supposed to go. I didn’t have a problem with that which maybe is what made it so much easier for me and I just fell into it. At first, I could only do 20–30 but it just got so much easier…. I don’t use the chest anymore; I use the belly all the time. I never really thought about how I breathed. I guess I didn’t realize I was shallow breathing, and I don’t do that anymore. Or if I do, I catch myself doing it and I stop. … And I use the techniques when I’m walking now…and I get into a rhythm, which I never really did before. It does work, it’s calming.
Theme 3: Clinical and implementation outcomes
Beyond surviving: Improved Well-Being and Resilience: It just helped me mentally, spiritually, and physically	[When] I get stressed out, I go back to this…. It doesn’t bother me anymore.…. Sometimes you’re outside and you get stuck while you’re walking and have one of these episodes, like the neck breathing. I was outside the other day and that caught me, and I remembered one of the techniques and I took a knee, and I did it for a few seconds, maybe 20–30 seconds, and my breathing came back. I was okay…. Struggling with breathing creates stress, stress is another added on, so doing these exercises you can eliminate that stress and eliminate the shortness of breath and finish doing what you’re doing. During the 8 sessions for 4 weeks, I felt mentally that I didn’t dwell upon what had happened in the past and I was very stable in my mood, mentally and physically. I didn’t dwell on the issue that brought me to CALM breathing and I thought that was very good. It was something that I needed….. [My traumatic event] was kind of on my mind. But with the sessions I found it relieved me mentally of continuously thinking and even now mentally I’m not continuously thinking about the episode that occurred 5 years ago [when] I needed to be hospitalized. ….I’m less stressed out. Mainly I felt better both physically and also psychologically, just by being engaged in something. So, I wasn’t thinking about how alone I feel. I wasn’t thinking about anything except doing the exercise and that engagement.
Less exertional dyspnea and anxiety, and greater autonomy: It’s less of an effort breath-wise and I can recover my breath faster	Because it is increasing my awareness of how [I was breathing]. I felt it was extremely important. Because very often I would tend to ignore things and now I’m more tuned into what I should do before I start an activity…. It makes life easier. I breathe easier. …. Now I just find myself quieter and having less trouble with my breathing when I’m doing activities. I’ll remember and begin breathing in a certain way, stretch or roll my shoulders to calm down while doing my routine. And I’m breathing slower and calmer. I feel more comfortable going up hills – I feel less out of breath. You feel less strained going uphill. It’s less of an effort breath wise. I’m much more confident about that. I don’t avoid. … The hills that I have around here, I can handle them. It helped me to do housework that I couldn’t do. It helped me walk without stopping. It helped me go to babysit my grandkids and pick them up because I couldn’t pick them up. It changed my life around, getting back to normal. It helped me a lot because I thought I wasn’t going to be able to get back to normal. Like I said I’m back to my normal life now. My physical capability is that I was able to do what I wanted to do because I couldn’t even clean my house, I couldn’t even walk my dogs, I couldn’t do anything! I couldn’t even go food shopping. Now, I could do all that by myself. It feels great. Because I don’t like to depend on anybody. I have my own independence back. I can control it now. I am not getting out of breath when I am walking up the stairs because I do the deep breathing. I do it while I am walking, and when I am going up the stairs…. I walked up 22 steps! I mean, that was great without stopping. I used to look at the stairs. I had stopped walking up about a year ago.
Relaxation for Improved sleep: I relax and fall asleep faster	It was perfect timing as I was at an incredible sleep deficit. And it just sort of like all happened at once. Phillips finally sent my machine, and I started getting sleep. So those exercises actually helped build a sleep routine for me, because I do a few of them, right before I go to bed as I’m setting up my CPAP machine…. And it’s exciting to wake up to know that you just got six, seven, or eight hours of sleep [teary and emotional] when I was not sleeping. It’s so bizarre that I’m getting sleep and learning to breathe. I mean it has just changed my life. I wear a mask for sleep apnea and I got a new machine… and have restless leg syndrome …. I try to incorporate the breathing so I can kind of like relax and go to sleep more quickly. And that’s helped a little bit…. The routine I had was when I went to bed, I would practice my breathing to slow down my breathing because I have really poor sleep. …. With the machine, sometimes I sleep through the night. You know, either diaphragmatic breathing or the wide ribcage breathing and also, I was sleeping on my back …. So now I’m concentrating on sleeping on the side and I’m getting longer blocks of sleep.
Acceptability of CALM Breathing – A Bridge to Pulmonary Rehab: This program is way overdue	It’s the best thing that could happen to you. It’s going to teach you how to breathe. We don’t really know how to breathe. And if you don’t breathe right, you’re not going live right, especially with COPD. … it just teaches you a lot about yourself, your breathing, and posture. This program is way overdue but it’s here and I’m glad it’s here and I’m just sorry that my time is ending here. But I still have the information with me. Anybody that I know that might be having difficulty breathing, asthma, or a lung problem, I would definitely suggest they come over here. …. I’ve learned some techniques that were very helpful. I learned how to catch my breath. It was absolutely wonderful…. When I was going to those sessions, they meant so much to me. I kind of like feel lost without coming to see you and because she was a great teacher and the exercises really do help me a lot. They help me to remain calmer, they help with the wheezing and it means a lot because I can really see a difference right now….So to me it was a very successful program.