Better breathing through playing the harmonica is a new program used at Sinai Hospital of Baltimore, to help pediatric patients who have asthma or pneumonia or are postoperative, to exercise their lungs. Jerry Henderson, assistant vice-president for perioperative services, contacted the respiratory department with the idea of using the harmonica as a tool to help patients with pulmonary disease.

This concept was introduced by Buddy Wakefield, who has been teaching the harmonica to patients with Parkinson’s disease, asthma, and chronic obstructive pulmonary disease. He says, “Playing the harmonica is like doing push-ups for the lungs.” [It was Buddy’s brother, diagnosed with Parkinson’s, who gave him the idea that the blow and draw involved in harmonica playing could help Parkinson’s patients—ed] Wakefield’s method is simple. He distributes a kit that contains a music book with a simple harmonica and instructions on how to play. He reviewed the instructions with a respiratory therapist, and within 15 minutes she was playing her first tune on the harmonica. Respiratory therapists and nurses are always looking for fun ways to help patients exercise their lungs, and this was a way to achieve that goal.

The initial respiratory therapist, coauthor Ann Ludwig, who is also the education and performance improvement coordinator, scheduled a harmonica seminar and had Wakefield introduce the “Tune into Better Breathing” program to Sinai Hospital’s Department of Pediatrics. During the 2-hour seminar, physicians, nurses, respiratory therapists, social workers, and child life specialists learned to play “Mary Had a Little Lamb,” and “Twinkle, Twinkle, Little Star.”

Ann M. Ludwig, BS, RRT-NPS, at Sinai Hospital of Baltimore, teaches 12-year-old Chijae Lockely and 13-year-old Imani Williams how to play the harmonica.

A multidisciplinary team consisting of nurses, respiratory therapists, and physicians worked on a plan to develop this program for the pediatrics department. The team obtained funding, purchased the kits, developed a target population, trained staff, and determined a start date.

In July 2010, the first patient was taught to play the harmonica to exercise his lungs. Sinai Hospital continues to provide this program to all pediatric patients admitted with asthma, pneumonia, or postoperative conditions.

Pathophysiology of Asthma, Pneumonia, and Postoperative Conditions—a Primer

Asthma. Asthma is a recurrent inflammatory lung disease typified by episodes of lower airway obstruction that are reversed spontaneously with treatment. Asthma produces constriction of the smooth muscles in the airway, wheezing, and dyspnea. It the most common chronic disease in childhood and a frequent cause of hospitalization for children in the United States.

With asthma, inflammatory mediators are believed to stimulate the vagus nerve, causing constriction of the bronchial smooth muscle and increased production of mucus. Increased airway resistance results in reduced expiratory volume; premature closing of airways, leading to air trapping in some regions and atelectasis in others; and hypoxemia. As the airway obstruction worsens, hyperinflation and decreased lung compliance ensue, resulting in increased work of breathing and impaired respiratory muscles. The child fatigues, minute ventilation is decreased, and hypercapnia develops.1

Pneumonia. Pneumonia is an infection of the lung that may occur due to bacteria, viruses, fungi, parasites, or atypical organisms. The causative organism begins the inflammatory response, causing alveolar edema. Edema presents a location for the organisms to reproduce. The inflammatory process of the lungs may engage the interstitial tissue and the pleura, leading to lung consolidation, decreased lung compliance, and decreased vital capacity and total lung capacity. As in asthma, the work of breathing increases and the child becomes fatigued.2

Postoperative Conditions. Complications after abdominal or thoracic surgery develop for a number of reasons. Anesthetic agents can decrease respiratory drive, and they can produce diaphragm and chest-wall relaxation, which decreases functional residual capacity. The decrease in lung volume can cause atelectasis in the dependent lung.3 There can be a reduced vital capacity of up to 50% and a decreased functional residual capacity up to 30% for children who also may have postoperative pain and splinting. Because of the pain, children do not want to move, which contributes to the risk of pulmonary complications.

Thirteen-year-old Imani Williams practices her harmonica skills.

Science of Playing the Harmonica

The harmonica requires diaphragmatic breathing, pursed-lip breathing, and the use of both phases of ventilation (inspiration and expiration) to play a tune. These are maneuvers that health care providers encourage when a patient is admitted to the hospital with pulmonary conditions. It is important to encourage all hospitalized patients to exercise their lungs.

Traditionally, incentive spirometry, PEP therapy, coughing, deep breathing, and ambulation have been used to expand and exercise the lungs during hospitalization. The challenge when providing traditional therapy is the lack of the fun factor. The harmonica can help with this challenge. It provides fun—playing music, which is uplifting and a therapy—and encourages deep breathing while controlling the diaphragm. The breathing required to play the harmonica can amplify and augment flexibility, capacity, and elasticity of the thin muscles of the diaphragm, which then can fuel the oxygen and carbon dioxide exchange in the alveoli.4

Playing the harmonica is not a traditional therapy; but two actions occur when teaching children to play: coughing and deep breathing, which help to mobilize secretions. Most important, children have fun and want to participate in exercising their lungs.

Future Plans

Sinai will continue to develop and expand the program to all pediatric patients older than 4 years of age. The program will be introduced to adult patients with pulmonary diseases. Presently, the hospital is working to introduce the program to a chronic care facility for adults.

Ann M. Ludwig, BS, RRT-NPS, is Education/PI Coordinator, Respiratory Care Services, and Patricia A. Moloney-Harmon, RN, MS, CCNS, FAAN, is Advanced Practice Nurse/Clinical Nurse Specialist, Children’s Services, Sinai Hospital of Baltimore. For further information, contact [email protected].

  1. Morris MJ. Asthma. Available at: Accessed November 15, 2010.
  2. Grant MJ, Webster HF. Pulmonary system. In: Slota MC, ed. Core Curriculum for Pediatric Critical Care Nursing. St Louis: Saunders Elsevier; 2006:40-160.
  3. Yoder MA, Sharma S. Perioperative Pulmonary Management. Available at: Accessed November 15, 2010.
  4. Labre J. Harmonica Therapy/Music for Life. Available at: Accessed November 15, 2010.