Rev Bras Fisiol Exerc. 2026;25:e255638

doi: 10.33233/rbfex.v25i1.5638

REVIEW

The effectiveness of respiratory muscle training in competitive swimmers: a systematic review

A efetividade do treinamento muscular respiratório em nadadores competitivos: uma revisão sistemática

 

Clarice da Silva Nogueira Neves1, George Alvicio Kieling1, Lucelia Luna Melo-Diaz2

 

1Universidade Federal do Paraná (UFPR), Curitiba, PR, Brasil

2Red River College Polytechnic, Winnipeg, Manitoba, Canada

 

Received: June17, 2025; Accepted: November 13, 2025.

Correspondence: Clarice da Silva Nogueira Neves: clariceneveslidia@hotmail.com

 

How to cite

Neves CSN, Kieling GA, Melo-Diaz LL. The effectiveness of respiratory muscle training in competitive swimmers: a systematic review. Rev Bras Fisiol Exerc 2026;25:e255638. doi: 10.33233/rbfex.v25i1.5638

 

Abstract

Introduction: Respiratory muscle training can enhance lung function, improving performance of competitive swimmers. However, there is a lack of studies that have comprehensively examined the impact of respiratory muscle training specifically on swimmers. Objective: The objective of this study was to verify the effectiveness of respiratory muscle training on respiratory muscle strength, lung function, swimming performance and aerobic capacity among competitive swimmers. Method: This is a systematic review of the current literature, conducted according to PRISMA criteria and registered with PROSPERO. A total of 629 articles were identified using the PICO search strategy. Following rigorous eligibility criteria, 13 studies were included in this review. Results: The results showed a significant improvement in maximum inspiratory pressure values. No significant changes were observed in lung function parameters. There was an improvement in swimming performance and no significant changes were observed in the aerobic capacity of competitive swimmers. Conclusion: Respiratory muscle training was effective in increasing respiratory muscle strength, particularly in the inspiratory muscles, and positively contributed to the sports performance of swimmers. However, this training did not exhibit effectiveness in improving lung function or the aerobic capacity of the athletes.

Keywords: breathing exercises; athletes; swimming

 

Resumo

Introdução: O treinamento muscular respiratório pode otimizar a função pulmonar, contribuindo para a melhora do desempenho de nadadores competitivos. No entanto, há uma escassez de estudos que investigaram o impacto do treinamento muscular respiratório especificamente em nadadores. Objetivo: O objetivo deste estudo foi verificar a eficácia do treinamento dos músculos respiratórios sobre a força dos músculos respiratórios, função pulmonar, desempenho na natação e capacidade aeróbica em nadadores competitivos. Método: Trata-se de uma revisão sistemática da literatura, conduzida de acordo com os critérios PRISMA e registrada no PROSPERO. Um total de 629 artigos foi encontrado como resultado da estratégia de busca baseada no modelo PICO. Após a rigorosa aplicação dos critérios de elegibilidade, 13 artigos foram incluídos nesta revisão. Resultados: Os resultados indicaram uma melhora significativa nos valores de pressão inspiratória máxima; não foram observadas alterações significativas nos parâmetros gerais de função pulmonar; houve melhora no desempenho na natação e não foram observadas mudanças relevantes na capacidade aeróbica dos nadadores competitivos. Conclusão: O treinamento dos músculos respiratórios foi eficaz em aumentar a força dos músculos respiratórios, especialmente dos músculos inspiratórios, e contribuiu positivamente para o desempenho esportivo dos nadadores. No entanto, esse treinamento não demonstrou eficácia na melhora da função pulmonar geral nem da capacidade aeróbica dos atletas.

Palavras-chave: exercícios respiratórios; atletas; natação

 

Introduction

 

Respiratory muscle training (RMT) is an intervention designed to improve the endurance of the inspiratory and/or expiratory muscles and optimize respiratory function [1]. These interventions utilize incentive spirometry devices (e.g., Respiron), pressure threshold (e.g., Threshold and PowerBreathe), or resistance devices [2]. Pressure threshold devices have calibrated valves that require a target pressure for airflow, while resistance devices provide constant resistance adjustable by the size of the air openings. Incentive spirometry devices promote deep, slow breaths to improve lung volumes based on predefined airflow feedback [2]. RMT is a cost-effective, easy-to-apply, and safe non-pharmacological intervention, considered essential in the management of certain cardiopulmonary diseases [3] and an adjunct for optimizing physical fitness and athletic performance [3,4].

The essential role of RMT is evident when examining the effect of respiratory muscle fatigue on sports performance [5], in healthy individuals [6] and individuals with cardiorespiratory diseases such as pulmonary hypertension [7] and chronic heart failure [8]. In athletes, limitations in physical performance may result from reduced blood flow to skeletal muscles due to vasoconstriction and redirection of blood flow to the respiratory muscles. This physiological response leads to an increase in metabolites, such as lactate, in the respiratory muscles, intensifying local fatigue and ultimately reducing athletic performance [5,9]

Athletes from various sports modalities have used RMT techniques to overcome these limitations, to enhance physiological responses and improve exercise tolerance [10]. Research has shown that improving respiratory mechanical efficiency, fatigue resistance, and reducing oxygen consumption leads to increased oxygen availability for skeletal muscles, resulting in enhanced exercise endurance, reduced respiratory fatigue, decreased sensation of dyspnea, and effort during exercise in both normoxia and hypoxia [3,5,11]. Studies support these findings, showing significant improvements in the performance of athletes across various sports, such as football [12,13], skating [14], rugby [15], kickboxing [16], basketball [17,18], running [19,20] and increased load endurance in triathletes [5].

However, swimming, unlike other sports, requires both strength and endurance and demands a balance between aerobic and anaerobic energy production. Inspiratory muscle fatigue can negatively affect athlete performance, particularly due to the respiratory demands associated with the prone position, resulting in a 16% decrease in the ability to generate force, restricted breathing frequency, and increased respiratory resistance due to water immersion and hydrostatic pressure surrounding the thoracic cavity [11,21,22]. The use of RMT in training can enhance respiratory strength and performance, as well as extends periods of apnea, hence improving immersion time and swimming endurance [23].

Although other systematic reviews have addressed RMT in athletes [3,24,25] and more targeted reviews relating RMT to sports such as football [26]. While the conclusion of these reviews highlights improvements in maximal inspiratory pressure (MIP) [26], maximal oxygen consumption [26], sports performance [3,10,24,25], lung function [3,10] and respiratory muscle strength [25], the specificities of swimming make the context for athletes in this sport limited due to the lack of studies that have investigated the effects of RMT on swimmers. Therefore, the objective of this study was to assess the effectiveness of respiratory muscle training on respiratory muscle strength, lung function, swimming performance, and aerobic capacity among competitive swimmers.

 

Methods

 

This is a systematic review conducted in accordance with the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) and it was registered in the public database PROSPERO under the number CRD42024518455.

 

Eligibility criteria

 

The inclusion criteria were studies with humans, swimming athletes, interventional studies, observational studies (prospective, retrospective, and cross-sectional), or experimental studies (randomized clinical trials), with no restrictions on race, sex, or country.

The exclusion criteria were studies that did not include respiratory muscle training, athletes with pathologies (e.g., asthma and spinal cord injury), para-athletes or athletes with disabilities, comparative studies between normoxia and hypoxia situations or in hypothermia, athletes from other sports (e.g., football, basketball, rugby, tennis), duplicate studies, case studies and case series, comments, conference abstracts, recommendations, letters to the editor, editorials, studies containing protocols for randomized clinical trials, guidelines, consensuses, reviews, and incomplete studies.

 

Information sources

 

The search was conducted in the following databases: PubMed, Web of Science, Scopus and Embase.

 

Search strategy

 

The “PICO” strategy was outlined according to the objectives of the study (Table I). A search was conducted for DeCS and MeSH descriptors related to the terms for the population ('athlete') and the intervention ('respiratory muscle training', i.e, a non-DeCS-MeSH term).

 

Table I - PICO Strategy

 

The Group column refers to the acronym “PICO”; Table developed by the authors based on data from the study

 

The search strategy used was ("respiratory muscle training" OR "inspiratory muscle training" OR "expiratory muscle training" OR "breathing exercises" OR "respiratory training" OR "breathing devices") AND ("Athlete*" OR "Athletic performance"). For the Embase database, the strategy used was ("respiratory muscle training" OR "inspiratory muscle training" OR "expiratory muscle training" OR "breathing exercises" OR "respiratory training" OR "breathing devices") AND ("Athletes" OR "Athletic performance") to maximize the retrieval of relevant articles.

Filter: Studies published in the last ten years (2014 to 2024) in Portuguese, English, and Spanish, with full texts available for free or accessible via institutional subscription, were selected according to the study's inclusion criteria.

 

Selection process

 

The study selection was conducted in pairs: two reviewers (C.N. and L.MD.) independently selected the studies according to the inclusion criteria. In case of disagreement between the two reviewers, a third reviewer (G.K.) served as mediator to assess and decide on study inclusion or exclusion. Individual studies included in the systematic reviews from the search strategy were consulted separately as an additional selection (outside the search strategy). The title and abstract of potentially eligible studies were read in full for the selection of studies according to the pre-established inclusion and exclusion criteria. Full-text studies were consulted when the information in the abstract was insufficient. The ZOTERO® software was used to manage data screening. Finally, a flowchart following the PRISMA recommendation (http://www.prisma-statement.org/) was used to present a summary of the study selection process.

 

Data collection process

 

All selected studies were read in full, and the data collection process was conducted similarly to the selection process, including two independent reviewers (in blind) and a third reviewer to mediate disagreements. The data collection was conducted without any automation using only the full reading of the report.

 

Data items

 

The following information was extracted from each study: author identification, publication year, country of origin, study design, sample size, sex, participants’ mean age, type of respiratory training, and key outcomes.

 

Study risk of bias assessment

 

The National Heart, Lung, and Blood Institute (NIHLBI) instrument “Quality Assessment of Controlled Intervention Studies” was used to assess the methodological quality of the studies. This instrument was selected due to its structured and reliable assessment of the methodological quality of intervention studies, assessing potential biases and internal validity. It consists of 14 items, with possible responses of “yes,” “no,” or “not reported.” A score of 1 is assigned for a “yes” response, while a score of 0 is assigned for the other responses. Therefore, the overall score represents the number of affirmative responses. For qualitative evaluation of the final scores, studies with a score above 12 were considered “good,” those scoring between 9 and 12 were considered “moderate,” and studies scoring below 9 were considered “weak.” The evaluation and quality assessment were conducted independently by two authors.

 

Synthesis methods

 

A narrative synthesis of the included studies was conducted, structured around study design, participants, type of respiratory muscle training, and outcomes assessed.

 

Reporting bias assessment

 

The risk of bias was assessed qualitatively using the Zotero platform, in addition to the The National Heart, Lung, and Blood Institute (NIHLBI) instrument “Quality Assessment of Controlled Intervention Studies”.

 

Certainty assessment

 

A formal assessment of the certainty of the body of evidence was interpreted qualitatively based on study design, methodological quality, sample size, and consistency of results across the included studies.

 

Results

 

The initial search yielded 629 studies: 111 from the PubMed platform, 200 from Embase, 205 from Scopus, and 113 from Web of Science. Of these, 351 were excluded due to duplication, for not meeting the inclusion criteria, and 60 for not including swimmers (Figure 1).

 

 

Figure 1 - PRISMA flowchart of study selection

 

Of the 13 selected articles, 11 were randomized clinical trials, one was an exploratory study, and one was a non-randomized trial. Regarding methodological quality, only one study had good quality, seven studies had moderate quality, and five studies were rated as having poor quality.

The studies were conducted in the United States (2 studies) [22,27], the United Kingdom (2 studies) [28,29], Chile (2 studies) [30,31], India [32], the Czech Republic [23], Mexico [21], Portugal [33], Latvia [34], China [11] and Japan [35] with one study each. Most studies included both sexes. One study did not specify the number of male and female participants [23] while three studies had exclusively male subjects [4,11,35]. The minimum sample size was 11 participants [21] and the maximum was 43 [11], with a minimum average age of 11 years [23] and a maximum average age of 21 years [11,29]. Twelve studies were published in English [4,11,21,22,23,27,28,29,32,33,34,35] and one in Spanish [31] (Table II).

 

Table II - Summary of the characteristics and outcomes of included studies

 

Among the respiratory muscle training methods, nine studies used "flow-resistive inspiratory muscle training," with seven of these utilizing POWERbreathe devices [11,28,29,30,31,33,35],one study using the Threshold device [23] and one study not stating the device type [22]. The remaining studies used the Yogic Breathing Practices (YBP) [32], controlled frequency breathing (CFB) [27], MRfit protocol [21] and modified breathing exercise [34] .

The outcome "respiratory muscle strength" was examined in ten studies [11,22,23,27,28,29,30,31,33,35]. Eight studies reported significant improvements in Maximum Inspiratory Pressure (MIP) [22,23,27,28,30,31,33,35]] in the Experimental Group (EG) compared to the Control Group (CG). However, results regarding Maximum Expiratory Pressure (MEP) were inconsistent. Vasickova et al. [23] reported an improvement in MEP between the EG and CG, while [28] did not find a statistically significant improvement between the groups. In addition to the improvement in respiratory muscle strength, Yañez-Sepulveda [30] also identified a significant improvement in maximum inspiratory flow between the EG and CG. In contrast, two studies [29,33] did not find any difference in MIP values between the groups after Respiratory Muscle Training (RMT). In the intragroup analysis, Tan et al. [11] identified improvements in MIP parameters in the EG when comparing pre- and post-RMT results.

Of the ten studies that examined the outcome "lung function" [11,22,23,27,29,30,31,32,33,34] seven of them [22,23,27,29,30,31,33] did not find statistically significant improvements in pulmonary function parameters when comparing the EG with the CG. Only the study by Hakked et al. [32] reported improvements in lung function parameters, including Maximum Voluntary Ventilation (MVV) and Forced Vital Capacity (FVC) in the EG compared to the CG. However, no improvements were observed in Slow Vital Capacity (SVC), Inspiratory Reserve Volume (IRV), Minute Ventilation (MV), and Peak Expiratory Flow (PEF) [32]. In intragroup comparisons, Tan et al. [11] reported improvements in vital capacity (VC) and Jakubovskis et al. [34] reported improvements in FVC and Peak Inspiratory Flow (PIF), both in the EG compared to the pre-training situation.

The outcome "Swimming performance" was examined in ten studies [11,23,27,29,30,31,32,33,34]. Among these, six studies [23,28,29,30,32,34] found improvements in performance in the EG compared to the CG. Hakked et al. [32] showed improvements through the reduction in the number of strokes; Jakubovskis et al. [34] reported the improvement in the world aquatic (WA) points ; Wilson et al. [29] found improved performance in the 100 m exclusively when respiratory muscle training (RMT) was combined with the warm-up and Yañez-Sepulveda [30] found significant improvements in swimming times for t50 m, 100 m, and 200 m. Lomax et al. [28] also found improvements in 100 m and 200 m performance following RMT, but these improvements were limited to athletes with higher training loads (above 31 km/week). Vasickova et al. [23] reported improvements in apnea time, with effects sustained for 1-month post-RMT in the EG compared to the CG due to the cross-over design. Intragroup analyses showed improvements in 50 m and 100 m performance times, reduced number of breaths during performance, and increased distance covered before the first inspiration in the EG [11]. Nevertheless, two studies did not find significant improvements in swimming performance. Burtch et al. ]27] and Cunha et al. [33] did not observe improvements in the 200 m performance.

Finally, the outcome, "aerobic capacity," was examined in only three studies [21,27,31]. None of the studies reported significant changes in aerobic capacity parameters in the EG compared to the CG [21,27,31].

 

Discussion

 

The objective of this study was to examine the effectiveness of respiratory muscle training on respiratory muscle strength, lung function, swimming performance, and aerobic capacity among competitive swimmers. The results showed that most of the studies included in this systematic review reported improvements in MIP [22,23,27,28,30,31,33,35] but not in lung function parameters. The studies reported improvements in swimming performance but did not identify changes in the aerobic capacity of competitive swimmers.

Regarding respiratory muscle strength, 8 of the 10 studies included showed improvement in MIP. MIP primarily assesses diaphragmatic strength [10]. This finding is supported by other studies examining this parameter in different sports, with increased MIP attributed to improvements in diaphragmatic oxidative capacity and an increase in strength that contributes to greater fatigue resistance [10], leading to better athletic performance. Studies with soccer players have shown that an increase in MIP resulted in reduced sprint times [12,36] improving exercise tolerance and enhancing the players' endurance [36]. Similarly, RMT in both elite and non-elite swimmers significantly increased MIP, regardless of participants' age, intervention duration, or baseline MIP [37].

In contrast, MEP was not largely examined in the studies, and only a few utilized this instrument as a measure of respiratory muscle strength. MEP assesses the strength of the respiratory muscles, particularly the internal intercostals and abdominal muscles [10]. Perhaps the well-established capacity of MIP to predict diaphragm weakness [38] aligned with enhancements in anaerobic performance are factors that may have favored the utilization of MIP over MEP in these studies [39].

The findings of this systematic review showed that there was no improvement in lung function among competitive swimmers following RMT, similar to what has been described by Carvajal-Tello et al. [37]. These findings may be related to supra-physiological limits of lung function in athletes. A meta-analysis has shown that, before RMT, the values of key lung function parameters were already approaching 100% of physiological levels in athletes [3]. Swimming is a sport that imposes a significant demand on lung function due to increased hydrostatic pressure and high inspiratory flow during breathing [40], factors that promote inspiratory muscle training [40]. Therefore, since lung function is already close to a maximum plateau, the possibility of additional gains is reduced [3,36]. Additionally, the use of insufficient RMT loads may have contributed to the lack of significant improvements, considering the already elevated pulmonary function of the athletes [3], particularly in the study by Hakked et al. [32], which incorporated Yogic Breathing practices without additional RMT load.

The lack of improvement in lung function, or improvement in only a few parameters, with RMT was also observed in other studies examining different sports, such as running [41], soccer [26], hockey [42], and martial arts [16]. Therefore, it is possible that lung function was already optimized prior to RMT in these athletes or that the resistance used in RMT was insufficient.

This systematic review showed an improvement in athletic performance among swimmers following RMT, despite the significant variability in performance measurement parameters. Improvement in athletic performance was observed not only in studies that also included swimmers [34,40], but also in other sports such as running [19], cycling [43], and soccer [36]. RMT enhances the oxidative capacity of inspiratory muscles, reduces the oxygen demand of the respiratory muscles, and promotes tissue remodelling of the respiratory muscles, such as diaphragm hypertrophy and an increase in type II fibres [44]. These adaptations increase the strength and functionality of the respiratory muscles, delay the respiratory metabolic reflex [40,45,46], facilitate the availability of oxygen to peripheral muscles [45], and reduce the perception of shortness of breath and discomfort in the limb muscles [45,47]. Therefore, these physiological improvements may explain the enhancement in athletic performance [3,45].

Finally, no improvements in aerobic capacity were observed; however, only three studies addressed this topic in our review. VO2max is related to the amount of oxygen diffused and utilized by the body during physical activity. Two meta-analyses examined this topic: Hajghanbari et al. [48], examining 13 studies, reported no improvements in VO2max, while Fernández-Lázaro et al. [10] observed that RMT produced improvements in aerobic capacity, although not significant [10]. Espinosa-Mendez et al. [21] found an improvement in VO2max in their study, although they acknowledged the scarcity of studies corroborating such findings. This may occur due to VO2max being more reliant on cardiac output than on the respiratory system [21]. It is estimated that, during intense exercise, the respiratory muscles can utilize up to 16% of cardiac output, reducing the availability of oxygen for the skeletal muscles responsible for mobility. This phenomenon occurs due to the sympathetic vasoconstrictor response, which decreases blood flow to the skeletal muscles, reducing their energy production and consumption. As a result, skeletal muscle may fatigue increase and blood flow is redistributed to preserve respiratory function without compromising the energy demands of the respiratory muscles [10].

This systematic review has limitations. The small number of studies reduces the robustness of the conclusions. Additionally, the variability in outcome measurement, particularly regarding swimming performance, limits comparisons among studies. The greatest variations were related to the RMT method, training load, and weekly frequency. Due to the lack of alignment in these key training variables, conducting a meta-analysis was not feasible. Regarding the assessment of methodological quality, among the 13 included studies, only one study was rated as good quality, seven as moderate quality, and five as poor quality. The findings show that the majority of the available evidence has important methodological limitations, which must be taken into account when interpreting the results of this review. However, given the lack of prior systematic reviews in this specific area, we decided to conduct the present study to synthesize the available evidence and highlight gaps to be addressed in future studies.

      Nevertheless, the strength of this study lies in its status as, to our knowledge, this is the first systematic review to examine the effectiveness of respiratory muscle training in athlete swimmers. This confers the study an innovative approach, establishing a framework for future investigations and filling a gap in this research area.

 

Recommendation for future research

 

Future studies should aim to improve methodological quality (e.g., randomization and blinding) and prioritize the standardization of RMT protocols, particularly regarding the type of device used, as well as key training variables such as load, frequency, and intervention duration, which showed considerable variability across studies. It is also recommended to include subgroup analyses based on athletes’ competitive level, as this may help to distinguish performance responses according to different levels of competition, even among professional swimmers. In addition, studies should explore the physiological mechanisms underlying performance gains and examine the effects of higher resistance parameters in RMT, especially in swimmers with greater baseline respiratory conditioning.

 

Conclusion

 

Respiratory muscle training was effective in increasing respiratory muscle strength, particularly inspiratory strength, in swimmers. Additionally, respiratory muscle training was effective in improving the athletic performance of these athletes. However, no effectiveness of this training was observed in improving pulmonary function and aerobic capacity among the swimmers.

 

Academic affiliation

This article is derived from a postgraduate thesis in Physical Education, conducted under the supervision of Dr. Lucélia Luna Melo-Diaz at the Hospital de Clínicas Complex of the Federal University of Paraná.

 

Conflict of interest

The authors declare that they have no competing interests.

 

Authors’ contributions

Conception and design of the research: Neves CNN, Kieling GA, Melo-Diaz LL; Data acquisition: Neves CNN, Kieling GA, Melo-Diaz LL; Data analysis and interpretation: Neves CNN; Kieling GA, Melo-Diaz LL; Statistical analysis: Neves CNN; Kieling GA; Melo-Diaz LL; Funding acquisition: Neves CNN, Kieling GA, Melo-Diaz LL; Manuscript writing: Neves CNN, Kieling GA, Melo-Diaz LL; Critical revision of the manuscript for important intellectual content: Neves CNN, Kieling GA, Melo-Diaz LL.

 

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