Radiation Breathing IQ Protocol
RAD-BIQ
Standardized Breathing Coaching for Radiation Therapy
A clinically validated protocol that standardizes diaphragmatic breathing coaching for Deep Inspiration Breath-Hold (DIBH), optimizing cardioprotection while reducing staff workload and patient anxiety.
The Challenge
DIBH adoption remains limited despite proven cardioprotective benefits.
Abdominal Deep Inspiration Breath-Hold (A-DIBH) has demonstrated significant cardioprotective results in breast cancer radiation therapy, particularly in reducing doses to the left anterior descending artery (LAD). Yet many treatment centers have not adopted DIBH into routine practice.
The barriers are operational, not clinical. Concerns about increased resource requirements, staff workloads, and the lack of standardized patient coaching have slowed implementation, even as the evidence base grows stronger.
Variable Patient Coaching
Cueing, educational materials, and instruction methods differ significantly between clinicians and institutions, producing inconsistent breath-hold quality.
Staff Workload Concerns
High staff turnover and limited resources make time-intensive patient coaching unsustainable without a scalable, standardized approach.
Patient Overwhelm
Patients frequently report feeling overwhelmed by the volume of information. Well-intentioned thoroughness can paradoxically increase anxiety and reduce compliance.
The Protocol
A systematic approach to breathing assessment and training for radiation therapy.
RAD-BIQ builds on the Breathing IQ (BIQ) methodology, a validated biomechanical screening and corrective protocol, and adapts it specifically for the demands of radiation therapy breath-hold.
Assess
Biomechanical Assessment
The Breathing IQ screening evaluates abdominothoracic respiratory flexibility, grading patients from A to F. It identifies whether the patient relies on diaphragmatic or auxiliary muscles, measures range of motion, and establishes a clear baseline for coaching.
Retrain
Corrective Training
Targeted correctives retrain breathing mechanics toward diaphragmatic engagement. Research demonstrates that certified instructors can move patients from BIQ Grade F (apical) to Grade A (diaphragmatic) in as little as 90 minutes, compared to approximately 4 weeks with prior retraining protocols.
Prepare
Radiation-Specific Preparation
The radiation module prepares patients for SIM and treatment breath-holds with consistent geometry. Patients practice producing large, stable diaphragmatic breaths with minimal drift, using a self-led curriculum of video, audio, and written materials aligned with clinic SOPs.
Protocol Differentiators
- Tested Cueing for Emotional Triggers
- Cues are designed to avoid known emotional triggers, informed by clinical observation of where patient understanding is commonly blocked.
- Patient-Controlled Information Pacing
- Patients choose their depth of engagement. Some prefer instructions only; others want the full medical and research context. Both approaches reduce anxiety.
- Staff SOP Alignment
- Patient-facing materials are designed to match and complement clinic-specific SOPs, ensuring consistent language between self-guided practice and in-clinic instruction.
- On-Demand, Self-Led Access
- The web-based curriculum allows patients to prepare independently at home, reducing demands on clinical staff while improving patient preparedness and confidence.
Clinical Evidence
Validated at MD Anderson Cancer Center.
The protocol was evaluated in a recently completed study at MD Anderson: "Impact of Diaphragmatic Breathing Coaching on Deep Inspiration Breath-Hold Reproducibility and Organ Protection" (PI: Melissa Mitchell, Ph.D.; Co-Investigators: Belisa Vranich, Psy.D.; Wendy Woodward, M.D., Ph.D.).
77%
Average increase in breath-hold duration (37 to 66 seconds) in BIQ retraining studies.
90 min
Time to retrain apical breathers (Grade F) to diaphragmatic breathers (Grade A), versus ~4 weeks with prior protocols.
~90%
Estimated prevalence of biomechanical breathing shortcomings in the general population, corroborating prior research.
A–F
Standardized grading scale for abdominothoracic respiratory flexibility, providing objective baseline and progress measurement.
Preliminary Study Outcomes
Reduced Patient Anxiety
Significant decrease in reported patient anxiety throughout the treatment process.
Improved Staff Workflow
Staff evaluations indicated easier workflow with coached patients compared to standard teaching methods.
Tangential Health Benefits
Patients reported significant additional benefits including resolution of GI issues and reduced reliance on anxiolytics.
Clinical Context
The diaphragm as a clinical lever.
The role of diaphragmatic breathing extends well beyond radiation therapy. Research has established its significance across multiple clinical domains.
- Cardioprotection in DIBH
- A-DIBH specifically protects the LAD artery through the mechanics of diaphragmatic displacement during abdominal breathing.
- Pain Threshold
- Diaphragmatic breathing has been shown to heighten pain threshold, relevant for patients undergoing extended treatment courses.
- Gastrointestinal Function
- Active diaphragmatic engagement ameliorates GI disturbances, a benefit reported by study participants independently.
- Lymphatic and CSF Circulation
- Diaphragmatic movement contributes to detoxification, lymph removal, and stimulation of cerebrospinal fluid flush.
- Anxiety Reduction
- Correcting shallow, rapid breathing patterns that push the system into chronic sympathetic states has significant anxiolytic effects.
- Pre-Surgical Preparation
- Robust research supports diaphragm strengthening prior to surgery, with implications for recovery outcomes and respiratory resilience.
The Toolkit
A comprehensive, self-led patient preparation system.
The RAD-BIQ toolkit is a web-based curriculum designed for independent patient use, with flexible pacing that adapts to each patient's timeline between diagnosis and SIM.
Patient-Facing Components
- Video Exercises
- Guided breathing correctives and practice sessions designed specifically for SIM and treatment breath-hold preparation.
- Audio Exercises
- On-demand audio guides for independent practice at home, reinforcing diaphragmatic breathing patterns.
- Educational Materials
- Written content with tiered depth — patients choose between concise instructions or comprehensive medical context, based on their preference.
- Flexible Curriculum Pacing
- Adaptive scheduling that adjusts content delivery based on the patient's timeline to SIM, whether days or weeks.
Clinical Integration
- Staff SOP Documentation
- Standardized operating procedures ensuring clinic cueing aligns with patient self-guided practice materials.
- Radiologist Education Curriculum
- Training materials for radiation therapy staff, connected with CEU accreditation for the BIQ certification process.
- Post-Treatment Recovery Protocol
- Breathing exercises designed to support recovery from treatment-related effects including dyspnea, thoracic rigidity, pain, fatigue, and pneumonitis.
- Gating System Adaptability
- Protocol can be adjusted for different gating systems and protocols that may prefer thoracic versus abdominal breath-holds.
Expanding Applications
Beyond breast cancer radiation.
RAD-BIQ is currently being adapted for additional clinical applications where diaphragmatic breathing assessment and training can improve treatment outcomes and patient experience.
Lung Radiation
Optimizing breath-hold consistency for lung radiation treatment planning.
Upper Abdominal Radiation
Adapting the protocol for upper abdominal treatment and pre-surgical tumor imaging.
ENT and Vocal Cord
Addressing vocal cord and ENT dysfunction through targeted breathing rehabilitation.
Pelvic Floor Radiation
Leveraging the diaphragm-pelvic floor connection for pelvic radiation protocols.
Long-Term Research Objectives
- 1 Refine abdominothoracic cueing to maximize diaphragmatic movement and evaluate lateral expansion to increase the anterior buffer.
- 2 Adjust the protocol for upper abdominal versus breast radiation, for both treatment planning and pre-surgical tumor imaging.
- 3 Accommodate different gating systems and institutional protocols that may prefer thoracic versus abdominal breath-holds.
Protocol Developer
Dr. Belisa Vranich, Psy.D.
Dr. Belisa Vranich is a clinical psychologist and the creator of the Breathing IQ methodology. She is a subject matter expert in breath-hold performance and arousal control under stress, with extensive work across military special operations, law enforcement, firefighters, and professional athletes.
Her 2025 study with a nonclinical population demonstrated that certified instructors using the BIQ protocol can retrain apical breathers to diaphragmatic breathers in 90 minutes — a process that previously required approximately 4 weeks. Participants in that study augmented their breath-hold duration by 77%, from an average of 37 to 66 seconds.
RAD-BIQ represents the application of this methodology to radiation oncology, developed in collaboration with researchers at MD Anderson Cancer Center.
Areas of Expertise
- Breath-hold performance and assessment
- Performance under stress and arousal control
- Military special operations consulting
- Law enforcement and first responders
- Professional athlete performance
- Biomechanical breathing assessment
MDA Study Team
- Principal Investigator
- Melissa Mitchell, Ph.D.
- Co-Investigators
- Belisa Vranich, Psy.D.
- Wendy Woodward, M.D., Ph.D.
Interested in implementing RAD-BIQ at your institution?
We are actively seeking clinical partners to expand the evidence base and bring standardized breathing coaching to radiation therapy departments.