Double blind randomised controlled trial of two different breathing techniques in the management of asthma

Effect of Buteyko breathing technique on clinical and functional parameters in adult patients with asthma: a randomized, controlled study

BACKGROUND

The established therapy of asthma might be supported by additional non-pharmaceutical measures, such as the Buteyko breathing technique (BBT); however, the available data are mixed. To clarify the effects of BBT in patients with asthma, we investigated whether it led to clinical improvements with correlation to functional parameters.

METHODS

Using a randomized, controlled design, we studied two groups (n = 30 each) of patients with asthma under either BBT or usual therapy (UT) w/o BBT over a period of 3 months. The primary outcome comprised the voluntary control pause (CP) after 3 months, secondary outcomes an additional breathhold parameter, forced expiratory volume in 1 s (FEV1), capnovolumetry, exhaled nitric oxide (FeNO), Asthma Control Questionnaire (ACQ) and Nijmegen Questionnaire (NQ), and the use of medication (β2-agonists; inhaled corticosteroids, ICS).

RESULTS

CP showed significant time-by-group interaction [F(1,58.09) = 28.70, p < 0.001] as well as main effects for study group [F(1,58.27) = 5.91, p = 0.018] and time [F(1,58.36) = 17.67, p < 0.001]. ACQ and NQ scores were significantly (p < 0.05 each) improved with BBT. This was associated with reductions in the use of β2-agonists and ICS (p < 0.05 each) by about 20% each. None of these effects occurred in the UT group. While FEV1 and the slopes of the capnovolumetric expiratory phases 2 and 3 did not significantly change, the capnovolumetric threshold volume at tidal breathing increased (p < 0.05) with BBT by about 10 mL or 10%, compared to baseline, suggesting a larger volume of the central airways. No significant changes were seen for FeNO.

CONCLUSIONS

BBT was clinically effective, as indicated by the fact that the improvement in symptom scores and the small increase in bronchial volume occurred despite the significant reduction of respiratory pharmacotherapy. As the self-controlled Buteyko breathing therapy was well-accepted by the participants, it could be considered as supporting tool in asthma therapy being worth of wider attention in clinical practice. Trial registration Retrospectively registered on 10 March 2017 at ClinicalTrials.gov (NCT03098849).

Effect of breathing re-training on end-tidal carbon-di-oxide in patients with asthma: a systematic review and meta-analysis

OBJECTIVE

The review aims to determine the effect of breathing re-training on End-tidal carbon-di-oxide (ETCO2) in patients with asthma.

DATA SOURCES

A systematic search of articles was performed in PubMed, Cochrane, PEDro, Scopus, and Ovid databases from their inception till May 2022.

STUDY SELECTIONS

Studies were included if the patients were clinically diagnosed with mild-moderate asthma. Randomized controlled trials that monitored ETCO2 as a primary or secondary outcome were included. Studies were examined for potential risk of bias using the Revised Cochrane risk of bias tool by two independent reviewers.

RESULTS

Eight articles were included. The trials used various techniques like Buteyko, Papworth, Biofeedback, and holistic approach. Quantitative analysis was conducted to examine the effects on ETCO2 at various time points. A significant large effect was seen on ETCO2 following breathing re-training post-treatment, 3 and 6 months post-intervention.

CONCLUSION

There is moderate evidence for a significant effect of breathing re-training on ETCO2 in the short and long term in patients with asthma. However, high-quality randomized controlled trials using standardized measurement of ETCO2 are required to evaluate the effects of different breathing re-training techniques.

Questions in Mild Asthma: An Official American Thoracic Society Research Statement

Background: Patients with mild asthma are believed to represent the majority of patients with asthma. Disease-associated risks such as exacerbations, lung function decline, and death have been understudied in this patient population. There have been no prior efforts from major societies to describe research needs in mild asthma. Methods: A multidisciplinary, diverse group of 24 international experts reviewed the literature, identified knowledge gaps, and provided research recommendations relating to mild asthma definition, pathophysiology, and management across all age groups. Research needs were also investigated from a patient perspective, generated in conjunction with patients with asthma, caregivers, and stakeholders. Of note, this project is not a systematic review of the evidence and is not a clinical practice guideline. Results: There are multiple unmet needs in research on mild asthma driven by large knowledge gaps in all areas. Specifically, there is an immediate need for a robust mild asthma definition and an improved understanding of its pathophysiology and management strategies across all age groups. Future research must factor in patient perspectives. Conclusions: Despite significant advances in severe asthma, there remain innumerable research areas requiring urgent attention in mild asthma. An important first step is to determine a better definition that will accurately reflect the heterogeneity and risks noted in this group. This research statement highlights the topics of research that are of the highest priority. Furthermore, it firmly advocates the need for engagement with patient groups and for more support for research in this field.

Immediate changes in chest mobility and trunk muscle activity during pelvic tilt following different trunk muscle exercises

BACKGROUND

Given the characteristics of the superficial trunk muscles that cross the chest and pelvis, their excessive contraction might limit chest mobility.

OBJECTIVE

To examine the immediate effects of two types of trunk muscle exercises on chest mobility and trunk muscle activities.

METHODS

Fourteen healthy men (age: 21.1 ± 1.0 years, height: 172.7 ± 5.6 cm, weight: 61.0 ± 7.1 kg, body mass index: 20.4 ± 1.7 kg/m2; mean ± SD) randomly performed trunk side flexion and draw-in exercises using a cross-over design. The chest kinematic data and trunk muscle activities were measured before and after each intervention during the following tasks: maximum inspiration/expiration and maximum pelvic anterior/posterior tilt while standing. Two-way repeated measures analysis of variance was used for statistical analysis (P< 0.05).

RESULTS

After the side flexion, upper and lower chest mobility significantly decreased, and superficial trunk muscle activity significantly increased during the maximum pelvic anterior tilt (P< 0.05). Additionally, after the draw-in, upper chest mobility significantly increased during the maximum pelvic anterior tilt (P< 0.05).

CONCLUSIONS

Increased activity of the superficial abdominal muscles might limit chest mobility during maximum pelvic anterior tilt. Conversely, the facilitation of deep trunk muscles might increase upper chest mobility during the maximum pelvic anterior tilt.

Breathing exercises and pranayamas to decrease perceived exertion during breath-holding while locked-down due to COVID-19 online randomized study

AIM

to compare anulom vilom pranayama (AVP), kapal bhati pranayama (KBP), diaphragmatic breathing exercises (DBE), and pursed-lip breathing (PLB) for breath holding time (BHT) and rating of perceived exertion (RPE). Methods- Participants were assessed for BHT and RPE, before training on any one intervention using online platforms, for one week during lockdown from COVID-19.15 participants in each group total N = 60 at- (α - 0.05), (1- β - 0.90) & (effect size - 0.55); were analysed. Results - AVP & DBE decreased RPE (p < 0.000). KBP & PLB did not decrease RPE as compared to AVP & DBE (p. > 0.05). DBE increased BHT more than KBP & PLB interventions (p < 0.05), but not more than AVP (p > 0.05). One-way ANOVA of four interventions revealed significant variation for RPE change (p < 0.05), for AVP. Conclusions - AVP reduces RPE maximally during breath-holding, whereas DPE increases BHT more.

Effects of Aerobic Training Versus Breathing Exercises on Asthma Control: A Randomized Trial

BACKGROUND

Aerobic training and breathing exercises are interventions that improve asthma control. However, the outcomes of these 2 interventions have not been compared.

OBJECTIVE

To compare the effects of aerobic training versus breathing exercises on clinical control (primary outcome), quality of life, exercise capacity, and airway inflammation in outpatients with moderate-to-severe asthma.

METHODS

Fifty-four asthmatics were randomized into either the aerobic training group (AG, n = 29) or the breathing exercise group (BG, n = 25). Both interventions lasted for 24 sessions (2/week, 40 minutes/session). Asthma clinical control (Asthma Control Questionnaire [ACQ]), quality of life (Asthma Quality of Life Questionnaire), asthma symptom-free days (ASFD), airway inflammation, exercise capacity, psychological distress (Hospital Anxiety and Depression Scale), daily-life physical activity (DLPA), and pulmonary function were evaluated before, immediately after, and 3 months after the intervention.

RESULTS

Both interventions presented similar results regarding the ACQ score, psychological distress, ASFD, DLPA, and airway inflammation (P > .05). However, participants in the AG were 2.6 times more likely to experience clinical improvement at the 3-month follow-up than participants in the BG (P = .02). A greater proportion of participants in the AG also presented a reduction in the number of days without rescue medication use compared with BG (34% vs 8%; P = .04).

CONCLUSIONS

Outpatients with moderate-to-severe asthma who participated in aerobic training or breathing exercise programs presented similar results in asthma control, quality of life, asthma symptoms, psychological distress, physical activity, and airway inflammation. However, a greater proportion of participants in the AG presented improvement in asthma control and reduced use of rescue medication.

Breathing exercises for adults with asthma

BACKGROUND

Breathing exercises have been widely used worldwide as a non-pharmacological therapy to treat people with asthma. Breathing exercises aim to control the symptoms of asthma and can be performed as the Papworth Method, the Buteyko breathing technique, yogic breathing, deep diaphragmatic breathing or any other similar intervention that manipulates the breathing pattern. The training of breathing usually focuses on tidal and minute volume and encourages relaxation, exercise at home, the modification of breathing pattern, nasal breathing, holding of breath, lower rib cage and abdominal breathing.

OBJECTIVES

To evaluate the evidence for the efficacy of breathing exercises in the management of people with asthma.

SEARCH METHODS

To identify relevant studies we searched The Cochrane Library, MEDLINE, Embase, PsycINFO, CINAHL and AMED and performed handsearching of respiratory journals and meeting abstracts. We also consulted trials registers and reference lists of included articles. The most recent literature search was on 4 April 2019.

SELECTION CRITERIA

We included randomised controlled trials of breathing exercises in adults with asthma compared with a control group receiving asthma education or, alternatively, with no active control group.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed study quality and extracted data. We used Review Manager 5 software for data analysis based on the random-effects model. We expressed continuous outcomes as mean differences (MDs) with confidence intervals (CIs) of 95%. We assessed heterogeneity by inspecting the forest plots. We applied the Chi2 test, with a P value of 0.10 indicating statistical significance, and the I2 statistic, with a value greater than 50% representing a substantial level of heterogeneity. The primary outcome was quality of life.

MAIN RESULTS

We included nine new studies (1910 participants) in this update, resulting in a total of 22 studies involving 2880 participants in the review. Fourteen studies used Yoga as the intervention, four studies involved breathing retraining, one the Buteyko method, one the Buteyko method and pranayama, one the Papworth method and one deep diaphragmatic breathing. The studies were different from one another in terms of type of breathing exercise performed, number of participants enrolled, number of sessions completed, period of follow-up, outcomes reported and statistical presentation of data. Asthma severity in participants from the included studies ranged from mild to moderate, and the samples consisted solely of outpatients. Twenty studies compared breathing exercise with inactive control, and two with asthma education control groups. Meta-analysis was possible for the primary outcome quality of life and the secondary outcomes asthma symptoms, hyperventilation symptoms, and some lung function variables. Assessment of risk of bias was impaired by incomplete reporting of methodological aspects of most of the included studies. We did not include adverse effects as an outcome in the review. Breathing exercises versus inactive control For quality of life, measured by the Asthma Quality of Life Questionnaire (AQLQ), meta-analysis showed improvement favouring the breathing exercises group at three months (MD 0.42, 95% CI 0.17 to 0.68; 4 studies, 974 participants; moderate-certainty evidence), and at six months the OR was 1.34 for the proportion of people with at least 0.5 unit improvement in AQLQ, (95% CI 0.97 to 1.86; 1 study, 655 participants). For asthma symptoms, measured by the Asthma Control Questionnaire (ACQ), meta-analysis at up to three months was inconclusive, MD of -0.15 units (95% CI -2.32 to 2.02; 1 study, 115 participants; low-certainty evidence), and was similar over six months (MD -0.08 units, 95% CI -0.22 to 0.07; 1 study, 449 participants). For hyperventilation symptoms, measured by the Nijmegen Questionnaire (from four to six months), meta-analysis showed less symptoms with breathing exercises (MD -3.22, 95% CI -6.31 to -0.13; 2 studies, 118 participants; moderate-certainty evidence), but this was not shown at six months (MD 0.63, 95% CI -0.90 to 2.17; 2 studies, 521 participants). Meta-analyses for forced expiratory volume in 1 second (FEV1) measured at up to three months was inconclusive, MD -0.10 L, (95% CI -0.32 to 0.12; 4 studies, 252 participants; very low-certainty evidence). However, for FEV1 % of predicted, an improvement was observed in favour of the breathing exercise group (MD 6.88%, 95% CI 5.03 to 8.73; five studies, 618 participants). Breathing exercises versus asthma education For quality of life, one study measuring AQLQ was inconclusive up to three months (MD 0.04, 95% CI -0.26 to 0.34; 1 study, 183 participants). When assessed from four to six months, the results favoured breathing exercises (MD 0.38, 95% CI 0.08 to 0.68; 1 study, 183 participants). Hyperventilation symptoms measured by the Nijmegen Questionnaire were inconclusive up to three months (MD -1.24, 95% CI -3.23 to 0.75; 1 study, 183 participants), but favoured breathing exercises from four to six months (MD -3.16, 95% CI -5.35 to -0.97; 1 study, 183 participants).

AUTHORS' CONCLUSIONS

Breathing exercises may have some positive effects on quality of life, hyperventilation symptoms, and lung function. Due to some methodological differences among included studies and studies with poor methodology, the quality of evidence for the measured outcomes ranged from moderate to very low certainty according to GRADE criteria. In addition, further studies including full descriptions of treatment methods and outcome measurements are required.

The impact of dysfunctional breathing on the level of asthma control in difficult asthma

BACKGROUND

Difficult asthma is defined as asthma requiring high dose treatment. However, systematic assessment is required to differentiate severe asthma from difficult-to-treat asthma. Dysfunctional breathing (DB) is a common comorbidity in difficult asthma, which may contribute to symptoms, but how it affects commonly used measures of symptom control is unclear.

METHODS

All adult asthma patients seen in four respiratory clinics over one year were screened prospectively, and patients with possible severe asthma according to ERS/ATS criteria ('Difficult asthma': high-dose inhaled corticosteroids/oral corticosteroids), underwent systematic assessment. Symptoms of DB were assessed utilizing a symptom based subjective tool, Nijmegen questionnaire (NQ), and objective signs of DB with the Breathing Pattern Assessment Tool (BPAT). Asthma control and quality of life were evaluated with the Asthma Control Questionnaire (ACQ) and the mini Asthma Quality of Life Questionnaire (AQLQ).

RESULTS

A total of 117 patients were included. Among these, 29.9% (35/117) had DB according to the NQ. Patients with DB had a poorer asthma control (ACQ: Mean (SD) 2.86 ± 1.05 vs. 1.46 ± 0.93) and lower quality of life (AQLQ score: Mean (SD) 4.2 ± 1.04 vs. 5.49 ± 0.85) compared to patients without DB. Similarly, patients with objective signs of DB according to the BPAT score had worse asthma control: BPAT >4 vs < 4: (ACQ: Mean (SD) 3.15 ± 0.93 vs 2.03 ± 1.15).

CONCLUSION

DB is common among patients with difficult asthma, and is associated with significantly poorer asthma control and lower quality of life. Assessment and treatment of DB is an important part of the management of difficult asthma.

Nonpharmacologic Therapy for Severe Persistent Asthma

The treatment of asthma largely depends on guideline-based pharmacologic therapies. However, nonpharmacologic therapies for asthma such as pulmonary rehabilitation, focused breathing techniques, and bronchial thermoplasty have an important, yet underappreciated, role. Structured pulmonary rehabilitation programs can reduce dyspnea and increase cardiopulmonary fitness. The educational component of these programs can ensure that therapies are being used appropriately, increase compliance, and decrease health care utilization. Studies have demonstrated a reduction in inflammatory mediators in patients with asthma who are engaged in an exercise program. Focused breathing techniques are commonly used by patients with asthma, yet benefit has not been clearly shown in randomized controlled trials. For the patients with severe asthma who are unresponsive to maximum medical therapy and have evidence of airway remodeling, bronchial thermoplasty has demonstrated long-term improvement in quality of life and reduction in severe exacerbations and health care utilization. Recent airway biopsy studies have demonstrated bronchial thermoplasty's disease-modifying effect on smooth muscle, inflammatory mediators, and bronchial nerve endings. These nonpharmacologic therapies are complementary to current guideline-based treatment, including the use of biologic modifiers, for severe asthma.

Patients' experiences of breathing retraining for asthma: a qualitative process analysis of participants in the intervention arms of the BREATHE trial

Poor symptom control and impaired quality of life are common in adults with asthma, and breathing retraining exercises may be an effective method of self-management. This study aimed to explore the experiences of participants in the intervention arms of the BREATHE trial, which investigated the effectiveness of breathing retraining as a mode of asthma management. Sixteen people with asthma (11 women, 8 per group) who had taken part in the intervention arms of the BREATHE trial (breathing retraining delivered by digital versatile disc (DVD) or face-to-face sessions with a respiratory physiotherapist) took part in semi-structured telephone interviews about their experiences. Interviews were analysed using thematic analysis. Breathing retraining was perceived positively as a method of asthma management. Motivations for taking part included being asked, to enhance progress in research, to feel better/reduce symptoms, and to reduce medication. Participants were positive about the physiotherapist, liked having the materials tailored, found meetings motivational, and liked the DVD and booklet. The impact of breathing retraining following regular practice included increased awareness of breathing and development of new habits. Benefits of breathing retraining included increased control over breathing, reduced need for medication, feeling more relaxed, and improved health and quality of life. Problems included finding time to practice the exercises, and difficulty mastering techniques. Breathing retraining was acceptable and valued by almost all participants, and many reported improved wellbeing. Face to face physiotherapy was well received. However, some participants in the DVD group mentioned being unable to master techniques.

Patients with asthma taught how to change their unconscious breathing patterns generally like non-pharmacological interventions. Researchers in the UK, led by Mike Thomas from the University of Southampton, interviewed 16 people about their experiences in a trial that tested breathing retraining exercises delivered by DVD or face-to-face sessions with a respiratory physiotherapist. Overwhelmingly, trial participants reported that breathing retraining sessions gave them greater control over their symptoms, helped them relax, improved their quality of life and reduced the need for medications. Some participants who received DVD instruction said they had trouble mastering the techniques, and many in both groups found it hard to find time to practice the exercises. Overall, however, patients were positive about the experience. The authors conclude that breathing exercises are likely to be a well-received method of asthma management.

A randomised controlled study of the effectiveness of breathing retraining exercises taught by a physiotherapist either by instructional DVD or in face-to-face sessions in the management of asthma in adults

BACKGROUND

Asthma control is suboptimal, resulting in quality of life (QoL) impairment and costs. Breathing retraining exercises have evidence of effectiveness as adjuvant treatment, but are infrequently used.

OBJECTIVES

To transfer the contents of a brief (three-session) physiotherapist-delivered breathing retraining programme to a digital versatile disc (DVD) and booklet format; to compare the effectiveness of the self-guided intervention with that of 'face-to-face' physiotherapy and usual care for QoL and other asthma-related outcomes; to perform a health economic assessment of both interventions; and to perform a process evaluation using quantitative and qualitative methods.

DESIGN

Parallel-group three-arm randomised controlled trial.

SETTING

General practice surgeries in the UK.

PARTICIPANTS

In total, 655 adults currently receiving asthma treatment with impaired asthma-related QoL were randomly allocated to the DVD (n = 261), physiotherapist (n = 132) and control (usual care) (n = 262) arms in a 2 : 1 : 2 ratio. It was not possible to blind participants but data collection and analysis were performed blinded.

INTERVENTIONS

Physiotherapy-based breathing retraining delivered through three 'face-to-face' respiratory physiotherapist sessions or a self-guided programme (DVD plus our theory-based behaviour change booklet) developed by the research team, with a control of usual care.

MAIN OUTCOME MEASURES

The primary outcome measure was asthma-specific QoL, measured using the Asthma Quality of Life Questionnaire (AQLQ). Secondary outcomes included asthma symptom control [Asthma Control Questionnaire (ACQ)], psychological state [Hospital Anxiety and Depression Scale (HADS)], hyperventilation symptoms (Nijmegen questionnaire), generic QoL [EuroQol-5 Dimensions (EQ-5D)], assessments of airway physiology (spirometry) and inflammation (exhaled nitric oxide) and health resource use and costs. Assessments were carried out at baseline and at 3, 6 and 12 months post randomisation. Patient engagement and experience were also assessed using quantitative and qualitative methods.

RESULTS

Primary efficacy analysis was between-group comparison of changes in AQLQ scores from baseline to 12 months in the intention-to-treat population with adjustments for prespecified covariates. Significant improvements occurred in the DVD group compared with the control group [adjusted mean difference 0.28, 95% confidence interval (CI) 0.11 to 0.44; p < 0.001] and in the face-to-face physiotherapy group compared with the control group (adjusted mean difference 0.24, 95% CI 0.04 to 0.44; p < 0.05), with equivalence between the DVD and the face-to-face physiotherapy groups (adjusted mean difference 0.04, 95% CI -0.16 to 0.24). In all sensitivity analyses, both interventions remained significantly superior to the control and equivalence between the interventions was maintained. In other questionnaire outcome measures and in the physiological measures assessed, there were no significant between-group differences. Process evaluations showed that participants engaged well with both of the active interventions, but that some participants in the DVD arm would have liked to receive tuition from a professional. Asthma health-care costs were lower in both intervention arms than in the control group, indicating 'dominance' for both of the interventions compared with the control, with lowest costs in the DVD arm. The rate of adverse events was lower in the DVD and face-to-face physiotherapy groups than in the control group.

CONCLUSIONS

Only 10% of the potentially eligible population responded to the study invitation. However, breathing retraining exercises improved QoL and reduced health-care costs in adults with asthma whose condition remains uncontrolled despite standard pharmacological therapy, were engaged with well by patients and can be delivered effectively as a self-guided intervention. The intervention should now be transferred to an internet-based platform and implementation studies performed. Interventions for younger patients should be developed and trialled.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN88318003.

FUNDING

This project was primarily funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 53. See the NIHR Journals Library website for further project information. Additional financial support was received from Comprehensive Local Research Networks.

Breathing exercises for adults with asthma

Asthma is a common long-term condition that remains poorly controlled in many people despite the availability of pharmacological interventions, evidence-based treatment guidelines and care pathways.(1) There is considerable public interest in the use of non-pharmacological approaches for the treatment of asthma.(2) A survey of people with asthma reported that many have used complementary and alternative medicine, often without the knowledge of their clinical team.(3) Such interventions include breathing techniques, herbal products, homeopathy and acupuncture. The role of breathing exercises within the management of asthma has been controversial, partly because early claims of effectiveness were exaggerated.(4) UK national guidance and international guidelines on the management of asthma have included the option of breathing exercise programmes as an adjuvant to pharmacological treatment.(5,6) Here we discuss the types of breathing exercises used and review the evidence for their effectiveness.

Diagnosis and investigation in the severe asthma clinic

Severe asthma is recognised as an important and emerging area of unmet need in asthma. The assessment of severe asthma should include three steps; (1) determining the diagnosis of asthma, including verification that the disease is severe asthma, (2) assessing comorbidities and contributing factors that will impact on clinical severity, as well as (3) assessing asthma phenotypes. These steps recognize the importance of heterogeneity in asthma as a key factor that determines the disease course and increasingly the choice of successful therapy. This assessment should be undertaken systematically and is best done by an expert multidisciplinary team. Here, we will outline the important aspects that should be included in the clinical assessment of the patient in the severe asthma clinic, including diagnosis, clinical history, the assessment of important comorbidities and the key investigations needed to support them.

Breathing exercises for asthma

Educational aims

To summarise the evidence of the role of breathing control approaches in the management of asthma

To provide information on the content of evidence-based breathing exercises programmes

Summary

Asthma is a complex, multi-dimensional condition that affects patients in many ways. Having asthma is inherently stressful and psychological problems are common and associated with poor asthma outcomes. Although most patients in clinical trials can achieve high levels of control with optimised pharmacotherapy, in “real-life” practice, poor control is common, with over-reliance on rescue bronchodilator medication and ongoing symptoms and quality-of-life impairment. Many patients are interested in non-pharmacological treatments to improve asthma control, particularly breathing control exercises but, until recently, the evidence base has been inadequate. The place of breathing exercises has been controversial, partly because some proponents have made exaggerated, implausible claims of effectiveness. Recent evidence, however, has resulted in endorsement of breathing exercises as add-on treatment in asthma in systematic reviews and guidelines.

This review summarises the current evidence of effectiveness of breathing exercises programmes as an adjuvant treatment to pharmacological strategies for people with asthma. The types of breathing training programmes used and the content of effective programmes are discussed. We conclude that patients whose asthma continues to cause symptoms and quality-of-life impairment, despite adequate pharmacological treatment, or who have high bronchodilator use, should be offered access to an effective breathing training programme as a part of holistic, integrated asthma care.

Key points

Asthma is frequently poorly controlled despite effective modern medication

Psychological factors can be as important as physiological ones in affecting symptom perception and disease impact

Breathing exercises can improve patient-reported outcomes and psychological state

Breathing exercises should be offered to all asthma patients with symptoms or impaired quality of life despite standard treatment

Incentive spirometry combined with expiratory positive airway pressure improves asthma control and quality of life in asthma: a randomised controlled trial

OBJECTIVES

The use of the incentive spirometer (IS) and expiratory positive airway pressure (EPAP) provides several benefits in patients with respiratory disorders. However, the effects of the use of these devices coupled (IS + EPAP) are still unknown in asthmatic patients. The aim of this study was to evaluate the effect of IS associated with EPAP on exercise tolerance (six-minute walk test - 6MWT), lung function (by spirometry), asthma control (Asthma Control Questionnaire - ACQ) and quality of life (Asthma Quality of Life Questionnaire - AQLQ) in patients with severe asthma.

METHODS

Patients were randomised into two groups: IS + EPAP (n = 8) and control (n = 6). The IS + EPAP group performed breathing exercises at home, twice daily for 20 min, over a period of 5 weeks.

RESULTS

There was no significant difference in spirometric variables and in the distance walked in the 6MWT in both groups. However, the IS + EPAP group showed an improvement in asthma control (p = 0.002) and quality of life (p = 0.02).

CONCLUSIONS

These findings demonstrate that the IS + EPAP protocol, when performed at home, provides an improvement in asthma control and quality of life for patients with severe asthma when evaluated by ACQ and AQLQ, respectively.

Hyperventilation in asthma: a validation study of the Nijmegen Questionnaire--NQ

INTRODUCTION

The Nijmegen questionnaire (NQ) has previously been used for screening the hyperventilation syndrome (HVS) in asthmatics. However, no validity study has been reported so far.

OBJECTIVE

To examine the validity and reliability of the NQ in asthma patients and identify the prevalence of HVS.

METHODS

The NQ (n = 162) was examined for translation, construct, cross-sectional and discriminant validity as well as for internal consistency and test-retest reliability.

RESULTS

Principal component analysis and exploratory factor analysis revealed a single factor solution with 11 items and 58.6% of explained variability. These 11 NQ items showed high internal consistency (Cronbach's alpha = 0.92) and test-retest reliability (IR = 0.98). Higher NQ scores were found in the following subgroups: women versus men (p < 0.01); participants with moderate versus mild asthma (p < 0.001) or uncontrolled versus controlled asthma (p < 0.001), and participants with breath-hold time (BHT) < 30 versus ≥ 30 s (p < 0.01) or end-tidal CO2 (ETCO2) ≤ 35 versus >35 mmHg (p < 0.001). A cut-off score of >17 discriminated the participants with regard to the presence of HVS. The NQ showed 92.73% sensitivity and 91.59% specificity. The total NQ score was found significantly correlated with ETCO2 (r = -0.68), RR (r = 0.66) and BHT (r = -0.65). The prevalence of HVS was found 34%.

CONCLUSION

The NQ is a valid and reliable questionnaire for screening HVS in patients with stable mild-to-moderate asthma.

Multimedia-assisted breathwalk-aware system

Breathwalk is a science of combining specific patterns of footsteps synchronized with the breathing. In this study, we developed a multimedia-assisted Breathwalk-aware system which detects user's walking and breathing conditions and provides appropriate multimedia guidance on the smartphone. Through the mobile device, the system enhances user's awareness of walking and breathing behaviors. As an example application in slow technology, the system could help meditator beginners learn "walking meditation," a type of meditation which aims to be as slow as possible in taking pace, to synchronize footstep with breathing, and to land every footstep with toes first. In the pilot study, we developed a walking-aware system and evaluated whether multimedia-assisted mechanism is capable of enhancing beginner's walking awareness while walking meditation. Experimental results show that it could effectively assist beginners in slowing down the walking speed and decreasing incorrect footsteps. In the second experiment, we evaluated the Breathwalk-aware system to find a better feedback mechanism for learning the techniques of Breathwalk while walking meditation. The experimental results show that the visual-auditory mechanism is a better multimedia-assisted mechanism while walking meditation than visual mechanism and auditory mechanism.

Breathing exercises for adults with asthma

BACKGROUND

Breathing exercises have been widely used worldwide as a complementary therapy to the pharmacological treatment of people with asthma.

OBJECTIVES

To evaluate the evidence for the efficacy of breathing exercises in the management of patients with asthma.

SEARCH METHODS

The search for trials led review authors to review the literature available in The Cochrane Library, MEDLINE, EMBASE, PsycINFO, CINAHL and AMED and to perform handsearching of respiratory journals and meeting abstracts. Trial registers and reference lists of included articles were also consulted.The literature search has been updated to January 2013.

SELECTION CRITERIA

We included randomised controlled trials of breathing exercises in adults with asthma compared with a control group receiving asthma education or, alternatively, with no active control group.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. RevMan software was used for data analysis based on the fixed-effect model. Continuous outcomes were expressed as mean differences (MDs) with confidence intervals (CIs) of 95%. Heterogeneity was assessed by inspecting the forest plots. The Chi(2) test was applied, with a P value of 0.10 indicating statistical significance. The I(2) statistic was implemented, with a value greater than 50% representing a substantial level of heterogeneity.

MAIN RESULTS

A total of 13 studies involving 906 participants are included in the review. The trials were different from one another in terms of type of breathing exercise performed, number of participants enrolled, number and duration of sessions completed, outcomes reported and statistical presentation of data. Asthma severity in participants from the included studies ranged from mild to moderate, and the samples consisted solely of outpatients. The following outcomes were measured: quality of life, asthma symptoms, number of acute exacerbations and lung function. Eleven studies compared breathing exercise with inactive control, and two with asthma education control groups. All eight studies that assessed quality of life reported an improvement in this outcome. An improvement in the number of acute exacerbations was observed by the only study that assessed this outcome. Six of seven included studies showed significant differences favouring breathing exercises for asthma symptoms. Effects on lung function were more variable, with no difference reported in five of the eleven studies that assessed this outcome, while the other six showed a significant difference for this outcome, which favoured breathing exercises. As a result of substantial heterogeneity among the studies, meta-analysis was possible only for asthma symptoms and changes in the Asthma Quality of Life Questionnaire (AQLQ). Each meta-analysis included only two studies and showed a significant difference favouring breathing exercises (MD -3.22, 95% CI -6.31 to -0.13 for asthma symptoms; MD 0.79, 95% CI 0.50 to 1.08 for change in AQLQ). Assessment of risk of bias was impaired by incomplete reporting of methodological aspects of most of the included trials.

AUTHORS' CONCLUSIONS

Even though individual trials reported positive effects of breathing exercises, no reliable conclusions could be drawn concerning the use of breathing exercises for asthma in clinical practice. This was a result of methodological differences among the included studies and poor reporting of methodological aspects in most of the included studies. However, trends for improvement are encouraging, and further studies including full descriptions of treatment methods and outcome measurements are required.

Physiotherapy in asthma--seeking consensus

OBJECTIVE

The evidence base for or against physiotherapy interventions in asthmatic adults remains ambiguous, and there are discrepancies between different clinical practice guidelines. We evaluated the level of agreement between the recommendations about physiotherapy for adults with asthma in two major clinical practice guidelines: the Global Initiative for Asthma (GINA 2011) and the British Thoracic Society and the Association of Chartered Physiotherapists in Respiratory Care (BTS/ACPRC 2009).

METHODS

We used the Appraisal of Guidelines for Research & Evaluation (AGREE II) instrument to assess the methodological rigor of the guideline development, the Assessment of Multiple Systematic Reviews (AMSTAR) tool and the Physiotherapy Evidence Database (PEDro) scale to assess the methodological quality of systematic reviews and clinical trials included in the analyzed documents. Additionally, we compared the reference lists of the analyzed sections to establish the overlap in included primary and secondary studies.

RESULTS

We observed no agreement between the two guidelines in the choice of source research articles. Only two studies out of 18 used in BTS guidelines were used in the GINA. The reason why GINA developers did not use the body of evidence included in BTS is that it is not clear. Three independent investigators indicated higher scores in all domains of the AGREE II in the BTS/ACPRC document in comparison with the GINA guidelines.

CONCLUSIONS

The significant differences in the content and in the development processes of the examined sections of the two guidelines suggest the need for more frequent and careful updating or directing the readers of the GINA to the BTS/ACPRC, a guideline addressing specifically and more comprehensively physiotherapy interventions in asthma.

Intermittent versus daily inhaled corticosteroids for persistent asthma in children and adults

BACKGROUND

Daily inhaled corticosteroids (ICS) are the recommended mainstay of treatment in children and adults with persistent asthma. However, often, ICS are used intermittently by patients or recommended by physicians to be used only at the onset of exacerbations.

OBJECTIVES

The aim of this review was to compare the efficacy and safety of intermittent versus daily ICS in the management of children and adults with persistent asthma and preschool-aged children suspected of persistent asthma.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register of trials (CAGR) and the ClinicalTrials.gov web site up to October 2012.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared intermittent ICS versus daily ICS in children and adults with persistent asthma. No co-interventions were permitted other than rescue relievers and oral corticosteroids used during exacerbations.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, methodological quality and extracted data. The primary efficacy outcome was the number of patients with one or more exacerbations requiring oral corticosteroids and the primary safety outcome was the number of patients with serious adverse health events. Secondary outcomes included exacerbations, lung function tests, asthma control, adverse effects, withdrawal rates and inflammatory markers. Equivalence was assumed if the risk ratio (RR) estimate and its 95% confidence interval (CI) were between 0.9 and 1.1. Quality of the evidence was assessed using GRADE.

MAIN RESULTS

Six trials (including one trial testing two relevant protocols) met the inclusion criteria for a total of seven group comparisons. The four paediatric trials (two involving preschool children and two school-aged children) and two adult parallel-group trials, lasting 12 to 52 weeks, were of high methodological quality. A total of 1211 patients with confirmed, or suspected, persistent asthma contributed to the meta-analyses. There was no statistically significant group difference in the risk of patients experiencing one or more exacerbations requiring oral corticosteroids (1204 patients; RR 1.07; 95% CI 0.87 to 1.32; the large confidence interval translates into a risk of exacerbations in the intermittent ICS group varying between 17% and 25%, assuming a 19% risk with daily ICS). Age, severity of airway obstruction, step-up protocol used during exacerbations and trial duration did not significantly influence the primary efficacy outcome. No group difference was observed in the risk of patients with serious adverse health events (1055 patients; RR 0.82; 95% CI 0.33 to 2.03). Compared to the daily ICS group, the intermittent ICS group displayed a smaller improvement in change from baseline peak expiratory flow rate (PEFR) by 2.56% (95% CI -4.49% to -0.63%), fewer symptom-free days (standardised mean difference (SMD) -0.15 (95% CI -0.28 to -0.03), fewer asthma control days -9% (95% CI -14% to -4%), more use of rescue β2-agonists by 0.12 puffs/day (95% CI 0 to 0.23) and a greater increase from baseline in exhaled nitric oxide of 16.80 parts per billion (95% CI 11.95 to 21.64). There was no significant group difference in forced expiratory volume in one second (FEV1), quality of life, airway hyper-reactivity, adverse effects, hospitalisations, emergency department visits or withdrawals. In paediatric trials, intermittent ICS (budesonide and beclomethasone) were associated with greater growth by 0.41 cm change from baseline (532 children; 95% CI 0.13 to 0.69) compared to daily treatment.

AUTHORS' CONCLUSIONS

In children and adults with persistent asthma and in preschool children suspected of persistent asthma, there was low quality evidence that intermittent and daily ICS strategies were similarly effective in the use of rescue oral corticosteroids and the rate of severe adverse health events. The strength of the evidence means that we cannot currently assume equivalence between the two options.. Daily ICS was superior to intermittent ICS in several indicators of lung function, airway inflammation, asthma control and reliever use. Both treatments appeared safe, but a modest growth suppression was associated with daily, compared to intermittent, inhaled budesonide and beclomethasone. Clinicians should carefully weigh the potential benefits and harm of each treatment option, taking into account the unknown long-term (> one year) impact of intermittent therapy on lung growth and lung function decline.

The effectiveness of physiotherapy in patients with asthma: a systematic review of the literature

Since the introduction of medical therapy for asthma the interest in non-medical treatments deteriorated. Physiotherapy could have beneficial effects in asthmatics. This review investigates the effectiveness of physiotherapy in the treatment of patients with asthma. A review was performed on the terms breathing exercises (BE), inspiratory muscle training (IMT), physical training (PhT) and airway clearance (AC) in patients with asthma. The search resulted in 237 potentially relevant articles, after exclusion 23 articles remained. BE (n = 9) may improve disease specific quality of life (QoL), reduce symptoms, hyperventilation, anxiety and depression, lower respiratory rate and medication use. IMT (n = 3) can improve inspiratory pressure and may reduce medication use and symptoms. PhT (n = 12) can reduce symptoms, improve QoL and improve cardiopulmonary endurance and fitness. In conclusion, physiotherapy may improve QoL, cardiopulmonary fitness and inspiratory pressure and reduce symptoms and medication use. Further studies, investigating combinations of techniques, are needed to confirm these findings.

Intermittent versus daily inhaled corticosteroids for persistent asthma in children and adults

BACKGROUND

Daily inhaled corticosteroids (ICS) are the recommended mainstay of treatment in children and adults with persistent asthma. Yet often, ICS are used intermittently by patients or recommended by physicians to be used only at the onset of exacerbations.

OBJECTIVES

The aim of this review was to compare the efficacy and safety of intermittent versus daily ICS in the management of children and adults with persistent asthma and preschool-aged children suspected of persistent asthma.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register of trials (CAGR) and the ClinicalTrials.gov website up to December 2011.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared intermittent ICS versus daily ICS in children and adults with persistent asthma. No co-interventions were permitted other than rescue relievers and oral corticosteroids used during exacerbations.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, methodological quality and extracted data. The primary efficacy outcome was the number of patients with one or more exacerbations requiring oral corticosteroids and the primary safety outcome was the number of patients with serious adverse health events. Secondary outcomes included exacerbations, lung function tests, asthma control, adverse effects, withdrawal rates and inflammatory markers. Equivalence was assumed if the risk ratio (RR) estimate and its 95% confidence interval (CI) were between 0.9 and 1.1.

MAIN RESULTS

Six trials (including one trial testing two relevant protocols) met the inclusion criteria for a total of seven group comparisons. The four paediatric trials (two involving preschool children and two school-aged children) and two adult parallel-group trials, lasting 12 to 52 weeks, were of high methodological quality. A total of 1211 patients with confirmed, or suspected, persistent asthma contributed to the meta-analyses. There was no statistically significant group difference in the risk of patients experiencing one or more exacerbations requiring oral corticosteroids (1204 patients; RR 1.07; 95% CI 0.87 to 1.32). The patients' age, severity of airway obstruction, step-up protocol used during exacerbations and trial duration did not significantly influence the primary efficacy outcome. No group difference was observed in the risk of patients with serious adverse health events (1055 patients; RR 0.82; 95% CI 0.33 to 2.03). Compared to the daily ICS group, the intermittent ICS group displayed a smaller improvement in change from baseline peak expiratory flow rate (PEFR) by 2.56% (95% CI -4.49% to -0.63%), fewer symptom-free days (standardised mean difference (SMD) -0.15 (95% CI -0.28 to -0.03), fewer asthma control days -9% (95% CI -14% to -4%), more use of rescue β(2)-agonists by 0.12 puffs/day (95% CI 0 to 0.23) and a greater increase from baseline in exhaled nitric oxide of 16.80 parts per billion (95% CI 11.95 to 21.64). There was no significant group difference in forced expiratory volume in one second (FEV(1)), quality of life, airway hyper-reactivity, adverse effects, hospitalisations, emergency department visits or withdrawals. In paediatric trials, intermittent ICS (budesonide and beclomethasone) were associated with greater growth by 0.41 cm change from baseline (532 children; 95% CI 0.13 to 0.69) compared to daily treatment.

AUTHORS' CONCLUSIONS

In children and adults with persistent asthma and in preschool children suspected of persistent asthma, intermittent and daily ICS strategies did not significantly differ in the use of rescue oral corticosteroids and the rate of severe adverse health events, neither did they reach equivalence. Daily ICS was superior to intermittent ICS in several indicators of lung function, airway inflammation, asthma control and reliever use. Both treatments appeared safe, but a modest growth suppression was associated with daily, compared to intermittent, inhaled budesonide and beclomethasone. The clinician should carefully weigh the potential benefits and harm of each treatment option, taking into account the unknown long-term (> one year) impact of intermittent therapy on lung growth and lung function decline.

Treating according to asthma control: does it work in real life?

Control-based asthma management has been incorporated in asthma guidelines for many years. This article reviews the evidence for its utility in adults, describes its strengths and limitations in real life, and proposes areas for further research, particularly about incorporation of future risk and identification of patients for whom phenotype-guided treatment would be effective and efficient. The strengths of control-based management include its simplicity and feasibility for primary care, and its limitations include the nonspecific nature of asthma symptoms, the complex role of β(2)-agonist use, barriers to stepping down treatment, and the underlying assumptions about asthma pathophysiology and treatment responses.

Comparison of the effects of Buteyko and pranayama breathing techniques on quality of life in patients with asthma - a randomized controlled trial

OBJECTIVE

To compare two breathing exercises (Buteyko and pranayama) with a control group in patients with asthma.

DESIGN

Randomized controlled trial.

SUBJECTS

One hundred and twenty subjects were randomized to three groups through block randomization. Subjects with an Asthma Quality of Life Questionnaire score <5.5 participated in the study.

SETTING

Outpatient pulmonary medicine department.

INTERVENTIONS

Subjects in the Buteyko and pranayama groups were trained for 3-5 days and instructed to practise the exercises for 15 minutes twice daily, and for three months duration. The control group underwent routine pharmacological management during the study period.

OUTCOME MEASURES

Asthma Quality of Life Questionnaire, Asthma Control Questionnaire and pulmonary function test.

RESULTS

The baseline characteristics were similar in all three groups. Post intervention, the Buteyko group showed better trends of improvement (mean (95% confidence interval), P-value) in total Asthma Quality of Life Questionnaire score than the pranayama (0.47 (-0.008-0.95), P = 0.056) and control groups (0.97 (0.48-1.46), P = 0.0001). In comparison between the pranayama and control groups, pranayama showed significant improvement (0.50 (0.01-0.98), P = 0.042) in total Asthma Quality of Life Questionnaire score.

CONCLUSION

The Buteyko group showed better trends of improvement in quality of life and asthma control than the group performing the pranayama breathing exercise.

Hypoventilation training for asthma: a case illustration

Hyperventilation-induced hypocapnia is common among asthma patients. This case study illustrates both methodology and results from a patient undergoing training in capnometry-assisted respiratory training (CART). CART is a 4-week training aimed at normalizing basal and acute levels of end-tidal carbon dioxide (PCO(2)) using a portable capnometer. In the presented case, basal levels of PCO(2) increased from hypocapnic to normocapnic range over the course of treatment. Improvements were accompanied by improvements in lung function and reductions in diurnal lung function variability. Improvements remained stable throughout follow-up.

Exercise-related quality of life in subjects with asthma: a systematic review

OBJECTIVE

The purpose of this review was to analyze, based on a review of the current literature, the effects of physical activity on the quality of life (QoL) of subjects with asthma.

METHODS

The authors conducted a search of randomized controlled trials (RCTs) between January 2000 and August 2010 in a group of major databases of health sciences (Academic Search Complete, Directory of Open Access Journals, Elsevier--Science Direct, Highwire Press, PubMed, Scielo Global, Scirus, Scopus, SpringerLink, Taylor & Francis, and Wiley Interscience) with the keywords asthma, QoL, physical activity, exercise, training, and program in all possible combinations. Citations and references of each study selected were also examined.

RESULTS

Of the 1075 studies identified, only 11 were included. Five of these studies were performed in children between the ages of 7 and 15 and the remaining studies were performed on adults. Intervention programs were divided into aerobic training programs and breathing exercises programs. All aerobic training programs showed improvements in QoL, demonstrating a positive influence of aerobic training on asthma.

CONCLUSIONS

There is a noticeable trend in the benefit of aerobic training programs in the QoL for individuals with asthma. The breathing exercises programs were few and heterogeneous, making it difficult to reach a positive conclusion on whether it could be recommended for the improvement of QoL in this pathology. There is a great need for more RCTs with methodological rigor.

Systematic review of the effectiveness of breathing retraining in asthma management

In asthma management, complementary and alternative medicine is enjoying a growing popularity worldwide. This review synthesizes the literature on complementary and alternative medicine techniques that utilize breathing retraining as their primary component and compares evidence from controlled trials with before-and-after trials. Medline, PubMed, Cumulative Index to Nursing and Allied Health Literature and the Cochrane Library electronic databases were searched. Reference lists of all publications were manually checked to identify studies not found through electronic searching. The selection criteria were met by 41 articles. Most randomized controlled trials (RCTs) of the Buteyko breathing technique demonstrated a significant decrease in β(2)-agonist use while several found improvement in quality of life or decrease in inhaled corticosteroid use. Although few in number, RCTs of respiratory muscle training found a significant reduction in bronchodilator medication use. Where meta-analyses could be done, they provided evidence of benefit from yoga, Buteyko breathing technique and physiotherapist-led breathing training in improving asthma-related quality of life. However, considerable heterogeneity was noted in some RCTs of yoga. It is reasonable for clinicians to offer qualified support to patients with asthma undertaking these breathing retraining techniques.

Mild asthmatics benefit from music therapy

OBJECTIVE

The aim of the study was to evaluate the effectiveness of pulmonary rehabilitation with music therapy in patients with asthma.

METHODS

Seventy-six selected inpatients (54 women and 22 men; mean age = 56.4 years; SD = 11.8) with stable asthma underwent pulmonary rehabilitation in two groups: standard versus music therapy.

RESULTS

After the intervention, an increase in analyzed spirometric values (forced expiratory volume at the first second (FEV(1)), FEV(1) as a percentage of vital capacity (FEV(1) % FVC), forced expiratory flow at 25%, 50%, and 75% of vital capacity (FEF(25), FEF(50), and FEF(75), respectively), and peak expiratory flow) was observed in both the groups (p < .05) but without any intergroup differences (p > .05). A greater increase of mean FEV(1) % FVC, FEF(50), and FEF(75) values was observed only in the patients with mild asthma from the music therapy group (p < .05). In both the groups, a dyspnea reduction was noted (p < .001). However, it was influenced neither by the type of rehabilitation nor by the gender (p > .05), but the interaction of these variables was significant (p = .044). A dyspnea reduction was observed in women in both the groups (p < .001) and in men in the music therapy group only (p = .001). A change in the value of anxiety (6.43, SD = 7.73) on the 10th day compared with the first day of the study was noticed (p < .001). However, this change was not influenced by the type of rehabilitation, gender, or a combination of these two variables (p > .05).

CONCLUSION

Music therapy improves the respiratory function in patients with mild asthma and reduces dyspnea mainly in men with asthma.

Home-based educational interventions for children with asthma

BACKGROUND

While guidelines recommend that children with asthma should receive asthma education, it is not known if education delivered in the home is superior to usual care or the same education delivered elsewhere. The home setting allows educators to reach populations (such as the economically disadvantaged) that may experience barriers to care (such as lack of transportation) within a familiar environment.

OBJECTIVES

To perform a systematic review on educational interventions for asthma delivered in the home to children, caregivers or both, and to determine the effects of such interventions on asthma-related health outcomes. We also planned to make the education interventions accessible to readers by summarising the content and components.

SEARCH STRATEGY

We searched the Cochrane Airways Group Specialised Register of trials, which includes the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, AMED and PsycINFO, and handsearched respiratory journals and meeting abstracts. We also searched the Education Resources Information Center database (ERIC), reference lists of trials and review articles (last search January 2011).

SELECTION CRITERIA

We included randomised controlled trials of asthma education delivered in the home to children, their caregivers or both. In the first comparison, eligible control groups were provided usual care or the same education delivered outside of the home. For the second comparison, control groups received a less intensive educational intervention delivered in the home.

DATA COLLECTION AND ANALYSIS

Two authors independently selected the trials, assessed trial quality and extracted the data. We contacted study authors for additional information. We pooled dichotomous data with fixed-effect odds ratio and continuous data with mean difference (MD) using a fixed-effect where possible.

MAIN RESULTS

A total of 12 studies involving 2342 children were included. Eleven out of 12 trials were conducted in North America, within urban or suburban settings involving vulnerable populations. The studies were overall of good methodological quality. They differed markedly in terms of age, severity of asthma, context and content of the educational intervention leading to substantial clinical heterogeneity. Due to this clinical heterogeneity, we did not pool results for our primary outcome, the number of patients with exacerbations requiring emergency department (ED) visit. The mean number of exacerbations requiring ED visits per person at six months was not significantly different between the home-based intervention and control groups (N = 2 studies; MD 0.04; 95% confidence interval (CI) -0.20 to 0.27). Only one trial contributed to our other primary outcome, exacerbations requiring a course of oral corticosteroids. Hospital admissions also demonstrated wide variation between trials with significant changes in some trials in both directions. Quality of life improved in both education and control groups over time.A table summarising some of the key components of the education programmes is included in the review.

AUTHORS' CONCLUSIONS

We found inconsistent evidence for home-based asthma educational interventions compared to standard care, education delivered outside of the home or a less intensive educational intervention delivered at home. Although education remains a key component of managing asthma in children, advocated in numerous guidelines, this review does not contribute further information on the fundamental content and optimum setting for such educational interventions.

The influence of fear of symptoms and perceived control on asthma symptom perception

OBJECTIVE

Self-reported asthma symptoms correlate only modestly with measures of underlying pathophysiological mechanisms. In this study, we investigated the role of fear of symptoms and perceived control on respiratory symptom perception in patients with asthma.

METHODS

Patients with intermittent to moderate persistent asthma (N=32) were administered 4 subsequent rebreathing challenges (one using 100% O(2) and three using 5% CO(2) and 95% O(2)). We manipulated perceived control by providing information on the availability/unavailability of rescue medication during the challenges (perceived control/no control condition). Perceived symptoms and lung function were assessed after each rebreathing challenge.

RESULTS

Persons with low fear of symptoms reported respiratory symptoms to be less unpleasant during the perceived control condition compared to the no control condition. The reverse was found for persons with high fear of symptoms. The interaction between fear of symptoms and the control manipulations was mediated by threat perception.

CONCLUSION

Messages intended to increase perceived control over symptoms may actually increase threat in persons with high fear of symptoms and eventually increase unpleasantness of respiratory sensations. This finding underlines the importance of affective processes in the perception of asthma symptoms and shows that instructions to patients should take pre-existing fear levels into account.

The effect of physiotherapy-based breathing retraining on asthma control

BACKGROUND

The mechanism of the breathing retraining effect on asthma control is not adequately based on evidence.

OBJECTIVE

The present study was designed to evaluate the effect of physiotherapy-based breathing retraining on asthma control and on asthma physiological indices across time.

STUDY DESIGN

A 6-month controlled study was conducted. Adult patients with stable, mild to moderate asthma (n = 40), under the same specialist's care, were randomized either to be trained as one group receiving 12 individual breathing retraining sessions (n = 20), or to have usual asthma care (n = 20). The main outcome was the Asthma Control Test score, with secondary outcomes the end-tidal carbon dioxide, respiratory rate, spirometry, and the scores of Nijmegen Hyperventilation Questionnaire, Medical Research Council scale, and SF-36v2 quality-of-life questionnaire.

RESULTS

The 2 × 4 ANOVA showed significant interaction between intervention and time in asthma control (F = 9.03, p < .001, η(2) = 0.19), end-tidal carbon dioxide (p < .001), respiratory rate (p < .001), symptoms of hypocapnia (p = .001), FEV1% predicted (p = .022), and breathlessness disability (p = .023). The 2 × 4 MANOVA showed significant interaction between intervention and time, with respect to the two components of the SF-36v2 (p < .001).

CONCLUSION

Breathing retraining resulted in improvement not only in asthma control but in physiological indices across time as well. Further studies are needed to confirm the benefits of this training in order to help patients with stable asthma achieve the control of their disease.

Yoga respiratory training improves respiratory function and cardiac sympathovagal balance in elderly subjects: a randomised controlled trial

OBJECTIVES

Since ageing is associated with a decline in pulmonary function, heart rate variability and spontaneous baroreflex, and recent studies suggest that yoga respiratory exercises may improve respiratory and cardiovascular function, we hypothesised that yoga respiratory training may improve respiratory function and cardiac autonomic modulation in healthy elderly subjects.

DESIGN

76 healthy elderly subjects were enrolled in a randomised control trial in Brazil and 29 completed the study (age 68 ± 6 years, 34% males, body mass index 25 ± 3 kg/m²). Subjects were randomised into a 4-month training program (2 classes/week plus home exercises) of either stretching (control, n=14) or respiratory exercises (yoga, n=15). Yoga respiratory exercises (Bhastrika) consisted of rapid forced expirations followed by inspiration through the right nostril, inspiratory apnoea with generation of intrathoracic negative pressure, and expiration through the left nostril. Pulmonary function, maximum expiratory and inspiratory pressures (PE(max) and PI(max), respectively), heart rate variability and blood pressure variability for spontaneous baroreflex determination were determined at baseline and after 4 months.

RESULTS

Subjects in both groups had similar demographic parameters. Physiological variables did not change after 4 months in the control group. However, in the yoga group, there were significant increases in PE(max) (34%, p<0.0001) and PI(max) (26%, p<0.0001) and a significant decrease in the low frequency component (a marker of cardiac sympathetic modulation) and low frequency/high frequency ratio (marker of sympathovagal balance) of heart rate variability (40%, p<0.001). Spontaneous baroreflex did not change, and quality of life only marginally increased in the yoga group.

CONCLUSION

Respiratory yoga training may be beneficial for the elderly healthy population by improving respiratory function and sympathovagal balance. Trial Registration CinicalTrials.gov identifier: NCT00969345; trial registry name: Effects of respiratory yoga training (Bhastrika) on heart rate variability and baroreflex, and quality of life of healthy elderly subjects.

Respiratory physiotherapy: towards a clearer definition of terminology

Interventions used in clinical practice and research need to be described in sufficient detail to permit accurate replication. Since words and phrases can change their meaning over time, it is important that authors choose their words carefully and define anything which might be ambiguous. 'Breathing exercises' is a phrase which covers a multitude of therapeutic approaches. Recent randomised controlled trials have established the value of teaching patients with asthma to retrain their breathing. However, the descriptions of the breathing interventions are generally inadequate. This problem stems partly from a degree of confusion surrounding terms such as 'diaphragmatic breathing' which has been variously interpreted. A more structured approach to reporting such interventions is proposed. This approach will help to avoid confusion, and will permit the transfer of those interventions found to be effective in research trials into routine clinical practice.

The role of breathing training in asthma management

PURPOSE OF REVIEW

There is considerable public interest in the use of breathing modification techniques in the treatment of asthma. Surveys suggest many people with asthma use them, often without the knowledge of their medical attendants. Extravagant claims have been made about the effectiveness of some techniques, resulting in scepticism from orthodox clinicians. The evidence supporting breathing training for asthma was previously weak, and limited by the small size and methodological limitations of published research.

RECENT FINDINGS

The evidence base for the effectiveness of breathing training has recently improved, with reports from several larger and more methodologically robust controlled trials. These trials are reviewed in this study, and the findings placed in context. Trials have investigated a variety of breathing training programmes delivered by different therapists in different ways. All incorporate some instruction in breathing pattern, usually focusing on slow, regular, nasal, abdominal breathing and reduced ventilation, with patients instructed to practise exercises at home and when symptomatic.

SUMMARY

Current evidence suggests that breathing training programmes can be effective in improving patient-reported outcomes such as symptoms, quality of life and psychological impact; and may reduce the use of rescue bronchodilator medication. There is little evidence that airways physiology, hyper-responsiveness or inflammation is affected by such training. The optimal way of providing breathing training within the context of routine asthma care is still uncertain.

Impact of comorbidities on asthma

Asthma is a common and serious illness with suboptimal outcomes of care. Epidemiological studies show certain comorbidities occurring more frequently than expected with asthma, with some being associated with poor control and a differential response to therapy options. This review summarizes the evidence of clinically important comorbidities, focusing on the best-explored conditions, including rhinitis and rhinosinusitis, anxiety and depression, obesity, gastroesophageal reflux, smoking and dysfunctional breathing. The evidence of epidemiological and pathophysiological associations for these comorbidities is explored, and the practical therapeutic implications are considered. Comorbidities are important for clinicians treating asthma as they may be markers of patients at risk of poor outcomes, they may point to specific effective treatment options and they are important to researchers as possible confounding factors in clinical trials.

Pediatric asthma: an integrative approach to care

Asthma in children and young adults is a complex disease with many different phenotypic expressions. Diagnosis is often made based on history and lung function including measuring airway reversibility. However, in children younger than 6 years of age, the diagnosis is more difficult because many children wheeze in the first 4-6 years of life, especially with viral infections. For those children, asthma treatment is often started empirically. Those who go on to develop chronic asthma most likely have a genetic predisposition and exposure to various environmental factors resulting in chronic inflammation of the lower respiratory tract. There are established national guidelines for diagnosing and treating asthma in children and adults. For persistent asthma, it is recommended that medications be taken on a regular basis after identifying and avoiding environmental triggers. Because many factors play a role in developing asthma in children, many nonmedical approaches to asthma and asthma-like conditions have been promoted even when the diagnosis is at times uncertain. The nonmedical approaches and therapies are often referred to as complementary and alternative medicine (CAM). This review will discuss the conventional therapies recommended for children with asthma in addition to CAM therapies, some of which have supporting scientific evidence. Integrating conventional and CAM therapies can prove to be an effective way to treat pediatric asthma, a common and chronic childhood lung disorder. A case is provided to illustrate how such an integrative approach was used in the successful treatment of a child with moderate persistent asthma.

Effectiveness of a photogrammetric model for the analysis of thoracoabdominal respiratory mechanics in the assessment of isovolume maneuvers in children

OBJECTIVE

To test the applicability of a geometric model, adapted to the supine position, for the analysis of respiratory mechanics regarding changes in lateral thoracoabdominal areas in children with asthma.

METHODS

Nineteen children (mean age, 11.26 +/- 1.28 years) performed isovolume maneuvers (IVMs) after maximal inspiration, followed by glottal closure and alternation of airflow between the abdominal and thoracic compartments. The maneuvers were recorded in a digital video camera placed perpendicularly to the movement plane, and the images of interest were selected. The geometric model was traced on each image based on surface landmarks of anatomical references. The traced areas were calculated using a computer program, and the results were converted into metric units (cm(2)) using a surface landmark of a known area. Relative contributions (RCs) of the subcompartments in relation to their original compartments and to the chest wall (CW) were calculated.

RESULTS

The model was based on 55 thoracic IVM images and 55 abdominal IVM images. Areas and subareas were compared between the maneuvers. There were significant differences in all subcompartments (p < 0.001). All of the RCs were significantly different for the CW (p < 0.001) but not for the ratios between the subcompartments and their original compartments.

CONCLUSIONS

This geometric model, applied in children and adapted to the supine position, was effective in profiling changes in the thoracoabdominal silhouette during the IVMs, and the selected subdivisions were useful for the identification of areas contributing the most and the least to CW composition.

Inaccurate perception of asthma symptoms: a cognitive-affective framework and implications for asthma treatment

Inaccurate perception of respiratory symptoms is often found in asthma patients. Typically, patients who inaccurately perceive asthma symptoms are divided into underperceivers and overperceivers. In this paper we point out that this division is problematic. We argue that little evidence exists for a trait-like stability of under- and overperception and that accuracy of respiratory symptom perception is highly variable within persons and strongly influenced by contextual information. Particularly, expectancy and affective cues appear to have a powerful influence on symptom accuracy. Based on these findings and incorporating recent work on associative learning, attention and mental representations in anxiety and symptom perception, we propose a cognitive-affective model of symptom perception in asthma. The model can act as a framework to understand both normal perception as well as under- and overperception of asthma symptoms and can guide the development of affect-related interventions to improve perceptual accuracy, asthma control and quality of life in asthma patients.

Asthma in childhood

Management decisions for pediatric asthma (in patients younger than 12 years of age) based on extrapolation from available evidence in adolescents and adults (age 12 years and older) is common but rarely appropriate. This article addresses the disparity in response between the two age groups, presents the available pediatric evidence, and highlights the important areas in which further research is required. Evidence-based recommendations for acute and interval management of pediatric asthma are provided.

The effect of various breathing exercises (pranayama) in patients with bronchial asthma of mild to moderate severity

BACKGROUND/AIM

The incidence of bronchial asthma is on increase. Chemotherapy is helpful during early course of the disease, but later on morbidity and mortality increases. The efficacy of yoga therapy though appreciated is yet to be defined and modified.

AIM

To study the effect of breathing exercises (pranayama) in patients with bronchial asthma of mild to moderate severity.

MATERIALS AND METHODS

Fifty cases of bronchial asthma (Forced Expiratory Volume in one second (FEV1) > 70%) were studied for 12 weeks. Patients were allocated to two groups: group A and group B (control group). Patients in group A were treated with breathing exercises (deep breathing,Brahmari, and Omkara, etc.) for 20 minutes twice daily for a period of 12 weeks. Patients were trained to perform Omkara at high pitch (forceful) with prolonged exhalation as compared to normal Omkara. Group B was treated with meditation for 20 minutes twice daily for a period of 12 weeks. Subjective assessment, FEV1%, and Peak Expiratory Flow Rate (PEFR) were done in each case initially and after 12 weeks.

RESULTS

After 12 weeks, group A subjects had significant improvement in symptoms, FEV1, and PEFR as compared to group B subjects.

CONCLUSION

Breathing exercises (pranayama), mainly expiratory exercises, improved lung function subjectively and objectively and should be regular part of therapy.

Investigating the claims of Konstantin Buteyko, M.D., Ph.D.: the relationship of breath holding time to end tidal CO2 and other proposed measures of dysfunctional breathing

OBJECTIVES

Konstantin Buteyko, M.D., Ph.D., claimed that breath holding time (BHT) can be used to detect chronic hyperventilation and that BHT predicts alveolar CO(2) (Pa(CO(2))) according to his patented mathematical formula. The Buteyko Breathing Technique (BBT) is believed to correct chronic hyperventilation as evidenced by increased BHT. In this study, we test Buteyko's claims and explore the relationship between BHT and end-tidal carbon dioxide (ETCO(2)) as well as measures of dysfunctional breathing (DB) including the Nijmegen questionnaire, the Self Evaluation of Breathing Questionnaire, and thoracic dominant breathing pattern.

SUBJECTS

Eighty-three (83) adults healthy or suspected of having dysfunctional breathing, 29 with abnormal spirometry readings, 54 with normal spirometry.

OUTCOME MEASURES

BHT, performed according to BBT protocols, was measured along with ETCO(2) and other measures of DB including the Nijmegen questionnaire, and manual assessment of respiratory motion, a palpatory technique for measuring thoraco-abdominal balance during breathing. Correlations between measures of DB were made in the whole sample and also in subgroups with normal or abnormal spirometry. DB measures were compared in normal and abnormal spirometry groups.

RESULTS

The results revealed a negative correlation between BHT and ETCO(2) (r= -0.241, p<0.05), directly opposite to Buteyko's claims. BHT was significantly shorter in people with abnormal spirometry (FEV(1) or FVC<15% below predicted), with no difference in ETCO(2) levels between the abnormal and normal spirometry groups. In the abnormal spirometry group, lower BHT was found to correlate with a thoracic dominant breathing pattern. (r= -0.408, p<0.028).

CONCLUSIONS

Although BHT does not predict resting ETCO(2), it does correlate with breathing pattern in subjects with abnormal spirometry. It is proposed that altered breathing pattern could contribute to breathing symptoms such as dyspnea and that breathing therapies such as BBT might influence symptoms by improving the efficiency of the biomechanics of breathing.

A randomised controlled trial of the Buteyko technique as an adjunct to conventional management of asthma

OBJECTIVE

To assess the effectiveness of a non-pharmacological intervention in patients with asthma on conventional therapy including inhaled corticosteroid.

DESIGN

A randomised controlled trial of the Buteyko technique in a group of adults with asthma. The control group was trained by a physiotherapist in breathing and relaxation techniques.

SETTING

A single centre associated with a University-based asthma programme.

MAIN OUTCOME MEASURE

Asthma control, defined by a composite score based on the Canadian asthma consensus report 6 months after completion of the intervention.

RESULTS

Both groups showed substantial and similar improvement and a high proportion with asthma control 6 months after completion of the intervention. In the Buteyko group the proportion with asthma control increased from 40% to 79% and in the control group from 44% to 72%. In addition the Buteyko group had significantly reduced their inhaled corticosteroid therapy compared with the control group (p=0.02). None of the other differences between the groups at 6 months were significant.

CONCLUSIONS

Six months after completion of the interventions, a large majority of subjects in each group displayed control of their asthma with the additional benefit of reduction in inhaled corticosteroid use in the Buteyko group. The Buteyko technique, an established and widely recognised intervention, or an intensive programme delivered by a chest physiotherapist appear to provide additional benefit for adult patients with asthma who are being treated with inhaled corticosteroid.

Integrative medicine and asthma

Childhood asthma is a spectrum of symptoms and clinical presentations. The treatment begins with developing goals of therapy for a child by the health care provider, the family, and the child as a team. The primary objective is to reduce symptoms and exacerbations using therapies that include conventional medications, environmental controls, and lifestyle modification while reducing the potential for adverse effects of medications and the disease. Complementary and alternative medicine (CAM) may play a role in meeting these objectives, and through the integration of conventional and CAM therapies, an integrative medicine approach may facilitate reaching these objectives in a more effective manner.