Breathing exercises for asthma

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.

Impact of Treatable Traits on Asthma Control and Quality of Life

BACKGROUND

Many adult patients with asthma have uncontrolled disease and impaired quality of life, despite current asthma-specific drug therapies.

OBJECTIVE

This study aimed to investigate the prevalence of 9 traits in patients with asthma, their associations with disease control and quality of life, and referral rates to nonmedical health care professionals.

METHODS

Retrospectively, data from patients with asthma were collected in 2 Dutch hospitals (Amphia Breda and RadboudUMC Nijmegen). Adult patients without exacerbation <3 months who were referred for a first-ever elective, outpatient, hospital-based diagnostic pathway were deemed eligible. Nine traits were assessed: dyspnea, fatigue, depression, overweight, exercise intolerance, physical inactivity, smoking, hyperventilation, and frequent exacerbations. To assess the likelihood of having poor disease control or decreased quality of life, the odds ratio (OR) was calculated per trait. Referral rates were assessed by checking patients' files.

RESULTS

A total of 444 adults with asthma were studied (57% women, age: 48 ± 16 years, forced expiratory volume in 1 second: 88% ± 17% predicted). Most patients (53%) were found to have uncontrolled asthma (Asthma Control Questionnaire ≥1.5 points) and decreased quality of life (Asthma Quality of Life Questionnaire <6 points). Generally, patients had 3.0 ± 1.8 traits. Severe fatigue was most prevalent (60%) and significantly increased the likelihood of having uncontrolled asthma (OR: 3.0, 95% confidence interval [CI]: 1.9-4.7) and decreased quality of life (OR: 4.6, 95% CI: 2.7-7.9). Referrals to nonmedical health care professionals were low; most referrals were to a respiratory-specialized nurse (33%).

CONCLUSION

Adult patients with asthma with a first-ever referral to a pulmonologist frequently exhibit traits justifying the deployment of nonpharmacological interventions, especially in those with uncontrolled asthma. However, referrals to appropriate interventions appeared infrequent.

Physical training in adults with asthma: An integrative approach on strategies, mechanisms, and benefits

Asthma is a chronic airway disease characterized by airflow limitation and respiratory symptoms associated with chronic airway and systemic inflammation, bronchial hyperreactivity (BHR), and exercise-induced bronchoconstriction (EIB). Asthma is a heterogeneous disease classified according to distinct airway and systemic inflammation. Patients commonly present with several comorbidities, including anxiety, depression, poor sleep quality, and reduced physical activity levels. Individuals with moderate to severe asthma often have more symptoms and difficulty achieving adequate clinical control, which is associated with poor quality of life, despite proper pharmacological treatment. Physical training has been proposed as an adjunctive therapy for asthma. Initially, it was suggested that the effect of physical training might be attributed to the improved oxidative capacity and reduced production of exercise metabolites. However, in the last decade, there has been evidence that aerobic physical training promotes anti-inflammatory effects in asthma patients. Physical training improves BHR and EIB, asthma symptoms, clinical control, anxiety, and depression levels, sleep quality, lung function, exercise capacity, and dyspnea perception. Furthermore, physical training reduces medication consumption. The most commonly used exercise strategies are moderate aerobic and breathing exercises; however, other techniques, such as high-intensity interval training, have shown promising effects. In the present study, we reviewed the strategies and beneficial effects of exercise on clinical and pathophysiological asthma outcomes.

Combination of diaphragmatic breathing with therapeutic walking exercise to increase peak expiratory flow rate in asthma patients

Objective: This study aimed to determine the effect of combined diaphragmatic breathing and therapeutic walking exercise on peak expiratory flow in asthma patients.

Methods: The research design used a quasi-experiment nonequivalent pretest and posttest design. The research sample contained 38 respondents divided into intervention and control groups, selected by simple random sampling. The control group received standard drug therapy, while the intervention group received standard drug therapy and a combination of diaphragmatic breathing and therapeutic walking exercise for 2 weeks. This exercise was carried out in the morning, 6 times a week, with 5 diaphragmatic breathing and exhalations per exercise. After that, a 1-min break was followed by a therapeutic walking exercise of 5–15 min, with an increased duration. Both groups measured the peak expiratory flow before and after the intervention using a peak flow meter. The data analysis used central tendency and t-test.

Results: The results showed that the mean peak expiratory flow in the intervention group was 306.84, while in the control group, it was 232.63, with the value of the t-test being −14.17 (P < 0.0001).

Conclusions: Diaphragmatic breathing and therapeutic walking exercise significantly increased the peak expiratory flow in asthma patients.

Increasing physical activity in severe asthma: a systematic review and meta-analysis

INTRODUCTION

Physical inactivity is common in asthma and is recognised as an important modifiable risk for poor clinical outcomes such as impaired asthma control and health-related quality of life (HRQoL). Despite evidence supporting the role of physical activity in reducing the risk of these outcomes, little is known about optimal interventions for increasing physical activity in those with severe disease. This systematic review and meta-analysis evaluates the effectiveness of interventions in increasing physical activity in severe asthma.

METHODS

MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, Embase, PubMed, Informit, SPORTDiscus and Cochrane databases were searched up to September 2021 for physical activity-based intervention studies that assessed physical activity outcomes (e.g. steps per day, time spent undertaking physical activity) in adults with severe asthma. Data on asthma-related (e.g. asthma control) and health-related outcomes (e.g. HRQoL) were assessed as secondary outcomes. The revised Cochrane Risk of Bias tool was used to assess risk of bias. Random-effects meta-analyses synthesised data where possible.

RESULTS

Four randomised controlled trials (all 12 weeks in duration) including 176 adults with moderate-to-severe asthma were included. An increase in physical activity was reported with a moderate-vigorous intensity aerobic and resistance training intervention (steps per day and time spent undertaking physical activity), and an unsupervised pedometer-based intervention (steps per day). Meta-analyses showed that physical activity interventions had an overall positive effect on steps per day (mean difference (MD) 1588, 95% CI 399-2778; p=0.009, I2=23), asthma control (MD -0.65, 95% CI -0.95--0.35; p<0.0001, I2=0%) and HRQoL (MD 0.56, 95% CI 0.10-1.01; p=0.02, I2=16%) compared to control.

CONCLUSION

While there is some evidence supporting the effectiveness of interventions in improving physical activity in adults with severe asthma, higher-quality, large-scale studies of longer duration are needed to determine the optimal intervention.

Influences of Breathing Exercises and Breathing Exercise Combined with Aerobic Exercise on Changes in Basic Spirometry Parameters in Patients with Bronchial Asthma

Scientific evidence shows that breathing or aerobic programs can improve the quality of life of asthma patients. The aim of this work was to find out the influences of breathing exercises and breathing exercises combined with aerobic exercise on changes in spirometry parameters in patients with bronchial asthma. Participants: The group consisted of 33 women with bronchial asthma—mild to moderate persistent levels of FEV1 reduction (80–50%)—with a mean age of 34.73 ± 1.53 years. They were randomly assigned to experimental group 1 (EX1), experimental group 2 (EX2) or the control group (CG). Materials and methods: Changes in spirometry parameters were evaluated over a 16-week period in the three groups: CG (placebo), EX1 (breathing exercises) and EX 2 (combination of breathing exercises with an aerobic program). To evaluate the pre-training and post-training diagnostics, we used MIR Spirobank II. The influences of the experimental and control factors were assessed using the following dependent variables: forced vital capacity (FVC), forced expiratory volume in one second (FEV1), Tiffeneau–Pinelli index (FEV1/FVC ratio), peak expiratory flow (PEF) and forced mid-expiratory flow (FEF25–75%). We used the Wilcoxon t-test and the Kruskal–Wallis test to evaluate the differences in the measured parameters. To examine the effect of our protocols, we used effect size (ES). Results: In CG we observed improvements in: FVC—(5%; p < 0.05; ES = 0.437). FEV1—(7.33%; p < 0.01; ES = 0.585). FEV1/FVC ratio (5.27%; p < 0.01; ES = 0.570). PEF (11.22%; p < 0.01; ES = 0.448). FEF25–75% (7.02%; p < 0.01; ES = 0.628). In EX1 we observed improvements in: FVC (5.23%; p < 0.01; ES = 0.631), FEV1 (20.67%; p < 0.01; ES = 0.627), FEV1/FVC ratio (16.06%; p < 0.01; ES = 0.628), PEF (13.35%; p < 0.01; ES = 0.627) and FEF25–75% (13.75%; p < 0.01; ES = 0.607). In EX2 we observed improvements in: FVC (9.12%; p < 0.01; ES = 0.627), FEV1 (27.37%; p < 0.01; ES = 0.626), FEV1/FVC ratio (15.32%; p < 0.01; ES = 0.610), PEF (30.66%; p < 0.01; ES = 0.626) and FEF25–75% (58.99%; p < 0.01; ES = 0.626). Significant differences compared to the control group were observed in EX1 for FEV1 (p < 0.05) and FEV1/FVC ratio (p < 0.01); and in EX2 for FEV1 (p < 0.05), FEV1/FVC ratio (p < 0.01), PEF (p < 0.05) and FEF (p < 0.05). A significant difference between EX1 and EX2 was observed in PEF (p < 0.05). Conclusions: It appears to be that combination of breathing exercises with aerobic activities is a more beneficial option for patients with bronchial asthma.

Novel Real-Time OEP Phase Angle Feedback System for Dysfunctional Breathing Pattern Training-An Acute Intervention Study

Dysfunctional breathing patterns (DBP) can have an impact on an individual’s quality of life and/or exercise performance. Breathing retraining is considered to be the first line of treatment to correct breathing pattern, for example, reducing ribcage versus abdominal movement asynchrony. Optoelectronic plethysmography (OEP) is a non-invasive 3D motion capture technique that measures the movement of the chest wall. The purpose of this study was to investigate if the use of a newly developed real-time OEP phase angle and volume feedback system, as an acute breathing retraining intervention, could result in a greater reduction of phase angle values (i.e., an improvement in movement synchrony) when compared to real-time OEP volume feedback alone. Eighteen individuals with a DBP performed an incremental cycle test with OEP measuring chest wall movement. Participants were randomly assigned to either the control group, which included the volume-based OEP feedback or to the experimental group, which included both the volume-based and phase angle OEP feedback. Participants then repeated the same cycle test using the real-time OEP feedback. The phase angle between the ribcage versus abdomen (RcAbPhase), between the pulmonary ribcage and the combined abdominal ribcage and abdomen (RCpAbPhase), and between the abdomen and the shoulders (AbSPhase) were calculated during both cycle tests. Significant increases in RcAbPhase (pre: −2.89°, post: −1.39°, p < 0.01), RCpAbPhase (pre: −2.00°, post: −0.50°, p < 0.01), and AbSPhase (pre: −2.60°, post: −0.72°, p < 0.01) were found post-intervention in the experimental group. This indicates that the experimental group demonstrated improved synchrony in their breathing pattern and therefore, reverting towards a healthy breathing pattern. This study shows for the first time that dysfunctional breathing patterns can be acutely improved with real-time OEP phase angle feedback and provides interesting insight into the feasibility of using this novel feedback system for breathing pattern retraining in individuals with DBP.

Sustainability in Inhaled Drug Delivery

Asthma and chronic obstructive pulmonary disease (COPD) are amongst the most common chronic diseases worldwide, and are largely preventable by improving the quality of the air we breathe. The most commonly deployed treatment, the metered dose inhaler (MDI), uses hydrofluorocarbon propellants, which are powerful greenhouse gases that contribute disproportionately to the climate crisis. Alternative treatment strategies are required if we are to avoid contributing to the worst effects of climate change. These strategies include promoting non-pharmacological therapies like smoking cessation and pulmonary rehabilitation; empowering patients to gain better disease control through written management plans and encouraging preventer, rather than reliever therapies. Pharmacological strategies include: improving inhaler technique and spacer use; minimising propellant release by using smaller volume MDIs and simpler dosing regimes; dose counters to prevent waste; switching to low global warming potential inhalers; and inhaler recycling. There are also opportunities to improve disease control alongside reduced greenhouse gas emissions, including better matching of patients' devices to inhaler technique rather than defaulting to MDIs, stopping unnecessary inhaled steroids in COPD and maintenance and reliever therapy in asthma. New, lower global warming potential propellants are on the horizon, and their introduction could offer a golden opportunity to enhance MDIs usability and sustainability by making them refillable, integrating whistles to optimise inhalation technique, adding integrated caps, optimising materials for recycling and adding dose counters to all MDIs.

Evaluation of a Choir as a Non-Medical Intervention for Children with Asthma: BreathStars

A shift in the current health policy has seen heightened focus on non-medical interventions which can be delivered out with formal health-care settings, to complement and enhance the clinical care of people with long-term conditions. Asthma is a common long-term condition managed by pharmacological and non-pharmacological interventions. Recent research activity has focused on the use of singing for respiratory health due to its similarity with the more well-known intervention of breathing exercises. The aim of this study was to determine if singing improved breathing in children with asthma. A realist evaluation study design with a mixed methods approach was adopted to evaluate a singing group for children aged 7-12. Results obtained through framework analysis of the data indicated notable improvement in asthma control with the added impact on self-esteem. Enjoyment of the singing group within a family centered approach was seen as a positive alongside the community benefit of wider asthma education. Lessons can be learnt from this evaluation which could inform future initiatives relevant to the current agenda of asset-based approaches such as social prescribing within the context of the current devolution of the health and social care budget in the North West of England.

Breathing pattern recordings using respiratory inductive plethysmography, before and after a physiotherapy breathing retraining program for asthma: A case report

Breathing retraining (BR) improves symptoms, psychological well-being and quality of life in adults with asthma; but there remains uncertainty as to mechanism of effect. One of the intuitively logical theories is that BR works through altering breathing pattern. There is currently no evidence, however, that BR does result in measurable changes in breathing pattern. In this case report we describe the effects of physiotherapy BR on a 57-year-old female with a 10-year history of asthma. Data were collected before and after a physiotherapy BR program comprising three sessions over 18 weeks: breathing pattern (respiratory inductive plethysmography (RIP); physiology (end tidal carbon dioxide (ETCO₂), heart rate, oxygen saturations, spirometric lung function); questionnaires (Asthma Control Questionnaire (ACQ), Hospital Anxiety and Depression Score, Nijmegen Questionnaire); and medication usage. After BR, the patient's symptoms improved. Her physiology was largely unchanged, although her FEV₁ increased by 0.12L, peak flow by 21L/min. The patient reported using less Salbutamol, yet her asthma control improved (ACQ down 1.5). Her Nijmegen score dropped from positive to negative for hyperventilation (from 39 to 7). Her anxiety-depression levels both reduced into 'normal' ranges. The patient's expiratory time increased, with longer respiratory cycles and slower respiratory rate. No changes were seen in relative contributions of ribcage and abdomen. Controlled trials are now needed to determine the generalizability of these findings.

Calculated ventilation and effort distribution as a measure of respiratory disease and Heliox effectiveness

In spite of numerous clinical studies, there is no consensus on the benefit Heliox mixtures can bring to asthmatic patients in terms of work of breathing and ventilation distribution. In this article we use a 3D finite element mathematical model of the lung to study the impact of asthma on effort and ventilation distribution along with the effect of Heliox compared to air. Lung surface displacement fields extracted from computed tomography medical images are used to prescribe realistic boundary conditions to the model. Asthma is simulated by imposing bronchoconstrictions to some airways of the tracheo-bronchial tree based on statistical laws deduced from the literature. This study illuminates potential mechanisms for patient responsiveness to Heliox when affected by obstructive pulmonary diseases. Responsiveness appears to be function of the pathology severity, as well as its distal position in the tracheo-bronchial tree and geometrical position within the lung.

The effect of a holistic self-management plan on asthma control

The holistic self-management plan includes lifelong actions that enable patients to cope with their disease. The present study was designed to evaluate the effect of a holistic self-management plan on asthma control. A 12-month controlled study was conducted. Adult patients with mild-to-moderate asthma (n = 24) who attended the emergency asthma department were randomized to two groups: One group followed four educational sessions and three personal home sessions (n = 12), while a second group received a short manual with asthma information (n = 12). The main measure was the asthma control test (ACT), while secondary outcomes were self-efficacy (general self-efficacy scale, GSE), end-tidal carbon dioxide (ETCO₂), respiratory rate (RR), breathing hold time (BHT), the Nijmegen Questionnaire (NQ), and spirometry (FEV₁% predicted (forced expiratory volume in 1 second % predicted)) scores. The 2 × 4 ANOVA showed a significant interaction effect between intervention and time in ACT (p = 0.001), GSE (p < 0.001), ETCO₂ (p < 0.001), RR (p < 0.001), BHT (p < 0.001), NQ (p = 0.05), and FEV₁% predicted (p < 0.001). Predictors of asthma control were self-efficacy and ETCO₂. In conclusion, this exploratory study provided support for the effectiveness of holistic self-management in asthma control. Behavioral changes, as indicated by the development of self-efficacy and the reduction of hyperventilation, contributed to the effectiveness of the intervention.

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.