Breathing Exercises for Asthma Patients in Specialist Care: A Multicenter Randomized Trial

Breath of relief: Transforming pediatric asthma care with telemedicine-guided exercises

BACKGROUND

Alternative non-pharmacological strategies such as breathing exercises can be used in combination with pharmacological treatments.

OBJECTIVE

The aim of this randomized, controlled, single-blind study was to investigate the effectiveness of breathing exercises in asthma patients on respiratory function, symptom control and quality of life.

METHODS

We enrolled pediatric asthma patients who were eligible and motivated for the study and randomly assigned them to either the exercise group (EG) or the control group (CG). The CG received a postural exercise program, while the EG received a breathing exercise program. At baseline and after 12 weeks, respiratory function (FEV1-FVC-FEV1/FVC-PEF), symptom control (using asthma control test, asthma control questionnaire, global initiative for asthma symptom control assessment), quality of life (using pediatric asthma quality of life questionnaire), breath-holding test (BHT) and sit-to-stand test (30sSTS) were assessed and compared.

RESULTS

One hundred twelve patients were randomized, and 99 (n = 51 EG, n = 48 CG) completed the 12-week study. Baseline data were also similar in both groups. After 12 weeks, FEV1, Peak expiratory flow (by spirometry and peak flow meter) and BHT were significantly better in EG than in CG (p = 0.01 and p = 0.007 and p = 0.005, respectively). Asthma Control Test and GINA symptom control tool values were also significantly better in both groups.

DISCUSSION

Our participants were children with mild to moderate asthma. We conclude that our results show that breathing exercises can be an effective intervention for children with partially controlled asthma with FEV1,PEF, and BHTs.

Translation and cross-cultural adaptation of the self evaluation of breathing questionnaire (SEBQ) into Danish

Background and Purpose

Dysfunctional breathing (DB) with or without an underlying medical condition is associated with impaired quality of life. DB-related symptoms can be measured with the 25-item Self Evaluation of Breathing Questionnaire (SEBQ). However, the SEBQ is not available in Danish.The aim of the present study was to translate and cross-culturally adapt the SEBQ into Danish and to assess the face validity of the Danish version of the questionnaire in individuals with DB-related symptoms.

Materials and Methods

The SEBQ was translated and cross-culturally adapted into Danish using an internationally acknowledged six-step forward-backward translation guideline in an interactive process with an expert committee of clinicians, translators, methodologists and the SEBQ developer. Face validity was explored through semi-structured interviews with 24 adult individuals with DB-related symptoms (age 20-70 years, female n = 14).

Results

The SEBQ was successfully translated and cross-culturally adapted into Danish. Three major modifications were made following the translation process and participant interviews. First, an introductory paragraph, including a recall period of the previous seven days, was added. Second, the administration of the questionnaire was changed from a paper to an electronic version. Finally, adaptations regarding semantic equivalence, especially concerning being 'breathless' and 'short of breath', were performed. The participants expressed that the final version of the SEBQ embraced their DB-related symptoms, was understandable, and easy to complete.

Conclusion

The SEBQ is the first available Danish questionnaire to measure DB-related symptoms, following an internationally acknowledged cross-cultural adaptation and face validity evaluation approach. This promising validation should be followed by an assessment of measurement properties in individuals with DB-related symptoms to investigate the adequacy of the SEBQ in a Danish context.

Breathing techniques to reduce symptoms in people with serious respiratory illness: a systematic review

BACKGROUND

In adults with serious respiratory illness, breathlessness is prevalent and associated with reduced health-related quality of life. The aim of this review was to assess the impact of breathing techniques on breathlessness in adults with serious respiratory illness.

METHODS

Electronic databases were searched to identify randomised controlled trials testing breathing techniques (techniques that aim to alter the respiratory pattern, excluding respiratory muscle training) in people with serious respiratory illness. The primary outcome was breathlessness and secondary outcomes were health-related quality of life and adverse events. Two authors independently screened for inclusion, evaluated risk of bias and extracted data.

RESULTS

73 randomised controlled trials were included with 5479 participants, most with COPD or asthma. Breathing exercises (pursed lip and/or diaphragmatic breathing) reduced breathlessness measured by the modified Medical Research Council scale compared to usual care (mean difference (MD) -0.40 points, 95% CI -0.70- -0.11, eight studies, n=323), although the effect did not exceed the minimal important difference. Yoga breathing also improved modified Medical Research Council score compared to usual care (MD -1.05 points, 95% CI -2.45-0.35, three studies, n=175). Breathing techniques consistently improved health-related quality of life in people with COPD and asthma on multiple health-related quality of life measures in comparison to usual care, with effects that generally exceeded the minimal important difference. No adverse events related to breathing techniques were reported.

CONCLUSION

Breathing techniques may improve breathlessness, and consistently improve health-related quality of life, in people with serious respiratory illness. These findings support the use of breathing exercises in the care of people with serious respiratory illness.

Understanding the impact of breathing pattern disorders in difficult-to-treat asthma

INTRODUCTION

Difficult-to-treat asthma is defined as asthma that is uncontrolled despite high-level treatment or requires such treatment to maintain good control and reduce exacerbations. Breathing pattern disorders (BPD) have been reported as a comorbidity in ~ 24-42% % of patients with difficult-to-treat asthma. This narrative review will assess the association, impact, and management of BPD in difficult-to-treat asthma.

AREAS COVERED

We outline current understandings of the nature of difficult-to-treat asthma and BPD. We then review the impact of BPD on difficult-to-treat asthma and Multidisciplinary Team (MDT) approaches to assessing and managing BPD in this patient group. A comprehensive literature search was performed by an asthma specialist MDT including physiotherapists, psychologists, and physicians to create a holistic perspective on this subject.

EXPERT OPINION

BPD exerts significant negative impacts across multiple domains in patients with difficult-to treat asthma. There is a need for further observational, interventional, qualitative and quantitative research to develop better diagnosis, treatment, and awareness of the impacts of BPD including health economic analysis. Studies should develop multimodal approaches that better treat both BPD and associated comorbidities within the multimorbidity framework of difficult-to-treat asthma. Recognizing and addressing BPD should be key elements in future difficult-to-treat asthma management guidelines and clinical practice.

Immediate and One-Year Outcomes of an Asthma-Tailored Pulmonary Rehabilitation Programme in Overweight and Obese People with Difficult-to-Treat Asthma

Introduction

Management of difficult-to-treat asthma is particularly challenging in people with elevated body mass index (BMI). Our randomised controlled trial of pulmonary rehabilitation (PR) showed improved outcomes at 8 weeks. Here we assess immediate and one-year effects of asthma-tailored PR in participants with difficult-to-treat asthma and BMI ≥25 kg/m2, and identify response predictors.

Methods

A prospective observational study of PR, tailored to asthma, comparing outcomes at baseline (V1), immediately after 8 weeks of PR (V2), and at 1 year (V3). Baseline characteristics were compared in responders/non-responders defined by achievement of minimum clinically important difference (MCID) for asthma control questionnaire (ACQ6) (0.5) at 8 weeks and 1 year.

Results

Of 92 participants, 56 attended V2 and 45 attended V3. Mean age was 60 (SD 13) years, 60% were female, and median (IQR) BMI was 33.8 (29.5-38.7) kg/m2. At V1, V2, and V3, respectively, there were significant differences in ACQ6 (mean (95% CI): 2.5 (2.1-2.9), 2.2 (1.8-2.5), and 2.3 (1.9-2.7), p<0.003), Borg breathlessness score post-6-minute walk test (median (IQR): 2 (0.5-3), 1 (0-2), and 1 (0.5-2), p<0.035), and annualised exacerbations requiring prednisolone (median (IQR): 3 (2-5), 0 (0-4.7), and 1.5 (0-4.2), p<0.003). A total of 27/56 (48%) had improvements >MCID for ACQ6 at V2 and 16 (33%) at V3. Participants with higher ACQ6 scores at baseline (suggesting poorer asthma control) were more likely to achieve MCID. Baseline BMI, within the range studied, was not predictive.

Conclusion

Pulmonary rehabilitation induced improvements in asthma-related outcomes including perception of breathlessness, asthma control, and exacerbation frequency at 1 year. Those with poorer baseline asthma control were more likely to benefit.

Mild asthma: Conundrums, complexities and the need to customize care

Mild and moderate asthma cover a wide range of asthma presentations, phenotypes and symptom burden, and account for the majority of people with asthma worldwide. Mild asthma has been difficult to define because of its heterogeneity and wide spectrum of impact and outcomes, including being associated with severe exacerbations. Assessment of mild-moderate asthma is best made by combining asthma symptom control and exacerbation risk as the principle means by which to determine treatment needs. Incontrovertible evidence and guidelines support treatment initiation with anti-inflammatory medication, completely avoiding reliever-only treatment of mild asthma. Shared decision making with patients and a treatable traits approach will ensure that a holistic approach is taken to maximize patient outcomes. Most importantly, mild asthma should be regarded as a reversible, potentially curable condition, remaining in long-term remission through minimizing triggers and optimizing care.

The treatable traits approach to adults with obstructive airways disease in primary and secondary care

The treatable traits approach is based on the recognition that the different clinical phenotypes of asthma and chronic obstructive airways disease (COPD) are a heterogeneous group of conditions with different underlying mechanisms and clinical manifestations, and that the identification and treatment of the specific clinical features or traits facilitates a personalised approach to management. Fundamentally, it recognises two important concepts. Firstly, that treatment for obstructive lung disease can achieve better outcomes if guided by specific clinical characteristics. Secondly, that in patients with a diagnosis of asthma, and/or COPD, poor respiratory health may also be due to numerous overlapping disorders that can present with symptoms that may be indistinguishable from asthma and/or COPD, comorbidities that might require treatment in their own right, and lifestyle or environmental factors that, if addressed, might lead to better control rather than simply increasing airways directed treatment. While these concepts are well accepted, how best to implement this personalised medicine approach in primary and secondary care within existing resource constraints remains uncertain. In this review, we consider the evidence base for this management approach and propose that the priority now is to assess different prototype templates for the identification and management of treatable traits in both asthma and COPD, in primary, secondary and tertiary care, to provide the evidence that will guide their use in clinical practice in different health care systems.