Breathing Exercises for Asthma : Evidence and Practice

Breathing Exercises forAsthma : Evidence andPracticeA simple and effective approach tominimise reliever use and improvesymptom controlChristine Jenkins, Airways GroupWoolcock Institute of Medical Research

Breathing Techniques Background Some physiologic rationale to consider breathingtechniques may be effective for asthma Dysfunctional breathing affects 30% asthma patients Several studies to date show improved symptoms andQoL, and reduced reliever use Cochrane review (2004) suggested no reliableconclusions could be drawn from 42 papers (7 RCT‟s) A proven low risk, low cost intervention would appeal topatients and to clinicians if it offered improved asthmacontrol

History lessonThose who do not learn the lessons of historyare bound to repeat them…..

Hyperventilation and asymptomaticchronic asthmaOsborne et al Thorax 2000 Studied patterns of breathing in 23 currently asymptomatic stableasthmatics, occasional reliever use, normal lung function, AHR tomethacholine and 17 matched controls, no asthma Asthmatics had• No current symptoms• No clinical evidence of hyperventilation• Normal lung function (97.6% vs 101.7%, NS)• Lower PaCO2 (p

Prevalence of dysfunctional breathing inpatients treated for asthma in primary care:cross-sectional surveyThomas et al BMJ 2001;322:1098 Evidence links dysfunctional breathing with asthma andrespiratory disorders (Howell Thorax 1990) Hyperventilation common in specialist respiratory clinics (Carret al J Pschysom Res 1998) Link between asthma and symptomatic hyperventilation inseveral studies (Demeter AJM 1986) 42% of patients in hospital clinic showed evidence ofhyperventilation disorder (McLean AJRCCM 1999) Hyperventilation may complicate and compound asthmapresentation (Han AJRCCM 1999)

Nijmegen questionnairefor dysfunctional breathing• Chest pain• Feeling tense• Blurred vision• Dizziness• Confusion or loss of touchwith reality• Fast or deep breathing• Shortness of breath• Tightness across chest• Bloated• Tingling in fingers and hand• Difficulty taking deep breath• Stiffness or cramps in fingersor hands• Tightness around mouth• Cold hands or feet• Palpitations• Anxiety Symptom measurement tool Score 0 (never) to 4 (veryoften) Assists in identifyingdysfunctional breathing andhyperventilation Total symptom score > 23has sensitivity 91% andspecificity 95% as ascreening instrument inpatients withhyperventilation syndrome

Prevalence of dysfunctional breathing in patientstreated for asthma in primary care: crosssectionalsurveyThomas et al BMJ 2001;322:1098 Sought to determine prevalence of dysfunctionalbreathing in asthma patients in UK primary care• 7033 patients; 4381 aged 17 – 65, semi-rural GP• 307 (7% ) met criteria – all patients who had asthmadiagnosed on clinical grounds, who had received > 1 script inpast 12m for inhaled or oral BD or ICS• Sent questionnaire to 307; response rate 74% No significant differences in severity of asthmabetween high and low scores 1/3 of women and 1/5 of men in had high scores on theNijmegen Q‟aire suggesting dysfunctional breathing

Prevalence of dysfunctional breathing inpatients treated for asthma in primary care:cross-sectional surveyThomas et al BMJ 2001;322:1098RECOMMENDATIONS• Dysfunctional breathing is frequently undiagnosed• Recommend scrutiny to identify dysfunctional breathingwhich should be addressed specifically rather thanincreasing medication for asthma• Need studies to identify the role of breathing retraining toaddress high prevalence of dysfunctional breathing inasthmatic patients

Types of breathing techniques andexercises used in breathing retraining

Problems studying breathingtechniques in asthma RCT must involve blinding subject and observer Practitioners must not have a vested interest in outcome, norunregulated contact time with the patient Alternatively patients are taught through an arms length process(eg video) Must standardise training period and practise periods Ideally active and control interventions must appear efficaciousto the subject Adequately powered studies Outcomes should be objective measures of asthma symptomand disease control, and validated quality-of-life questionnaires

Yoga studies

Yoga (pranayama)regularising and slowing the breathingfrequency by• prolonging the expiratory phase• enhancing abdominal/diaphragmatic breathing• imposing resistance to inspiration and expirationyogasanas and chanting which includemanoeuvres to control breathing aimed at• slowing respiratory frequency• reducing depth of breathing

Mimicking Pranayama yoga in clinicaltrials of breathing techniques Slow breathing retraining exercises using Pink Citylung exerciser (Pink City represents Jaipur India) mouthpiece attached to a disc with a selection ofapertures of 2-5 mm, any one of which can beselected, through which all inspired and expired airmust pass apertures carry a one-way valve which halves thecross-sectional area of the aperture during expiration,imposing a 1:2 ratio on the duration of inspiration andexpiration Smaller aperture slower respiratory rate

RCT of two breathing exercises (Buteykoand pranayama) in asthmaCooper et al Thorax 2003;58:674 90 patients with asthma Used a Pink City Lung Exerciser or placebo PCLE orButyeko (BBT) for 6 months Practised BD and used techniques during symptomepisodes No change on PD20M Symptoms reduced in BBT (p

Yoga studiesVempati R. et al BMC Pul Med 2009; 9: 37 Lifestyle modification based on yoga, versus wait-list• intervention consisted of 2-wk supervised training in lifestylemodification and stress management based on yogafollowed by closely monitored continuation of the practices athome for 6-wk• n=57• Control waitlisted – usual care• Outcome measures assessed at 0, 2, 4 & 8 wk• significant reduction in EIB in the yoga group• Improved lung function, exercise challenge QoL vs control• Improved rescue use in both groups• No change in inflammatory markers

Yoga for Breathing retrainingYoga is taught in eight steps of which one,pranayama deals explicitly with control ofbreathingPranayama has four objectives• a stepwise reduction in breathing frequency• attainment of a 1:2 ratio for duration of inspirationand expiration• a breath holding period at the end of inspirationthat lasts twice the length of expiration• mental concentration on breathing

Buteyko Breathing Technique Aims to reduce hyperventilation through periods ofcontrolled reduction in breathing, known as „slowbreathing‟ and „reduced breathing‟ Combined with periods of breath holding, known as„control pauses‟ and „extended pauses‟ emphasis is on self-monitoring using the pulse rateand the pauses as objective measures of outcome Longer pauses = better breathing control Includes advice and training on the benefits of nasalbreathing over oral breathing

Common features in Buteyko breathing,yoga and deep diaphragmatic breathing Practising a series of exercises which help reducethe depth and frequency of respiration Learned mastery over breathing rate and depth Breath “holding” ability at end expiration duringnormal respiration used to monitor progress May also involve• Physical Relaxation• Thought control• Nasal route of breathing

Rationale for Buteykobreathing People with asthma hyperventilate tachypnea,bronchoconstriction, low airway CO2 and arterial CO2 morestimulus to increase respiratory rate Increased respiratory rate cooling and drying of airways bronchoconstriction β 2 agonists sympathetic overdrive tachypnea and overbreathing hypocapnia bronchoconstriction Promoting nasal breathing over oral breathing warms, filtersand humidifies air less bronchoconstriction Deep inspiration and deep breaths are counter effective, hencemust avoid performing PEF and spirometry= Asthma control can be learned

Breathing exercises for asthmaHolloway & Ram Cochrane Library 2004Assessed evidence the efficacy of breathingretraining in the treatment of asthma42 full text papers 35 studies excluded Most of small size, 2 studies show significant reductions inreliever use 3 studies showed reductions in acute exacerbations 2 studies showed improvements in QoL Overall benefits only in isolated outcome measures, in singlestudies

Buteyko breathing techniques inasthmaBowler et al MJA 1998;169:575Prospective blinded randomized study compared BBTwith control relaxation classes• 39 subjects with asthma, aged 12 – 70• Median daily SABA use 900 mcgs, ICS 1500 mcgs• Mean FEV1 75% predicted, end tidal CO2 33.0At 3m, BBT group had median reduction of 904 mcgSABA vs 54mcgs (controls) Daily ICS dose fell 49% BBT vs 0 (p = 0.06) Improvement in QoL (p< 0.4) Reduction in SABA use (p < 0.008) NS improvement in am PEF (16.7L/min)

PEFWashoutStudy DesignGroup A video and exercises dailyRun-inICS dose stableICS dose reductionGroup B video and exercises dailyICS dose stableICS dose reductionWeekPEFPEFPEF* *-2 0 6 12 14 16 22 28 30V1 V2 V3 V4 V5 V6 V7 V8 V9* ICS

Baseline CharacteristicsVariable Group A (n=28) Group B (n=29)Gender (M:F) 11 : 17 14 : 15Smoking Hx (Never: Former) 19 : 9 23 : 6Atopy (non-atopic: atopic) 2 : 23 4 : 23OCS Use % (past year) 42.9 27.6FEV 1 % pred. 80.8%(74.5-87.0%)78.9%(72.5-85.4%)Reliever Use(median, puffs/day)AQLQ(mean)ACQ-7(mean)Daytime Symptom IntensityScore (mean)2.2(1.4-3.9)0.77(0.57-0.96)1.5(1.22-1.70)2.00(1.00-3.00)2.9(1.3-4.4)0.54(0.43-0.65)1.4(1.16-1.58)2.00(1.50-2.00)

Video interventionActive video teaching hypoventilation, prolonged expirationand nasal breathing techniques• Nasal route of breathing (“gentle breathing”)• Hypoventilation (“awareness of reduced breath”)• Breath hold at FRC (“breath check”) Control video teaching non-specific exercises :• Forward curl, arm raise, good posture and relaxation Each video included a demonstrated exercise session of 20minutes which subjects watched daily and performed theexercises for 20 minutes twice daily during the wholetreatment period (weeks 0 to 30) Advised to use the exercises as needed for the relief ofsymptoms in place of reliever medication. If the exercises didnot relieve symptoms, reliever medication was to be used

Symptom Score, mean (SD)Daily Asthma Symptom ScoreNSp=0.04NS4NSNSp=0.01(1=None- 5=Severe)321Week 0 Week 12 Week 28Group AGroup B

Reliever use, median (IQR)(puffs/24 hrs)Reliever UsePuffs/24 hours87p=0.0005p=0.0003NSp

Week 6Week 12Week 14Week 16Week 22Week 28Week 302.52RESULTS : Median Daily Reliever UseMedian Daily RelieverUseGroup AGroup B1.510.50

ACQ score, mean (SD)(range 0-6)Asthma Control Questionnaire3NSNSp=0.00562p=0.03NSp=0.001410Week 0 Week 12 Week 28Group AGroup B

ResultsQuality of life: no difference between groupsSymptom scores: small improvement in both groupsReliever use: 86% reduction in both groups!ICS dose: halved in both groupsPhysiological or inflammatory outcomes: No differencePhysician assessment: similar improvement in both groupsQualitative feedback from patients•Sense of personal control•Breathing exercises good for mild/moderate symptoms•Not effective for symptoms due to colds, allergy orexercise

Breathing techniquesIn this study, either abdominal & upper body breathingtechniques, or shallow nasal breathing exercisesReduced SABA useEnabled ICS dose reductionMaintained or improved symptom scoresMaintained or improved ACQBenefits were not affected by PF monitoring

Breathing ExercisesStudy ParticipationRegular monitoringIncreased awarenessBeing in controlIncreased complianceCalm & relaxedLess reliant on medicationFewer side effectsPerception of improved control & exercise efficacy

Patients’ commentsThe exercises were described as being “Initially not a great advantage, but as the study continued I havebeen able to „breathe‟ myself out of many situations” “Extremely useful, even if it wasn‟t enough it gave the space towait before medicating without the desperate panicky feeling” “Not very useful. Symptoms mean shortness of breath, so deep,relaxed breathing is very difficult….”BUT the exercises were “No match for URTI, dust, vigorous exercise, animal response” “The exercises did not work when I had viral illnesses (e.g. cold,sinusitis) or when I was doing „dusty‟ housework”

When asked if they would use theexercises in futureFor mild symptoms, 86% would try theexercises firstFor moderate symptoms, 52% would try theexercises first followed by relieverif there was insufficient effectFor severe symptoms, 0% would try theexercises first

Using breathing techniques as a behaviouralexperiment (CBT) Patient tests preconception (asthma will worsen) of an alternativebehaviour (breathing technique) in place of maladaptive behaviour(over-use of rescue medication)BeliefAlternativeperspectiveExperimentSpecificpredictionResultsConclusionI need to takemy Ventolinevery time Ifeel breathlessotherwise I‟llhave anasthma attackMybreathlessnessmay improve bydoing breathingtechniques. Iwont alwaysneed to useVentolinWhen feelingbreathless Ido breathingtechniquesfirst and onlyuse Ventolin ifsymptomspersistIf I don‟ttakeVentolinwhen I ambreathlessmy asthmawill getworseOn at leasthalf of theoccasionsmybreathlessnessgotbetter withbreathingtechniquesaloneMybreathlessnessoften improvesby usingbreathingtechniques . Idon‟t alwaysneed to useVentolinEdelman 2007 AFP 36 (3)www.racgp.org.au/afp/200704

Exercises for Asthma : an RCTBreathing Exercises for Asthma : an RCTThomas et al Thorax 2009;64:55-61 prospective, parallel group, single-blind RCT, n= 183 89 patients with asthma and impaired QoL,randomised to• 3 sessions of physiotherapist-supervised breathing training (n=94)or• asthma nurse-delivered asthma education 1 month post intervention : similar improvements in AQLQscores in both groups, trends (NS) to improved ACQ 6 months : significant between-group difference favouringbreathing training - 0.38 units, 95% CI 0.08 to 0.68 6-months : significant between-group differences in HAD anxietyfavouring breathing training (1.1,95% CI 0.2-1.9), HADdepression (0.8, 95% CI 0.1-1.4) and Nijmegen scores(3.2, 95%CI 1.0 to 5.4)

Breathing Exercises for Asthma : an RCTThomas et al Thorax 2009;64:55-61

How do patients take up newpractices? No single theory dominates research or practice inhealth education Three theories predominate• Health Belief Model• Bandura‟s Social Learning Theory• Ajzen and Fishbein‟s Theory of Reasoned Action These models presume that people are able andwilling to change their health behaviours if givensufficient information, appropriate role models,incentives and support1. Bandura et al. 19902. Glanz, Lewis et al. Health Behaviour and Health Ed 19903. Eagar, Garrett et al. Health Planning Aust Perspectives 20014. Horne and Weinemn Psychol Health. 2002;17:17–32.

ConclusionsBreathing techniques COMPRISING DIFFERENTSETS OF UPPER BODY MOVEMENTS andRELAXATION EXERCISES or NASAL ROUTE OFBREATHING and REDUCED RATE AND DEPTH OFBREATHING, taught by video or healthprofessionals, and practiced regularly, may be usefulin the management of symptomatic patients withmild-moderate asthma