Breathing Exercises for

Asthma : Evidence and

Practice

A simple and effective approach to

minimise reliever use and improve

symptom control

Christine Jenkins, Airways Group

Woolcock Institute of Medical Research

Delivering Breathing Techniques in the

Community

Conflict of Interest statement

The Breathing Techniques study was conducted through

funding by the Co-operative Research Centre for Asthma, which

is a collaborative research programme funded jointly by the

Australian Government and Industry partners. During this period

the CRC was funded in part by support from GlaxoSmithKline

and AstraZeneca

Breathing Techniques Background

Some physiologic rationale to consider breathing

techniques may be effective for asthma

Dysfunctional breathing affects 30% asthma patients

Several studies to date show improved symptoms and

QoL, and reduced reliever use

Cochrane review (2004) suggested no reliable

conclusions could be drawn from 42 papers (7 RCT‟s)

A proven low risk, low cost intervention would appeal to

patients and to clinicians if it offered improved asthma

control

History lesson

Those who do not learn the lessons of history

are bound to repeat them…..

1957

Hyperventilation and asymptomatic

chronic asthma Osborne et al Thorax 2000

Studied patterns of breathing in 23 currently asymptomatic stable asthmatics, occasional reliever use, normal lung function, AHR to methacholine 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<0.01) 4.96 vs 5.27 kPa

Lower PETCO2 (p<0.02) 4.89 vs 5.28 kPa

Reduced PaCO2 correlated with PD20M (r = 0.56, p<0.01), but not with sputum eos, anxiety/depression or lung function

More anxiety (p<0.02) but scores were within normal range

NS differences in ventilatory or respiratory pattern between asthma and controls

Prevalence of dysfunctional breathing in

patients treated for asthma in primary care:

cross-sectional surveyThomas et al BMJ 2001;322:1098

Evidence links dysfunctional breathing with asthma and

respiratory disorders (Howell Thorax 1990)

Hyperventilation common in specialist respiratory clinics (Carr

et al J Pschysom Res 1998)

Link between asthma and symptomatic hyperventilation in

several studies (Demeter AJM 1986)

42% of patients in hospital clinic showed evidence of

hyperventilation disorder (McLean AJRCCM 1999)

Hyperventilation may complicate and compound asthma

presentation (Han AJRCCM 1999)

Nijmegen questionnaire

for dysfunctional breathing

Chest pain

Feeling tense

Blurred vision

Dizziness

Confusion or loss of touch with 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 fingers or hands

Tightness around mouth

Cold hands or feet

Palpitations

Anxiety

Symptom measurement tool

Score 0 (never) to 4 (very

often)

Assists in identifying

dysfunctional breathing and

hyperventilation

Total symptom score > 23

has sensitivity 91% and

specificity 95% as a

screening instrument in

patients with

hyperventilation syndrome

Prevalence of dysfunctional breathing in patients

treated for asthma in primary care: cross-

sectional surveyThomas et al BMJ 2001;322:1098

Sought to determine prevalence of dysfunctional breathing in asthma patients in UK primary care

7033 patients; 4381 aged 17 – 65, semi-rural GP

307 (7% ) met criteria – all patients who had asthma

diagnosed on clinical grounds, who had received > 1 script in

past 12m for inhaled or oral BD or ICS

Sent questionnaire to 307; response rate 74%

No significant differences in severity of asthma

between high and low scores

1/3 of women and 1/5 of men in had high scores on the

Nijmegen Q‟aire suggesting dysfunctional breathing

Prevalence of dysfunctional breathing in

patients treated for asthma in primary care:

cross-sectional surveyThomas et al BMJ 2001;322:1098

RECOMMENDATIONS

Dysfunctional breathing is frequently undiagnosed

Recommend scrutiny to identify dysfunctional breathing

which should be addressed specifically rather than

increasing medication for asthma

Need studies to identify the role of breathing retraining to

address high prevalence of dysfunctional breathing in

asthmatic patients

Types of breathing techniques and

exercises used in breathing retraining

Problems studying breathing

techniques in asthma

RCT must involve blinding subject and observer

Practitioners must not have a vested interest in outcome, nor

unregulated 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 efficacious

to the subject

Adequately powered studies

Outcomes should be objective measures of asthma symptom

and disease control, and validated quality-of-life questionnaires

Yoga studies

Yoga (pranayama)

regularising and slowing the breathing

frequency by

prolonging the expiratory phase

enhancing abdominal/diaphragmatic breathing

imposing resistance to inspiration and expiration

yogasanas and chanting which include

manoeuvres to control breathing aimed at

slowing respiratory frequency

reducing depth of breathing

Mimicking Pranayama yoga in clinical

trials of breathing techniques

Slow breathing retraining exercises using Pink City

lung exerciser (Pink City represents Jaipur India)

mouthpiece attached to a disc with a selection of

apertures of 2-5 mm, any one of which can be

selected, through which all inspired and expired air

must pass

apertures carry a one-way valve which halves the

cross-sectional area of the aperture during expiration,

imposing a 1:2 ratio on the duration of inspiration and

expiration

Smaller aperture slower respiratory rate

RCT of two breathing exercises (Buteyko

and pranayama) in asthmaCooper et al Thorax 2003;58:674

90 patients with asthma

Used a Pink City Lung Exerciser or placebo PCLE or

Butyeko (BBT) for 6 months

Practised BD and used techniques during symptom

episodes

No change on PD20M

Symptoms reduced in BBT (p<0.003) by mean 3;

SABA use reduced by 2 puffs/day at 6m

No change in FEV1, exacerbations, or ICS dose

reduction

Yoga studies Vempati 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 lifestyle modification and stress management based on yoga followed by closely monitored continuation of the practices at home 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 retraining

Yoga is taught in eight steps of which one,

pranayama deals explicitly with control of

breathing

Pranayama has four objectives

a stepwise reduction in breathing frequency

attainment of a 1:2 ratio for duration of inspiration

and expiration

a breath holding period at the end of inspiration

that lasts twice the length of expiration

mental concentration on breathing

Buteyko Breathing Technique

Aims to reduce hyperventilation through periods of

controlled reduction in breathing, known as „slow

breathing‟ and „reduced breathing‟

Combined with periods of breath holding, known as

„control pauses‟ and „extended pauses‟

emphasis is on self-monitoring using the pulse rate

and the pauses as objective measures of outcome

Longer pauses = better breathing control

Includes advice and training on the benefits of nasal

breathing over oral breathing

Common features in Buteyko breathing,

yoga and deep diaphragmatic breathing

Practising a series of exercises which help reduce

the depth and frequency of respiration

Learned mastery over breathing rate and depth

Breath “holding” ability at end expiration during

normal respiration used to monitor progress

May also involve

Physical Relaxation

Thought control

Nasal route of breathing

Rationale for Buteyko

breathing

People with asthma hyperventilate tachypnea,

bronchoconstriction, low airway CO2 and arterial CO2 more

stimulus to increase respiratory rate

Increased respiratory rate cooling and drying of airways

bronchoconstriction

β2 agonists sympathetic overdrive tachypnea and over-

breathing hypocapnia bronchoconstriction

Promoting nasal breathing over oral breathing warms, filters

and humidifies air less bronchoconstriction

Deep inspiration and deep breaths are counter effective, hence

must avoid performing PEF and spirometry

= Asthma control can be learned

Breathing exercises for asthmaHolloway & Ram Cochrane Library 2004

Assessed evidence the efficacy of breathing

retraining in the treatment of asthma

42 full text papers 35 studies excluded

Most of small size, 2 studies show significant reductions in

reliever use

3 studies showed reductions in acute exacerbations

2 studies showed improvements in QoL

Overall benefits only in isolated outcome measures, in single

studies

Buteyko breathing techniques in

asthma Bowler et al MJA 1998;169:575

Prospective blinded randomized study compared BBT

with 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 33.0

At 3m, BBT group had median reduction of 904 mcg

SABA 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)

Study Design

* ICS

Week

Group A video and exercises daily

Run-in

Group B video and exercises daily

-2 0 6 12 14 22 28

PEF PEF

* *16

ICS dose stable ICS dose reduction

ICS dose stable ICS dose reduction

30

PE

F

Wa

sh

ou

t

V1 V2 V3 V4 V5 V6 V7 V8 V9

PEF

Variable Group A (n=28) Group B (n=29)

Gender (M:F) 11 : 17 14 : 15

Smoking Hx (Never: Former) 19 : 9 23 : 6

Atopy (non-atopic: atopic) 2 : 23 4 : 23

OCS Use % (past year) 42.9 27.6

FEV1% pred. 80.8%

(74.5-87.0%)

78.9%

(72.5-85.4%)

Reliever Use

(median, puffs/day)

2.2

(1.4-3.9)

2.9

(1.3-4.4)

AQLQ

(mean)

0.77

(0.57-0.96)

0.54

(0.43-0.65)

ACQ-7

(mean)

1.5

(1.22-1.70)

1.4

(1.16-1.58)

Daytime Symptom Intensity

Score (mean)

2.00

(1.00-3.00)

2.00

(1.50-2.00)

Baseline Characteristics

Video intervention

Active video teaching hypoventilation, prolonged expiration and 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 20 minutes which subjects watched daily and performed the exercises for 20 minutes twice daily during the whole treatment period (weeks 0 to 30)

Advised to use the exercises as needed for the relief of symptoms in place of reliever medication. If the exercises did not relieve symptoms, reliever medication was to be used

Sym

pto

m S

co

re,

mea

n (

SD

)

Group A

Group B

1

2

3

4

(1=

None

-5=

Severe

)

Week 0 Week 12 Week 28

p=0.04NSNS

NSNSp=0.01

Daily Asthma Symptom Score

Reliever

use,

med

ian

(IQ

R)

Group A

Group B

Week 0 Week 12 Week 280

1

2

3

4

5

6

7

8

(puffs/2

4 h

rs)

NSp=0.0005p<0.0001

NSp=0.0003p=0.0007

Reliever Use

Puffs/24 hours

Wee

k 1

2

Week 1

4

Week 1

6

Week 2

2

Week 2

8

0

0.5

1

1.5

2

2.5

Week 6

Week 3

0

Group A

Group B

RESULTS : Median Daily Reliever UseMedian Daily Reliever

Use

AC

Q s

co

re,

mean

(S

D)

Group A

Group B

0

1

2

3

(range 0

-6)

Week 0 Week 12 Week 28

NSNSp=0.0056

NSp=0.03p=0.0014

Asthma Control Questionnaire

Quality of life: no difference between groups

Symptom scores: small improvement in both groups

Reliever use: 86% reduction in both groups!

ICS dose: halved in both groups

Physiological or inflammatory outcomes: No difference

Physician assessment: similar improvement in both groups

Qualitative feedback from patients

•Sense of personal control

•Breathing exercises good for mild/moderate symptoms

•Not effective for symptoms due to colds, allergy or

exercise

Results

Breathing techniques

In this study, either abdominal & upper body breathing

techniques, or shallow nasal breathing exercises

Reduced SABA use

Enabled ICS dose reduction

Maintained or improved symptom scores

Maintained or improved ACQ

Benefits were not affected by PF monitoring

Breathing Exercises Study Participation

Regular monitoring

Increased awareness

Being in control

Increased compliance

Calm & relaxed

Less reliant on medication

Fewer side effects

Perception of improved control & exercise efficacy

Patients’ comments

The exercises were described as being

“Initially not a great advantage, but as the study continued I have been able to „breathe‟ myself out of many situations”

“Extremely useful, even if it wasn‟t enough it gave the space to wait 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 the

exercises in future

For mild symptoms, 86% would try the

exercises first

For moderate symptoms, 52% would try the

exercises first followed by reliever

if there was insufficient effect

For severe symptoms, 0% would try the

exercises first

Using breathing techniques as a behavioural

experiment (CBT)

Patient tests preconception (asthma will worsen) of an alternative

behaviour (breathing technique) in place of maladaptive behaviour

(over-use of rescue medication)

Belief Alternative

perspective

Experiment Specific

prediction

Results Conclusion

I need to take

my Ventolin

every time I

feel breathless

otherwise I‟ll

have an

asthma attack

My

breathlessness

may improve by

doing breathing

techniques. I

wont always

need to use

Ventolin

When feeling

breathless I

do breathing

techniques

first and only

use Ventolin if

symptoms

persist

If I don‟t

take

Ventolin

when I am

breathless

my asthma

will get

worse

On at least

half of the

occasions

my

breathless-

ness got

better with

breathing

techniques

alone

My

breathlessness

often improves

by using

breathing

techniques . I

don‟t always

need to use

Ventolin

Edelman 2007 AFP 36 (3) www.racgp.org.au/afp/200704

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 AQLQ scores in both groups, trends (NS) to improved ACQ

6 months : significant between-group difference favouring breathing training - 0.38 units, 95% CI 0.08 to 0.68

6-months : significant between-group differences in HAD anxiety

favouring breathing training (1.1,95% CI 0.2-1.9), HAD depression (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 RCTBreathing Exercises for Asthma : an RCT

Thomas et al Thorax 2009;64:55-61

Breathing Exercises for Asthma : an RCT

Thomas et al Thorax 2009;64:55-61

How do patients take up new

practices? No single theory dominates research or practice in

health 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 and willing to change their health behaviours if given sufficient information, appropriate role models, incentives and support

1. Bandura et al. 1990

2. Glanz, Lewis et al. Health Behaviour and Health Ed 1990

3. Eagar, Garrett et al. Health Planning Aust Perspectives 2001

4. Horne and Weinemn Psychol Health. 2002;17:17–32.

Conclusions

Breathing techniques COMPRISING DIFFERENT

SETS OF UPPER BODY MOVEMENTS and

RELAXATION EXERCISES or NASAL ROUTE OF

BREATHING and REDUCED RATE AND DEPTH OF

BREATHING, taught by video or health

professionals, and practiced regularly, may be useful

in the management of symptomatic patients with

mild-moderate asthma