What makes difficult asthma difficult?
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What makes difficult asthma difficult? SCH Journal Club Nicki Barker 2012 Dysfunctional breathing in children 1
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What makes difficult asthma difficult?. Nicki Barker 2012. SCH Journal Club . Aim. To determine whether breathing retraining improves quality of life for children with dysfunctional breathing. Objectives. Clarify the problem identified - PowerPoint PPT Presentation
Transcript of What makes difficult asthma difficult?
What makes difficult asthma difficult?SCH Journal Club
Nicki Barker2012
June 2012
Dysfunctional breathing in children 1
Aim
To determine whether breathing retraining improves quality of life for children with dysfunctional breathing
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Objectives
• Clarify the problem identified• Share an understanding of difficult asthma and
dysfunctional breathing• Critically appraise a relevant piece of literature• Assess the impact of the literature on current
practice
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Difficult asthma
‘persistent symptoms and/or frequent exacerbations despite treatment
at step 4 or step 5’
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Difficult asthma?
• Compliance issues
• Incorrect diagnosis
• Asthma plus a co-morbidity
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BTS guidelines 2012
‘dysfunctional breathing should be considered as part of a difficult
asthma assessment’
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BreathWorks• Specialist assessment of
dysfunctional breathing• Children aged 8-16• Referral currently via
respiratory clinics• Thursday afternoon in
physiotherapy O/P’s
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Dysfunctional breathing (DB)
Dysfunctional breathing
HVS VCD Breathing pattern disorder
Dysfunctional breathing in children
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DB: A model
HVS
BPDVCD
DB: A paediatric model
HVS
BPDVCD
Evidence for breathing ex’s
• Buteyko breathing technique may be considered to help patients to control the symptoms of asthma
• Reduces symptoms and bronchodilator use
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The Clinical Question
Population Children with dysfunctional breathing
Intervention Breathing retraining
Comparison Normal care
Outcome QOL, symptom scores, changes in asthma medication,
objective measures
Design Intervention RCT
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Breathing retraining for dysfunctional breathing in asthma: a
randomised controlled trial
Thomas M, McKinley RK, Freeman E, Foy C, Prodger P, Price D.
Thorax Feb 2003; 58(2):110-5
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The Clinical Question
Population Adult asthma patients with dysfunctional breathing
Intervention Breathing retraining
Comparison Equivalent amount of professional attention
Outcome QOL, symptom scores, changes in asthma medication
Design Intervention RCT
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Methods• Patients aged 17 to 65• n=33• Diagnosis of currently treated asthma• Single semi-rural UK GP practice• Nijmegen questionnaire score of 23• Randomised to breathing retaining or asthma
education
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Study flow diagram
Thomas M et al. Thorax 2003;58:110-115
Outcome measures• Primary
– Asthma specific health status (AQLQ)– Nijmegen questionnaire scores
• Secondary– Changes in asthma medication and medication usage
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Using the CASP tool
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A/ Are the results of the trial valid?
Screening Questions 1 Did the trial address a clearly focused issue? Yes Can't tell No
2 Was the assignment of patients to treatments randomized? Yes Can't tell
No
3 Were all of the patients who entered the trial properly accounted for at its conclusion ? Yes Can't tell No
CASP cont.
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Detailed Questions
4 Were patients, health workers and study personnel ‘blind’ to treatment? Yes Can't tell No - Virtually impossible with physiotherapy interventions
5 Were the groups similar at the start of the trial? Yes Can't tell
No- Control group appeared to have greater inhaled steroid dose
6 Aside from the experimental intervention, were the groups treated equally? Yes Can't tell No - 75mins versus 60mins and in a different format
CASP cont.
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B/ What are the results? 7 How large was the treatment effect? - Not clearly stated and no MCID available for Nijmegen Questionnaire
8 How precise was the estimate of the treatment effect? - Confidence interval and limits not stated
C/ Will the results help locally? 9 Can the results be applied to the local population? Yes Can't tell No – Questionable choice of measures, adult to paediatric applicability
10 Were all clinically important outcomes considered? Yes No - No objective measures used
11 Are the benefits worth the harms and costs? Yes No- Minimal likelihood of harm. Costs – time of therapist and patient
Key thoughts• 50% benefitted at 1 month• 25% benefitted at 6 months• Small numbers• Short duration intervention• Intervention not representative of clinical situation• Application of findings to children• Impact of co-existent asthma
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Quality of life as measured by PedsQL
MCID = minimal clinically important difference
Symptom score using Nijmegen Questionnaire
Take home messages• Consider dysfunctional breathing in cases of difficult
asthma• Key signs of DB are:
• Frequent sighing, unsteadiness/irregularity of breathing, upper chest dominated breathing, mouth breathing, difficulty breathing in, throat tightness
• Refer appropriate cases to BreathWorks• Support the research needed to better understand
DB in children
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