Breathing techniques for asthma
CA Slader, HK Reddel, LM Spencer, EG Belousova, CL Armour, SZ Bosnic-Anticevich,
FK Thien, CR Jenkins
CRC for Asthma
A cure for asthma?
Breathing Techniques Background
Some physiologic rationale to consider breathing techniques as possibly effective for asthma
Dysfunctional breathing affects 30% asthma patients Several studies to date show improved symptoms and
QoL, and reduced reliever use Cochrane review (August 2002) 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
Problems with breathing techniques studies
• Varying techniques of breathing retraining
• Varying length and frequency of treatment.
• Widely differing interventions
• Significant differences between control and intervention
• Small studies unable to provide a reliable estimate of the efficacy of breathing exercises
CRC for Asthma
• 7 year funding • Industry and Academic partnerships• Federal government funding added • Must be multicentre, collaborative research• CRC for partners • Project 7 : Targeting treatment • Opportunity to assess non-drug therapies
CRC Project Title
A randomised controlled trial of the
effect of breathing techniques on
symptoms, AHR, QOL and dose of ICS
in subjects with symptomatic asthma.
Study Design
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
sho
ut
V1 V2 V3 V4 V5 V6 V7 V8 V9
PEF
* = ICS down titration
Group A Video
• Based on the main components of previously tested breathing techniques:
– Nasal route of breathing (“gentle breathing”)– Hypoventilation (“awareness of reduced breath”)– Breath hold at FRC (“breath check”)
• Panoramic scenery and background music during periods of hypoventilation
Group B Video• Exercises designed by CT physios at RPAH
• Components (repeated in sets):– Shoulder rotation– Forward curl– Arm raise– + focussing on good posture and relaxation (“control of
breathing”)
• No evidence for clinical impact of these exercises on asthma
• Route of breathing not specified, but mixed oral and nasal route of breathing demonstrated.
Instruction About Reliever
“If you feel your asthma symptoms starting, before you take your symptom reliever, pause, and do your breathing exercises.
You should feel as though your symptoms start to resolve within a few minutes.
If you are still experiencing symptoms, don’t panic. Relax, and try your exercises again.
If your symptoms still don’t improve, use your symptom reliever.”
Results
Quality of Life (AQLQ)Group A
Group B
To
tal S
core
, mea
n (
SD
)
0
1
2
(Ran
ge 0
-5)
Week 0
p=0.0417
Week 12
p=0.29
Week 28
p=0.27
p=0.01NSNS
NSNSNS
Reliever UseR
elie
ver
use
, med
ian
(IQ
R)
Week 0
p=0.23
Week 12
p=0.17
Week 28
p=0.99
0
1
2
3
4
5
6
7
8
(puf
fs/2
4 hr
s)
NSp=0.0005p<0.0001
NSp=0.0003p=0.0007
Group A
Group B
Wee
k 12
Wee
k 14
Wee
k 16
Wee
k 22
Wee
k 28
0
0.5
1
1.5
2
2.51
Wee
k 6
Wee
k 30
Group A
Group B
Median Daily Reliever Use
Airway Hyperresponsiveness to MannitolR
DR
Man
nit
ol,
geo
met
ric
mea
n (
SD
)
-0.20
0.00
0.20
0.40
0.60
(% fa
ll/m
g)
Week 0n= 48
p=0.28
Week 12n=26
p=0.54
Week 28n=26
p=0.30
NSNSp=0.03
NSNSNS
Group A
Group B
Results Summary• Primary:
– Quality of life NO CHANGE– Daily symptom score IMPROVEMENT - B
• Secondary:– FEV1 NO CHANGE– AHR (mannitol) NO CHANGE– Reliever use 86% REDUCTION– ICS dose 50% REDUCTION– ACQ (Juniper) NO CHANGE– Patient global assessments NO CHANGE– Physician global assessments IMPROVEMENT - B– Route of breathing TREND TO NASAL - A– End-tidal CO2 NO CHANGE– Airways resistance (FOT) NO CHANGE
Comparison with Previous Studies
• Similar:– Improvement in patient centred outcomes– Marked reduction in reliever use– No consistent changes in physiological
measures• Lung function• Airway responsiveness
• End tidal CO2
However…why different results to previous studies?
In this study :
• NO consistent differences between the two groups
• Double blinding of subjects and investigators
• Closely matched control intervention in this study
• Identical advice given to both groups in this study regarding as needed reliever use
In Previous studies :
• Dissimilar comparison interventions in the control arms:
– Asthma education
– Physiotherapy
– Relaxation
• No matched reliever substitute
In terms of our results….
• All process elements were matched including suggestions of relaxation
• Direct comparison of the specific elements i.e. the actual exercises were the only difference between the two study groups
• Previous “weaker” controls may have led to an overestimation of the effect of the exercises
Patient perception of benefit
Changes in Asthma
How is your asthma now, compared with before you started the breathing exercises?
Much worse Much better
Less asthma and constriction of breathing
MF-A
I’m not woken throughout the night because of my
asthma
JH-B
…about the same, but medication has been successfully halved
TS-A
Patient perception of benefit
Utility of the Breathing Exercises
I tried them a couple of times and didn’t get the same benefit as a puff
of Ventolin. This put me off trying them again.
KL-B
I had a lack of confidence in the
efficacy of the routine [initially]
SR-A
…as the study continued I have been able to ‘breathe’ myself
out of many situations
AD-A
Not very useful. Symptoms mean
shortness of breath, so deep, relaxed breathing is
very difficult….
AL-A
…the symptom control exercises helped me to take time out to relax and distress [sic] instead of always taking
my Ventolin
SB-B
Extremely useful, even if it wasn’t enough, it gave me the space to wait before medicating without that
desperate panicky feeling.
GP-B
Patient perception of benefit
Utility of the Breathing Exercises
The Bottom Line
Breathing techniques taught by video
may be useful in the management of
patients with mild asthma symptoms
who use reliever frequently.