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Systematic Review of the Effectiveness of Breathing Retraining in Asthma Management

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Systematic Review of the Effectiveness of Breathing Retraining in Asthma Management Review For reprint orders, please contact [email protected] Systematic review of the effectiveness of breathing retraining in asthma management Expert Rev. Respir. Med. 5(6), 789–807 (2011) John Burgess1, In asthma management, complementary and alternative medicine is enjoying a growing Buddhini Ekanayake1, popularity worldwide. This review synthesizes the literature on complementary and alternative Adrian Lowe1, medicine techniques that utilize breathing retraining as their primary component and compares David Dunt2, evidence from controlled trials with before-and-after trials. Medline, PubMed, Cumulative Index 3 to Nursing and Allied Health Literature and the Cochrane Library electronic databases were Francis Thien and searched. Reference lists of all publications were manually checked to identify studies not found 1 Shyamali C Dharmage* through electronic searching. The selection criteria were met by 41 articles. Most randomized 1Centre for Molecular, Environmental, controlled trials (RCTs) of the Buteyko breathing technique demonstrated a significant decrease Analytic and Genetic Epidemiology, in b -agonist use while several found improvement in quality of life or decrease in inhaled Melbourne School of Population 2 Health, The University of Melbourne, corticosteroid use. Although few in number, RCTs of respiratory muscle training found a Victoria 3010, Australia significant reduction in bronchodilator medication use. Where meta-analyses could be done, 2Centre for Health Program Evaluation, they provided evidence of benefit from yoga, Buteyko breathing technique and physiotherapist- Melbourne School of Population led breathing training in improving asthma-related quality of life. However, considerable Health, The University of Melbourne, Victoria 3010, Australia heterogeneity was noted in some RCTs of yoga. It is reasonable for clinicians to offer qualified 3Department of Respiratory Medicine, support to patients with asthma undertaking these breathing retraining techniques. Box Hill Hospital and Monash University, Nelson Road, Box Hill, KEYWORDS: asthma • Buteyko breathing technique • complementary medicine • respiratory muscle retraining Victoria 3138, Australia • systematic review *Author for correspondence: [email protected] Complementary and alternative medicine Buteyko theorized that hyperventilation was the (CAM) has been defined as “a broad domain pathological basis of many diseases including of healing resources that encompasses all asthma, suggesting that hypocapnia consequent health systems, modalities and practices and to hyperventilation initiates bronchospasm, and their accompanying theories and beliefs, other patented a formula based on breath-hold time than those intrinsic to the politically dominant which, he claimed, predicted end-tidal CO2 health system of a particular society or culture [201]. BBT utilizes shallow, controlled breathing in a given historical period” [1]. CAM is popular and respiratory pauses in an attempt to increase in the general community for the self-manage- alveolar and arterial CO2 tension, which BBT ment of asthma. Between 20–30% of adults proponents suggest may reverse bronchospasm. and 50–60% of children have been identified Other breathing retraining techniques in more rigorously designed studies as having forming part of CAM include��������������� yoga, biofeed- used CAM for asthma yet approximately half back and respiratory muscle training. Yoga of CAM users do not inform their general prac- techniques include deep-breathing exercises titioner of their CAM use [2]. Breathing retrain- (pranayama), postures (asanas), mucus expec- ing, a popular form of CAM, is the subject of toration (kriyas), meditation, prayer and often this review. dietary changes to reduce asthma symptoms. Prominent among breathing retraining thera- Biofeedback aims to reduce symptoms through pies is the Buteyko breathing technique (BBT), gain of voluntary control over autonomic pro- based on the work of Konstantin Buteyko [3]. cesses. Direct biofeedback training consists of www.expert-reviews.com 10.1586/ERS.11.69 © 2011 Expert Reviews Ltd ISSN 1747-6348 789 790 Table 1. Randomized controlled trials of breathing modification techniques. Review Study† (year) Sample Design Intervention Withdrawals Follow-up Difference between groups Ref. (intervention vs control) Bowler et al. 39 community RCT 1-week training with 2 (1 intervention, 12 weeks ↓ MV: 3.6 l/min (p = 0.004) [12] (1998) volunteers with True randomization Buteyko representative 1 control) ↓ b2-agonist: 847 µg/day (p = 0.002) Burgess, Dunt, Thien Lowe, &Dharmage Ekanayake, asthma Double blind versus relaxation and ↑ AQOL score (p trend = 0.09) asthma education No between-group difference in PEF or FEV1 No change in ETCO2 in either group Opat et al. 36 community RCT 4 weeks BBT training 8 4 weeks ↑ AQOL: -1.29 for total score (p = 0.043) [20] (2000) volunteers with Sample size estimate video versus nature video ↓ b2-agonist: 210 µg /day (p = 0.008) asthma True randomization Thomas et al. 33 volunteers with RCT 2 weeks retraining with 5 (1 intervention, 1 and At 1 month: ↑ AQLQ total score‡ [22] (2003) asthma/ Sample size estimate physiotherapist versus 4 control [3 at 6 months At 6 months: ↑AQLQ activities score‡ dysfunctional True randomization nurse-led asthma 6 months]) At 6 months: ↓ Nijmegen score‡ breathing education Cooper et al. 89 community RCT 2 weeks BBT with 20 (7 intervention, 6 months ↓ symptom scores by two points (p = 0.003) [15] (2003) volunteers with Sample size estimate certified practitioner 6 PCLE, 7 placebo) ↓ b2-agonist: two puffs/day (p = 0.005) asthma True randomization veruss PCLE or placebo No between-group difference in FEV1, ICS Double blind use, asthma exacerbations or AQLQ scores [16] McHugh et al. 38 community RCT 1-week BBT with Buteyko 4 6 weeks, ↓ b2-agonist 6 weeks; 38% between-group (2003) volunteers with Sample size estimate representative versus 3 months, difference§ asthma True randomization asthma education 6 months 3 months: 35% between-group difference§ Double blind ↓ ICS 6 weeks: 24% between-group difference§ 3 months: 34% between-group difference§ 6 months: 51% between-group difference§ No difference in lung function [17] Slader et al. 57 community RCT 28 weeks BBT taught by 7 (3 intervention, 12 and ↑ b2-agonist-free days at 12 weeks in both (2006) volunteers with Sample size estimate video versus 28 weeks 4 control) 28 weeks groups compared with baseline (p < 0.001) asthma True randomization non-specific upper body No between-group difference in b2-agonist- Double blind exercises taught by video free days at 12 or 28 weeks ↓ ICS use (50%) in each group at 13 weeks compared with baseline (p < 0.0001) No lung function or ETCO2 change Expert Rev. Respir. Med. †Studies listed in order of year of publication. ‡All p-values <0.02. §All p-values <0.04. ↑: Increase in ↓: Decrease in; ACT: Airway control test; AQLQ: Asthma Related Quality-of-Life Questionnaire; AQOL: Asthma-related quality of life; BBT: Buteyko breathing technique; BT: Breathing training; CCMAS: Chinese Children’s Manifest Anxiety Scale; ETCO2: End tidal carbon dioxide; FEV1: Forced expiratory volume in 1 s; GASCC: General Anxiety Scale for Chinese Children; HAD: Hospital Anxiety and Depression Questionnaire; ICS: Inhaled corticosteroid; MAQOLQ: Mini Asthma Quality-of-Life questionnaire (Juniper); MV: Minute volume; NQ: Nijmegen questionnaire; PCLE: Pink City Lung Exerciser; PEF: Peak expiratory flow; PEFR: Peak expiratory flow rate; RCT: Randomized controlled trial; SF-36v2 PC: Short Form-36 version 2 Health Survey physical component; SGRQ: St George Respiratory Questionnaire. 5(6), (2011) www.expert-reviews.com Table 1. Randomized controlled trials of breathing modification techniques (cont.). Study† (year) Sample Design Intervention Withdrawals Follow-up Difference between groups Ref. (intervention vs control) Holloway et al. 85 subjects with RCT Five 1-h sessions 13 (7 intervention, 6 and ↓ SGRQ symptom score at 6 and 12 months: [19] (2007) mild or well- Sample size estimate physiotherapy (Papworth 6 control) 12 months between-group difference 8.6 points Systematic of the review effectiveness of breathing retraining in asthma management controlled asthma True randomization method) plus usual (p = 0.007) recruited from treatment versus usual ↓ HAD anxiety score at 6 and 12 months: semirural general treatment between-group difference 1.5 points practice (p = 0.006) ↓ HAD depression score at 12 months: between-group difference 0.5 points (p = 0.03) ↓ NQ total score at 6 and 12 months: between-group difference 2.3 points (p = 0.015) No between-group difference in lung function at either follow-up Meuret et al. 12 adults with RCT Capnometry-assisted None 8 weeks in In intervention group: [13] (2007) asthma recruited Not clear whether breathing retraining plus intervention ↓ ACQ score (p < 0.05) by advertisement truly randomized usual treatment versus group (n = 8) ↓ Steen asthma symptom score (p < 0.01) usual treatment ↓ PEF variability (p < 0.05) No change in FEV1 Cowie et al. 129 subjects from RCT Five sessions of BBT from 11 (9 intervention, 3 and At 6 months: [21] (2008) university-based Sample size estimate accredited practitioner 2 control) 6 months ↑ in asthma control (79 vs 72% controlled) asthma program True randomization versus five sessions of BT but no between-group difference (p = 0.4) from physiotherapist ↑ MAQOLQ scores same in both groups (0.96 vs 0.95) ↓ ICS use: 317 vs 56 µg/day (p = 0.02) Thomas et al.
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