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.