Breathing pattern recordings using respiratory inductive plethysmography, before and after a physiotherapy breathing retraining program for asthma: A case report.

Breathing retraining (BR) improves symptoms, psychological well-being and quality of life in adults with asthma; but there remains uncertainty as to mechanism of effect. One of the intuitively logical theories is that BR works through altering breathing pattern. There is currently no evidence, however, that BR does result in measurable changes in breathing pattern. In this case report we describe the effects of physiotherapy BR on a 57-year-old female with a 10-year history of asthma. Data were collected before and after a physiotherapy BR program comprising three sessions over 18 weeks: breathing pattern (respiratory inductive plethysmography (RIP); physiology (end tidal carbon dioxide (ETCO2), heart rate, oxygen saturations, spirometric lung function); questionnaires (Asthma Control Questionnaire (ACQ), Hospital Anxiety and Depression Score, Nijmegen Questionnaire); and medication usage. After BR, the patient's symptoms improved. Her physiology was largely unchanged, although her FEV1 increased by 0.12L, peak flow by 21L/min. The patient reported using less Salbutamol, yet her asthma control improved (ACQ down 1.5). Her Nijmegen score dropped from positive to negative for hyperventilation (from 39 to 7). Her anxiety-depression levels both reduced into 'normal' ranges. The patient's expiratory time increased, with longer respiratory cycles and slower respiratory rate. No changes were seen in relative contributions of ribcage and abdomen. Controlled trials are now needed to determine the generalizability of these findings.

Patients' experiences of breathing retraining for asthma: a qualitative process analysis of participants in the intervention arms of the BREATHE trial.

Poor symptom control and impaired quality of life are common in adults with asthma, and breathing retraining exercises may be an effective method of self-management. This study aimed to explore the experiences of participants in the intervention arms of the BREATHE trial, which investigated the effectiveness of breathing retraining as a mode of asthma management. Sixteen people with asthma (11 women, 8 per group) who had taken part in the intervention arms of the BREATHE trial (breathing retraining delivered by digital versatile disc (DVD) or face-to-face sessions with a respiratory physiotherapist) took part in semi-structured telephone interviews about their experiences. Interviews were analysed using thematic analysis. Breathing retraining was perceived positively as a method of asthma management. Motivations for taking part included being asked, to enhance progress in research, to feel better/reduce symptoms, and to reduce medication. Participants were positive about the physiotherapist, liked having the materials tailored, found meetings motivational, and liked the DVD and booklet. The impact of breathing retraining following regular practice included increased awareness of breathing and development of new habits. Benefits of breathing retraining included increased control over breathing, reduced need for medication, feeling more relaxed, and improved health and quality of life. Problems included finding time to practice the exercises, and difficulty mastering techniques. Breathing retraining was acceptable and valued by almost all participants, and many reported improved wellbeing. Face to face physiotherapy was well received. However, some participants in the DVD group mentioned being unable to master techniques. ASTHMA: PATIENTS RECEPTIVE TO BREATHING RETRAINING: Patients with asthma taught how to change their unconscious breathing patterns generally like non-pharmacological interventions. Researchers in the UK, led by Mike Thomas from the University of Southampton, interviewed 16 people about their experiences in a trial that tested breathing retraining exercises delivered by DVD or face-to-face sessions with a respiratory physiotherapist. Overwhelmingly, trial participants reported that breathing retraining sessions gave them greater control over their symptoms, helped them relax, improved their quality of life and reduced the need for medications. Some participants who received DVD instruction said they had trouble mastering the techniques, and many in both groups found it hard to find time to practice the exercises. Overall, however, patients were positive about the experience. The authors conclude that breathing exercises are likely to be a well-received method of asthma management.

Patients' perceptions of the potential of breathing training for asthma: a qualitative study.

BACKGROUND: Poor symptom control is common in asthma. Breathing training exercises may be an effective adjunct to medication; it is therefore important to understand facilitators and barriers to uptake of breathing training exercises. AIMS: To gain insight into patients' perceptions of breathing training exercises designed to help control asthma symptoms. METHODS: Semi-structured think-aloud interviews were conducted with 29 people with asthma about their views of a booklet on breathing training exercises. RESULTS: Thematic analysis showed breathing training exercises were seen as acceptable in principle because they were viewed as nonpharmacological, holistic, unobtrusive, and likely to increase patient confidence in managing symptoms. Anticipated disadvantages included the time required and perceived irrelevance for those with well-controlled asthma. These views were influenced by prior experience of changing breathing, wanting to self-manage asthma, negative views of medication, and perceived asthma control/severity. Anticipated barriers to carrying out the exercises included difficulties with nose breathing, remembering to do them, and persevering with them. Anticipated facilitators included monitoring tools and social support. CONCLUSIONS: The idea of breathing training was viewed positively as an acceptable non-pharmacological treatment that patients can do discreetly to help them breathe more easily and reduce their reliance on medication. Uptake of breathing training may be greater among those who perceive their asthma as severe and/or have negative views of medication. To enhance uptake, it might be helpful to present breathing training exercises as holistic skills that can also benefit those with mild symptoms.

Are crackles an appropriate outcome measure for airway clearance therapy?

BACKGROUND: There is an urgent need to develop new outcome measures for respiratory therapy, to evaluate its effectiveness. Adventitious sounds generated from the lungs (crackles and wheezes), can now be quantified and characterized objectively with computer technology. To our knowledge, this is the first reported study designed to assess any change in lung crackles before and after a single session of airway clearance therapy. METHODS: Twenty-three stable bronchiectasis patients were recruited from United Kingdom out-patient clinics and treated with a single session of airway clearance therapy, using the active cycle of breathing technique. Sound recordings were made before and after the session at 7 anatomical chest locations. Computerized lung sound analysis was used to measure crackle parameters: 2-cycle deflection width (2CD), and crackle number per breath cycle (nBC). Perceived breathlessness, lung function, and oxygen saturation data were also recorded. RESULTS: Crackle mean 2CD and mean nBC increased post intervention. Sixteen participants (70%) showed a statistically significant difference in mean crackle 2CD before and after the session at ≥ 1 chest location. Thirteen (57%) participants had a difference between mean crackle 2CD before and after the intervention > 1 Smallest Real Difference (SRD, mean SRD = 2.23 ms) at ≥ 1 chest location. Differences in mean crackle nBC before and after the intervention did not exceed the SRD (mean SRD = 32 crackles per breath cycle) in any participant. Perceived breathlessness was significantly reduced post intervention; no significant changes were observed in either lung function or oxygen saturation. CONCLUSIONS: Crackle duration (2CD) was found to change after a single session of airway clearance therapy, and shows promise as a new outcome measure for respiratory therapy interventions.

Respiratory physiotherapy: towards a clearer definition of terminology.

Interventions used in clinical practice and research need to be described in sufficient detail to permit accurate replication. Since words and phrases can change their meaning over time, it is important that authors choose their words carefully and define anything which might be ambiguous. 'Breathing exercises' is a phrase which covers a multitude of therapeutic approaches. Recent randomised controlled trials have established the value of teaching patients with asthma to retrain their breathing. However, the descriptions of the breathing interventions are generally inadequate. This problem stems partly from a degree of confusion surrounding terms such as 'diaphragmatic breathing' which has been variously interpreted. A more structured approach to reporting such interventions is proposed. This approach will help to avoid confusion, and will permit the transfer of those interventions found to be effective in research trials into routine clinical practice.

The role of breathing training in asthma management.

PURPOSE OF REVIEW: There is considerable public interest in the use of breathing modification techniques in the treatment of asthma. Surveys suggest many people with asthma use them, often without the knowledge of their medical attendants. Extravagant claims have been made about the effectiveness of some techniques, resulting in scepticism from orthodox clinicians. The evidence supporting breathing training for asthma was previously weak, and limited by the small size and methodological limitations of published research. RECENT FINDINGS: The evidence base for the effectiveness of breathing training has recently improved, with reports from several larger and more methodologically robust controlled trials. These trials are reviewed in this study, and the findings placed in context. Trials have investigated a variety of breathing training programmes delivered by different therapists in different ways. All incorporate some instruction in breathing pattern, usually focusing on slow, regular, nasal, abdominal breathing and reduced ventilation, with patients instructed to practise exercises at home and when symptomatic. SUMMARY: Current evidence suggests that breathing training programmes can be effective in improving patient-reported outcomes such as symptoms, quality of life and psychological impact; and may reduce the use of rescue bronchodilator medication. There is little evidence that airways physiology, hyper-responsiveness or inflammation is affected by such training. The optimal way of providing breathing training within the context of routine asthma care is still uncertain.

Acupuncture for respiratory disorder: what's the point?

Acupuncture has been an integral part of Traditional Chinese Medicine for thousands of years. It has been used for the treatment of many painful and nonpainful conditions. Its use within Western medicine has increased since the 1970s and acupuncture is now practiced by a variety of healthcare practitioners across Europe. There is an accepted body of evidence to support the use of acupuncture for back or neck pain. Anecdotal evidence from both clinicians and patients suggests there may be some beneficial effect of acupuncture in the treatment of respiratory symptoms, such as bronchospasm, breathlessness and hyperventilation syndromes. Some respiratory clinicians are introducing acupuncture as a treatment modality for the management of respiratory symptoms, despite the lack of available objective evidence to support this practice. This article reviews the available evidence for the use of acupuncture in respiratory disorders and provides discussion of the methodological issues that are evident within this literature. It also highlights reasons for the lack of objective evidence to support acupuncture for respiratory conditions and the difficulties faced by acupuncture researchers when designing randomized, placebo-controlled trials. Currently, there is insufficient evidence to support a recommendation for the use of acupuncture in respiratory disorders.

Effects of acupuncture as a treatment for hyperventilation syndrome: a pilot, randomized crossover trial.

BACKGROUND: Sustained and subtle hyperventilation can result in a wide variety of symptoms, leading to a chronic condition that has been termed hyperventilation syndrome (HVS). Treatment options include physiotherapy, in the form of breathing retraining (BR), but additional approaches aim to reduce the anxiety that is recognized as being a frequent component of this condition. OBJECTIVES: The aim of this study was to evaluate whether acupuncture is an appropriate treatment for HVS to reduce anxiety, and whether a crossover trial is an appropriate study design to evaluate acupuncture in this condition. DESIGN: A single-blind crossover trial was carried out comparing the effects of 4 weeks (30 minutes twice weekly) acupuncture and BR on patients with HVS. SUBJECTS: Ten (10) patients diagnosed with HVS were recruited to the trial and randomized into two groups. Both groups received acupuncture and BR with a washout period of 1 week. OUTCOME MEASURES: The primary outcome measure used was the Hospital Anxiety and Depression (HAD) Scale. Other outcome measures used were the Nijmegen questionnaire and Medical Research Council Dyspnea scale. RESULTS: The results showed statistically significant treatment differences between acupuncture and breathing retraining, in favor of acupuncture. Reductions were found in the HAD A (anxiety) (p = 0.02) and Nijmegen (symptoms) (p = 0.03) scores. There was no statistical evidence of any carryover effects. However, when graphically examining individual anxiety scores, in those who received acupuncture first, there was a reduction in anxiety levels which persisted through the washout period, suggesting that there may have been some carryover effect from this treatment. CONCLUSIONS: This study suggests that acupuncture may be beneficial in the management of HVS in terms of reducing anxiety levels and symptom severity. However, there may be some carryover effect, after acupuncture treatment, which went undetected because the small sample size. This preliminary study provides the basis for a larger, sufficiently powered and methodologically sound trial.

Hypocapnia and asthma: a mechanism for breathing retraining?

There is some evidence that breathing retraining may be beneficial for patients with asthma, but the mechanism behind this benefit is still unknown. One hypothesis is that individuals can be trained to raise carbon dioxide levels and thereby reverse the bronchoconstrictive effects of hypocapnia and utilize the bronchodilatory effects of hypercapnia. This theory presupposes that individuals with asthma have lower carbon dioxide levels than the healthy population. This article reviews the available evidence supporting the hypothesis and concludes that although attractive, there is currently insufficient evidence to attribute the benefits of breathing retraining to this mechanism.