Evaluation of a breathing retraining intervention to improve quality of life in asthma: quantitative process analysis of the BREATHE randomized controlled trial.

OBJECTIVE: Explore qualitative differences between interventions (DVD and booklet (DVDB) versus face-to-face and booklet (F2FB) versus usual care) in the BREATHE (Breathing Retraining for Asthma Trial of Home Exercises) trial of breathing retraining for asthma. DESIGN: Quantitative process analysis exploring group expectancy, experience and practice before and after intervention delivery for the main trial. SETTING: Primary care. SUBJECTS: Adults with asthma (DVD and booklet, n = 261; F2FB, n = 132). MAIN MEASURES: Baseline - expectancy about breathing retraining; follow-up 3, 6 and 12 months - self-efficacy, treatment experience (enjoyment of treatment, perceptions of physiotherapist, perceptions of barriers), amount of practice (weeks, days/week, times/day), continued practice; all time points - anxiety (Hospital Anxiety and Depression Scale), AQLQ (Asthma Quality of Life Questionnaire). RESULTS: No group differences in baseline expectancy. Statistically significant results (P < 0.05) indicated that at follow-up, F2FB participants perceived greater need for a physiotherapist than DVD and booklet participants (3.43 (0.87) versus 2.15 (1.26)). F2FB participants reported greater enjoyment of core techniques (such as stomach breathing: 7.42 (1.67) versus 6.13 (1.99) (DVD and booklet)). Fewer F2FB participants reported problems due to doubts (24 (22.9%) versus 90 (54.2%)). F2FB participants completed more practice sessions (75.01 (46.38) versus 48.56 (44.71)). Amount of practice was not significantly related to quality of life. In the DVD and booklet arm, greater confidence in breathing retraining ability explained 3.9% of variance in quality of life at 12 months. CONCLUSION: Adults with asthma receiving breathing retraining face-to-face report greater enjoyment and undertaking more practice than those receiving a DVD and booklet. Greater confidence in ability to do breathing retraining is associated with improved QoL.

Giving hope, ticking boxes or securing services? A qualitative study of respiratory physiotherapists' views on goal-setting with people with chronic obstructive pulmonary disease.

OBJECTIVE: To explore respiratory physiotherapists' views and experiences of using goal-setting with people with chronic obstructive pulmonary disease in rehabilitation settings. PARTICIPANTS: A total of 17 respiratory physiotherapists with ⩾12 months current or previous experience of working with patients with chronic obstructive pulmonary disease in a non-acute setting. Participants were diverse in relation to age (25-49 years), sex (13 women), experience (Agenda for Change bands 6-8) and geographic location. METHOD: Data were collected via face-to-face qualitative in-depth interviews (40-70 minutes) using a semi-structured interview guide. Interview locations were selected by participants (included participants' homes, public places and University). Interviews followed an interview guide, were audio-recorded and transcribed verbatim. DATA ANALYSIS: Data were analysed using thematic analysis; constant comparison was made within and between accounts, and negative case analysis was used. RESULTS: Three themes emerged through the process of analysis: (1) 'Explaining goal-setting'; (2) 'Working with goals'; and (3) 'Influences on collaborative goal-setting'. Goal-setting practices among respiratory physiotherapists varied considerably. Collaborative goal-setting was described as challenging and was sometimes driven by service need rather than patient values. Lack of training in collaborative goal-setting at both undergraduate and postgraduate level was also seen as an issue. CONCLUSION: Respiratory physiotherapists reflected uncertainties around the use of goal-setting in their practice, and conflict between patients' goals and organisational demands. This work highlights a need for wider discussion to clarify the purpose and implementation of goal-setting in respiratory rehabilitation.

Interactive digital interventions to promote self-management in adults with asthma: systematic review and meta-analysis.

BACKGROUND: To identify, summarise and synthesise the evidence for using interactive digital interventions to support patient self-management of asthma, and determine their impact. METHODS: Systematic review with meta-analysis. We searched MEDLINE, EMBASE, CINAHL, PsycINFO, ERIC, Cochrane Library, DoPHER, TROPHI, Social Science Citation Index and Science Citation Index. The selection criteria requirement was studies of adults (16 years and over) with asthma, interventions that were interactive digital interventions and the comparator was usual care. Outcomes were change in clinical outcomes, cost effectiveness and patient-reported measures of wellbeing or quality of life. Only Randomised Controlled Trials published in peer-reviewed journals in English were eligible. Potential studies were screened and study characteristics and outcomes were extracted from eligible papers independently by two researchers. Where data allowed, meta-analysis was performed using a random effects model. RESULTS: Eight papers describing 5 trials with 593 participants were included, but only three studies were eligible for inclusion for meta-analysis. Of these, two aimed to improve asthma control and the third aimed to reduce the total dose of oral prednisolone without worsening control. Analyses with data from all three studies showed no significant differences and extremely high heterogeneity for both Asthma Quality of Life (AQLQ) (Standardised Mean Difference (SMD) 0.05; 95 % Confidence Interval (CI) 0.32 to -0.22: I2 96.8) and asthma control (SMD 0.21; 95 % CI -0.05 to .42; I2 = 87.4). The removal of the third study reduced heterogeneity and indicated significant improvement for both AQLQ (SMD 0.45; 95 % CI 0.13 to 0.77: I2 = 0.34) and asthma control (SMD 0.54; 95 % CI 0.22 to 0.86: I2 = 0.11). No evidence of harm was identified. CONCLUSION: Digital self-management interventions for adults with asthma show promise, with some evidence of small beneficial effects on asthma control. Overall, the evidence base remains weak due to the lack of large, robust trials.

Uncertainty prior to pulmonary rehabilitation in primary care: A phenomenological qualitative study in patients with chronic obstructive pulmonary disease.

Pulmonary rehabilitation (PR) is recommended for patients functionally restricted by chronic obstructive pulmonary disease (COPD). However, attendance and adherence to PR remains suboptimal. No previous research has explored COPD patient experiences during the key period from referral to initiation of PR in the United Kingdom. This research aimed to explore the lived experience of COPD patients referred to PR programmes prior to participation. COPD participants were recruited from referrals to two community PR programmes. Semi-structured interviews with COPD participants occurred following PR referral, but prior to programme initiation. Data were analyzed using applied interpretive phenomenology. Twenty-five COPD participants aged 42-90 were interviewed. 'Uncertainty' affected participants throughout their lived experience of COPD that negatively impacted illness perceptions, PR perceptions and increased participant's panic and anger. Participants who perceived COPD less as a chronic condition and more as a cyclical process experienced fewer feelings of panic or anger. The experience of uncertainty was disabling for these COPD participants. Recognition of the role that uncertainty plays in patients with COPD is the first step towards developing interventions focused on reducing this uncertainty, thereby reducing the burden of the disease for the individual patient and facilitating PR attendance.

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.

Ambulatory oxygen: why do COPD patients not use their portable systems as prescribed? A qualitative study.

BACKGROUND: Patients with COPD on long term oxygen therapy frequently do not adhere to their prescription, and they frequently do not use their ambulatory oxygen systems as intended. Reasons for this lack of adherence are not known. The aim of this study was to obtain in-depth information about perceptions and use of prescribed ambulatory oxygen systems from patients with COPD to inform ambulatory oxygen design, prescription and management. METHODS: A qualitative design was used, involving semi-structured face-to-face interviews informed by a grounded theory approach. Twenty-seven UK community-dwelling COPD patients using NHS prescribed ambulatory systems were recruited. Ambulatory oxygen systems comprised cylinders weighing 3.4 kg, a shoulder bag and nasal cannulae. RESULTS: Participants reported that they: received no instruction on how to use ambulatory oxygen; were uncertain of the benefits; were afraid the system would run out while they were using it (due to lack of confidence in the cylinder gauge); were embarrassed at being seen with the system in public; and were unable to carry the system because of the cylinder weight. The essential role of carers was also highlighted, as participants with no immediate carers did not use ambulatory oxygen outside the house. CONCLUSIONS: These participants highlighted previously unreported problems that prevented them from using ambulatory oxygen as prescribed. Our novel findings point to: concerns with the lack of specific information provision; the perceived unreliability of the oxygen system; important carer issues surrounding managing and using ambulatory oxygen equipment. All of these issues, as well as previously reported problems with system weight and patient embarrassment, should be addressed to improve adherence to ambulatory oxygen prescription and enhance the physical and social benefits of maintaining mobility in this patient group. Increased user involvement in both system development and service provision planning, could have avoided many of the difficulties highlighted by this study.

The importance of movement for people living with chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is a chronic respiratory disease that gives rise to symptoms of breathlessness, chronic fatigue, and cough. The impact of COPD on people's activity has been widely acknowledged, yet it appears that we know little about how individuals experience activity. We employed a grounded theory study with 18 participants with COPD to explore their dimensions of activity. We identified two core concepts that captured participants' experience of activity; these were stagnation and movement. We found fresh air to be the single most important aspect affecting participants' experience of stagnation and movement; this was linked to a changed perception of symptoms. We identified the environment as an important context influencing the experience of COPD and activity. Our stagnation-movement theory explains the experience of activity within its environmental context, and how this experience might be affected on physical, social, and psychological levels.

Asthma and psychological dysfunction.

Despite effective treatment, asthma outcomes remain suboptimal. Anxiety and depression occur more commonly in people with asthma than expected, and are associated with poor asthma outcomes. The direction of the relationship and the mechanisms underlying it are uncertain. Whether screening for and treating co-morbid anxiety and depression can improve asthma outcomes is unclear from the current evidence. Primary care clinicians treating asthma should be aware of the possibility of psychological dysfunction in asthmatics, particularly those with poor control. Further research is required to assess the importance of detecting and treating these conditions in community asthma care.

Changes in quantifiable breathing pattern components predict asthma control: an observational cross-sectional study.

BACKGROUND: Breathing pattern disorders are frequently reported in uncontrolled asthma. At present, this is primarily assessed by questionnaires, which are subjective. Objective measures of breathing pattern components may provide additional useful information about asthma control. This study examined whether respiratory timing parameters and thoracoabdominal (TA) motion measures could predict and classify levels of asthma control. METHODS: One hundred twenty-two asthma patients at STEP 2- STEP 5 GINA asthma medication were enrolled. Asthma control was determined by the Asthma Control Questionnaire (ACQ7-item) and patients divided into 'well controlled' or 'uncontrolled' groups. Breathing pattern components (respiratory rate (RR), ratio of inspiration duration to expiration duration (Ti/Te), ratio of ribcage amplitude over abdominal amplitude during expiration phase (RCampe/ABampe), were measured using Structured Light Plethysmography (SLP) in a sitting position for 5-min. Breath-by-breath analysis was performed to extract mean values and within-subject variability (measured by the Coefficient of Variance (CoV%). Binary multiple logistic regression was used to test whether breathing pattern components are predictive of asthma control. A post-hoc analysis determined the discriminant accuracy of any statistically significant predictive model. RESULTS: Fifty-nine out of 122 asthma patients had an ACQ7-item < 0.75 (well-controlled asthma) with the rest being uncontrolled (n = 63). The absolute mean values of breathing pattern components did not predict asthma control (R2 = 0.09) with only mean RR being a significant predictor (p < 0.01). The CoV% of the examined breathing components did predict asthma control (R2 = 0.45) with all predictors having significant odds ratios (p < 0.01). The ROC curve showed that cut-off points > 7.40% for the COV% of the RR, > 21.66% for the CoV% of Ti/Te and > 18.78% for the CoV% of RCampe/ABampe indicated uncontrolled asthma. CONCLUSION: The within-subject variability of timing parameters and TA motion can be used to predict asthma control. Higher breathing pattern variability was associated with uncontrolled asthma suggesting that irregular resting breathing can be an indicator of poor asthma control.

Mixed methods process evaluation of my breathing matters, a digital intervention to support self-management of asthma.

This study aimed to explore user engagement with 'My Breathing Matters', a digital self-management intervention for asthma, and identify factors that may influence engagement. In a mixed methods design, adults with asthma allocated to the intervention arm of a feasibility trial (n = 44) participated in semi-structured interviews (n = 18) and a satisfaction questionnaire (n = 36) to explore their views and experiences of the intervention. Usage data highlighted that key intervention content was delivered to most users. The majority of questionnaire respondents (78%; n = 28) reported they would recommend the intervention to friends and family. Interviewees expressed positive views of the intervention and experienced several benefits, mainly improved asthma control, medication use, and breathing technique. Factors that may influence user engagement were identified, including perceptions of asthma control, current self-management practices, and appeal of the target behaviours and behaviour change techniques. Findings suggested My Breathing Matters was acceptable and engaging to participants, and it was used as intended.

The effect of pulmonary rehabilitation on perceptions of breathlessness and activity in COPD patients: a qualitative study.

AIM: The aim of this study was to explore, using qualitative research methods, how pulmonary rehabilitation (PR) programmes affect the experience of activity and breathlessness of people with COPD. METHODS: A qualitative, interview-based approach was employed. Participants were interviewed pre- and post-PR. Data were analysed using systematic strategies informed by grounded theory methods. RESULTS: Nine participants (three female) took part. A change in participants' perception of breathlessness and lessening of fear of activity were the main themes identified. PR appeared to impact on the experience of physical social activities, allowing participants to overcome feelings of social isolation. CONCLUSIONS: Prior to PR, participants associated activities with breathlessness and panic; post PR, participants reported reduced fear and felt able to increase their activities. These findings add to our understanding of the impact of PR on individuals' experience of activity and may contribute to improved programmes by addressing patients' needs.

One year later: Highlighting the challenges and opportunities in disseminating a breathing-retraining digital behaviour change intervention.

Digital behaviour change interventions can provide effective and cost-effective treatments for a range of health conditions. However, after rigorous evaluation, there still remain challenges to disseminating and implementing evidence-based interventions that can hinder their effectiveness 'in the real world'. We conducted a large-scale randomised controlled trial of self-guided breathing retraining, which we then disseminated freely as a digital intervention. Here we share our experience of this process after one year, highlighting the opportunities that digital health interventions can offer alongside the challenges that must be addressed in order to harness their effectiveness. Whilst such treatments can support many individuals at extremely low cost, careful dissemination strategies should be proactively planned in order to ensure such opportunities are maximised and interventions remain up to date in a fast-moving digital landscape.

The reliability of lung crackle characteristics in cystic fibrosis and bronchiectasis patients in a clinical setting.

Lung sounds provide useful information for assessing and monitoring respiratory patients, but standard auscultation is subjective. Computer aided lung sound analysis (CALSA) enables the quantification and characterisation of added lung sounds (e.g. crackles). At present, little is known about the reliability of these sound characteristics. Therefore, the aim of this study was to explore the reliability of crackle initial deflection width (IDW) and two-cycle deflection (2CD) in a clinical population. Fifty-four subjects (37 bronchiectasis, 17 cystic fibrosis) were recruited from out-patient clinics. Three repeated lung sound recordings were taken at seven anatomical sites with a digital stethoscope connected to a laptop computer. The intra-subject reliability of crackle IDW and 2CD was found to be 'good' to 'excellent', estimated by the analysis of variance, intraclass correlation coefficient (IDW 0.76;0.85, 2CD 0.83;0.94), Bland and Altman 95% limits of agreement (IDW -0.50;0.47 ms, 2CD -2.12;1.87 ms) and smallest real difference (IDW 0.30;0.66 ms, 2CD 1.57;2.42 ms). Crackle 2CD was found to be more reliable than IDW. It is concluded that crackle IDW and 2CD characterized by CALSA have good test-retest reliability. This technique requires further evaluation since CALSA has potential to diagnose or monitor respiratory conditions, and provide an objective physiological measure for respiratory interventions.

Feasibility trial of a digital self-management intervention 'My Breathing Matters' to improve asthma-related quality of life for UK primary care patients with asthma.

OBJECTIVE: To assess the feasibility of a randomised controlled trial (RCT) and acceptability of an asthma self-management digital intervention to improve asthma-specific quality of life in comparison with usual care. DESIGN AND SETTING: A two-arm feasibility RCT conducted across seven general practices in Wessex, UK. PARTICIPANTS: Primary care patients with asthma aged 18 years and over, with impaired asthma-specific quality of life and access to the internet. INTERVENTIONS: 'My Breathing Matters' (MBM) is a digital asthma self-management intervention designed using theory, evidence and person-based approaches to provide tailored support for both pharmacological and non-pharmacological management of asthma symptoms. OUTCOMES: The primary outcome was the feasibility of the trial design, including recruitment, adherence and retention at follow-up (3 and 12 months). Secondary outcomes were the feasibility and effect sizes of specific trial measures including asthma-specific quality of life and asthma control. RESULTS: Primary outcomes: 88 patients were recruited (target 80). At 3-month follow-up, two patients withdrew and six did not complete outcome measures. At 12 months, two withdrew and four did not complete outcome measures. 36/44 patients in the intervention group engaged with MBM (median of 4 logins, range 0-25, IQR 8). Consistent trends were observed to improvements in asthma-related patient-reported outcome measures. CONCLUSIONS: This study demonstrated the feasibility and acceptability of a definitive RCT that is required to determine the clinical and cost-effectiveness of a digital asthma self-management intervention. TRIAL REGISTRATION NUMBER: ISRCTN15698435.

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.

Physiotherapy breathing retraining for asthma: a randomised controlled trial.

BACKGROUND: Despite effective pharmacotherapy, asthma continues to impair quality of life for most patients. Non-pharmacological approaches, including breathing retraining, are therefore of great interest to patients. However, clinicians rarely advocate breathing retraining and access to this intervention is restricted for most patients due to the limited availability of suitable physiotherapists and poor integration of breathing retraining into standard care. We aimed to assess the effectiveness of a digital self-guided breathing retraining intervention. METHODS: In this randomised controlled trial, we recruited patients from 34 general practices in the UK. Eligibility criteria for patients with asthma were broad, comprising a physician diagnosis of asthma, age of 16-70 years, receipt of at least one anti-asthma medication in the previous year, and impaired asthma-related quality of life (Asthma Quality of Life Questionnaire [AQLQ] score of <5·5). We developed a self-guided intervention, which was delivered as a DVD plus a printed booklet (DVDB). Participants were randomly assigned to receive either the DVDB intervention, three face-to-face breathing retraining sessions, or standard care, in a 2:1:2 ratio, for 12 months. Randomisation was achieved using the Southampton Clinical Trials Unit telephone randomisation service by use of random number generators. The primary outcome was the AQLQ score in the intention-to-treat population at 12 months. The trial was powered to show equivalence between the two active intervention groups, and superiority of both intervention groups over usual care. Secondary outcomes included patient-reported and physiological measures of asthma control, patient acceptability, and health-care costs. This trial was registered with International Standard Randomised Controlled Trial Number registry, number ISRCTN88318003. FINDINGS: Between Nov 5, 2012 and Jan 28, 2014, invitations to participate in the study were sent to 15 203 patients with general practitioner-diagnosed asthma, of whom 655 were recruited into the study. AQLQ scores at 12 months were significantly higher in the DVDB group (mean 5·40, SD 1·14) than in the usual care group (5·12, SD 1·17; adjusted mean difference 0·28, 95% CI 0·11 to 0·44), and in the face-to-face group (5·33, SD 1·06) than in the usual care group (adjusted mean difference 0·24, 95% CI 0·04 to 0·44); AQLQ scores were similar between the DVDB group and the face-to-face group (0·04, 95% CI -0·16 to 0·24). There were no significant differences between the randomisation groups in FEV1 or fraction of exhaled nitric oxide. 744 adverse events occurred in 272 patients: 101 (39%) of 261 patients in the DVDB group, 55 (42%) of 132 patients in the face-to-face group, and 132 (50%) of 262 in the usual care group, with patients reporting one or more event. 11 (4%) patients in the DVDB group, four (3%) patients in the face-to-face group, and 20 (8%) patients in the usual care group had a serious adverse event. INTERPRETATION: Breathing retraining programmes improve quality of life in patients with incompletely controlled asthma despite having little effect on lung function or airway inflammation. Such programmes can be delivered conveniently and cost-effectively as a self-guided digital audiovisual programme, so might also reduce health-care costs. FUNDING: UK National Institute of Health Research.

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.

Motivational interviewing in respiratory therapy: What do clinicians need to make it part of routine care? A qualitative study.

Motivational interviewing (MI) is a method for building motivation for behaviour change that has potential for use in respiratory contexts. There is a paucity of published research exploring the feasibility of this intervention from the clinicians' perspective. This study aimed to explore respiratory clinicians' views of MI: Is it perceived as useful? Could it be integrated into practice? What training would be required to make it part of routine care? Nine respiratory clinicians attended a one-day MI workshop and a semi-structured face-to-face interview two weeks later. All interviews were audio-recorded, transcribed verbatim and analysed with thematic analysis. Four main themes are presented-1) MI's suitability for use in respiratory contexts: participants saw potential in using MI to motivate their patients to engage with prescribed respiratory interventions, such as increased physical activity. Those who experimented with new skills post-workshop were encouraged by patient responsiveness and outcomes. 2) MI's relationship with routine clinical practice: some believed they already used elements of MI, but most participants felt MI was fundamentally 'different' to their normal style of working. 3) Implementation issues: additional time would need to be made available to enable an appropriate depth of conversation. 4) Training issues: Participants sensed the complexity of MI could make it difficult to learn and that it would take them time to become competent. On-going supervision was perceived as necessary. One key challenge identified was how to suppress behaviours that are antithetical to MI. These findings lend support to the feasibility of using MI in respiratory contexts such as pulmonary rehabilitation programmes, but highlight implementation and training issues that would need to be overcome. The insights have informed the development of another study, testing the effect of a tailored training package on MI skill, specifically for respiratory clinicians delivering pulmonary rehabilitation programmes.