Breathing techniques for asthma

1. Breathing techniques for asthma CA Slader, HK Reddel, LM Spencer, EG Belousova, CL Armour, SZ Bosnic-Anticevich, FK Thien, CR Jenkins CRC for Asthma

2. A cure for asthma?

3. 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

4. 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

5. 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

6. 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.

7. Group A video and exercises daily ICS dose stable ICS dose reduction Run-in  Group B video and exercises daily ICS dose stable ICS dose reduction PEF Washout PEF PEF PEF * * 30 -2 0 6 12 14 16 22 28 V2 V3 V4 V5 V6 V7 V8 V9 V1 Study Design Week * = ICS down titration

8. 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

9. 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.

10. 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.”

11. Results

12. NS p=0.01 NS NS NS NS 2 1 (Range 0-5) Total Score, mean (SD) 0 Week 0 p=0.0417 Week 12 p=0.29 Week 28 p=0.27 Group A Group B Quality of Life (AQLQ)

13. p=0.0005 NS p<0.0001 p=0.0003 NS p=0.0007 8 7 6 5 (puffs/24 hrs) Reliever use, median (IQR) 4 3 2 Week 0 p=0.23 Week 12 p=0.17 Week 28 p=0.99 1 0 Group A Group B RelieverUse

14. Median Daily RelieverUse Group A 2.5 Group B 2 1.5 1 0.5 0 1 Week 6 Week 30 Week 28 Week 12 Week 14 Week 16 Week 22

15. NS NS p=0.03 0.60 NS NS NS 0.40 0.20 RDR Mannitol, geometric mean (SD) (% fall/mg) 0.00 Week 0 n= 48 p=0.28 Week 12 n=26 p=0.54 Week 28 n=26 p=0.30 -0.20 Group A Group B Airway Hyperresponsiveness to Mannitol

16. 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

17. 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

18. 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

19. 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

20. How is your asthma now, compared with before you started the breathing exercises? Much worse Muchbetter I’m not woken throughout the night because of my asthma JH-B Less asthma and constriction of breathing MF-A Patient perception of benefitChanges in Asthma …about the same, but medication has been successfully halved TS-A

21. Patient perception of benefitUtility of the Breathing Exercises …as the study continued I have been able to ‘breathe’ myself out of many situations AD-A I had a lack of confidence in the efficacy of the routine [initially] SR-A 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

22. Patient perception of benefitUtility of the Breathing Exercises Extremely useful, even if it wasn’t enough, it gave me the space to wait before medicating without that desperate panicky feeling. GP-B …the symptom control exercises helped me to take time out to relax and distress [sic] instead of always taking my Ventolin SB-B Not very useful. Symptoms mean shortness of breath, so deep, relaxed breathing is very difficult…. AL-A

23. The Bottom Line Breathing techniques taught by video may be useful in the management of patients with mild asthma symptoms who use reliever frequently.