His recent article ‘Behavioural Approaches to Asthma Management’, published in ‘Irish Pharmacist’. Click Here to view publication and article is on page 24 to 25.
Dr Alan Ruth takes a look at recent trials, which suggest that in conjunction with essential medical treatment, behavioural medicine can have a significant role to play in asthma management.
According to the Asthma Society of retraining as their primary component. The Ireland (ASI), Ireland has the fourth evidence for the effectiveness of breathing largest prevalence of asthma in the retraining was examined in a recent extensive world. Almost 1 in 10 members of review published in Expert Review of Respiratory the Irish population has asthma Medicine.
and 18.9 per cent of 13 to 15-year- In the review, all peer-reviewed journal articles olds have asthma. In addition, more than one related to the use of breathing techniques as a
asthma were included. This review referred to breathing retraining as a popular form of CAM (complementary and alternative medicine) and noted that CAM is popular in the general community for the self-management of asthma.
Breathing may be considered the most important of all of the functions of the body, because all of the other functions depend upon it. We can live for about three months without food before we die and we can live about three days without water before we die. However, we can only live for a few minutes without breathing. Breathing is the one behaviour, which we engage in more than any other. The average person breathes up to 30,000 times per day. Breathing is innate and instinctual. Babies don’t have to learn how to breathe. However, as we grow older our breathing can change to becoming sub-optimal in relation to metabolic requirements. As behaviour, breathing is subject to the same principles of learning (re-learning) as any other behaviour. Breathing directly regulates body chemistry, including pH, electrolyte balance, blood flow, haemoglobin chemistry, and kidney function. Breathing is unique as a vital physiological function in that it is the only one, which is directly subject to both voluntary and involuntary control. There is a motor pathway from the cerebral cortex to spinal motoneurones that allows a direct voluntary influence on the respiratory muscles. Given that breathing is an extremely important behaviour, in my view, breathing retraining is more appropriately designated as a behavioural intervention, rather than a CAM intervention.
YOGA AND ASTHMA
The expert review examined studies on yoga, biofeedback, respiratory muscle training and breathing modification techniques. Yoga techniques include voluntarily regulated yoga breathing techniques (called pranayama), postures, meditation, prayer and often-dietary changes to reduce asthma symptoms.
The longest yoga study in terms of follow-up, found significant benefit from integrated yoga exercises as well as usual treatment with increased PEFR (Peak Expiratory Flow Rate), decreased medication use and a decrease in asthma attack severity. Before-and-after trials of yoga techniques tended to show improvement in outcomes such as
person a week in Ireland dies from asthma and there are about 20,000 asthma related hospital emergency department attendances annually.
According to the ASI, recent research has found that “more than half of Irish people with asthma are awakened at night by asthma symptoms, and nearly three-quarters of sufferers experience some limitation in their normal activities due to asthma. Worryingly, almost eight in ten children with asthma do not have their illness under control”.
BEHAVIOURAL TREATMENT OF ASTHMA
A recent systematic review entitled ‘Psychosocial Factors and Behavioural Medicine Interventions in Asthma’ published in the Journal of Consulting and Clinical Psychology, had the following conclusion:
“In concert with an essential medication treatment, behavioural medicine treatment of asthma is moving closer toward an integrated biopsychosocial approach to disease management.”
The term biopsychosocial was first coined in 1977 by George Engel, an American professor of medicine and psychiatry. Whilst the traditional biomedical model of clinical medicine focuses on pathophysiology and other biological approaches to disease, the biopsychosocial approach emphasises the importance of understanding human health and illness in their fullest contexts. This approach considers biological, psychological and social factors and their complex interactions in understanding health, illness, and the delivery of health care. The focus of the biopsychosocial model is health rather than disease and spans the continuum of healthcare beginning with prevention. Patients are viewed as proactive agents in promoting positive health outcomes for themselves, rather than passive recipients of treatment.
BREATHING RETRAINING
Prominent among the behavioural approaches for treating asthma are those, which use breathing
treatment for asthma were examined. The initial search strategy identified 101 original articles of which 60 were excluded for various reasons, leaving 41 articles that were analysed. Breathing modification through retraining had to be the primary component of the intervention. Studies in chronic asthma and acute exercised-induced
medication use and lung function parameters. A meta-analysis showed a favourable effect of yoga on ‘Asthma-specific Quality of Life’ and a similar, although limited, effect was seen on one measure of lung function.
Biofeedback aims to reduce symptoms through gain of voluntary control over autonomic processes. Direct biofeedback training consists of ‘rewards’ (visual or auditory signals) if the subject maintains a measured respiratory parameter within predetermined limits. This feedback facilitates learning. Six randomised controlled trials and two before-and-after studies found significant improvement in lung function, medication use, or asthma symptoms. However, participant numbers were generally small and follow-up times were short.
Respiratory muscle training aims to strengthen muscles to meet the increased work of breathing in asthma. A total of four randomised controlled trials investigated the effect of respiratory muscle training on asthma. All studies found significant improvement in lung function, β2-agonist use
or symptoms in the active intervention groups compared with the control groups. The reviewers felt that the results warranted further examination of this technique.
BUTEYKO BREATHING TECHNIQUE
In relation to breathing modification techniques, the reviewers evaluated the results of twelve randomised controlled trials. Six of these employed respiratory physiotherapy and six employed the Buteyko breathing technique.
The review authors noted that it wasn’t possible to include data from all studies in a meta-analysis of breathing retraining due to differences in outcome reporting. However, where such analyses could be done, they showed a favourable effect of breathing retraining on ‘Asthma specific Quality of Life’ and on end-tidal CO2 i.e. the level of carbon dioxide in the air exhaled from the body.
The reviewers noted that the Buteyko breathing technique has been the most
widely publicised of the breathing retraining techniques used in asthma management. They also noted that individual studies using this technique consistently demonstrated a reduction in asthma medication use, and often showed an improvement in ‘Asthma specific Quality of Life’ and the subjective experience of asthma symptoms. However, they pointed out that there was no significant improvement in lung function in any of the Buteyko breathing technique studies to account for the positive results. However, importantly, they observed that it was possible that the deep inspiration required for lung function testing might induce
bronchoconstriction and override any beneficial effect from the technique. They also observed that it was possible the studies were inadequately powered to detect changes in lung function parameters and that larger studies might reveal an effect.
Another recently published extensive review titled ‘Breathing Exercises and/or Retraining Techniques in the Treatment of Asthma: Comparative Effectiveness’ was published by the Agency for Healthcare Research and Quality (a U.S. government agency). In the ‘Summary of Results’ section of this review, the reviewers noted that:
“The body of evidence suggests that selected intensive behavioural approaches that include breathing retraining or exercises may improve asthma symptoms or reduce reliever medication use in adults with poorly controlled asthma.”
Hyperventilation reduction techniques (e.g. Buteyko) provided the strongest evidence for improvement in asthma symptoms and reliever medication use, and reductions in asthma symptoms (when they occurred) were likely clinically significant and scale scores for symptoms and quality of life often changed in an amount associated with clinically significant differences.
Reductions in reliever medication use were generally in the 1.5 to 2.5 puffs per day range, which were also likely of clinical significance.
The reviewers called for future trials on breathing retraining techniques to examine asthma symptom outcomes, reliever medication use, and pulmonary function, thereby making it possible to increase the strength of evidence.
Interestingly, in 2008, the British Thoracic Society, in their Guideline on the Management of Asthma, upgraded the Buteyko breathing technique to category B, meaning that there were high quality clinical trials supporting the effectiveness of the method in reducing symptoms and bronchodilator use. In its revised (January 2012) guideline, it states: “Buteyko Breathing Technique may be considered to help patients to control the symptoms of asthma.”
