1. health and fitness
2. disease
3. asthma

Breathing Exercises for
Asthma : Evidence and
Practice
A simple and effective approach to
minimise reliever use and improve
symptom control
Christine Jenkins, Airways Group
Woolcock Institute of Medical Research
Delivering Breathing Techniques in the
Community
Conflict of Interest statement
The Breathing Techniques study was conducted through
funding by the Co-operative Research Centre for Asthma, which
is a collaborative research programme funded jointly by the
Australian Government and Industry partners. During this period
the CRC was funded in part by support from GlaxoSmithKline
and AstraZeneca
Breathing Techniques Background
 Some physiologic rationale to consider breathing
techniques may be effective for asthma
 Dysfunctional breathing affects 30% asthma patients
 Several studies to date show improved symptoms and
QoL, and reduced reliever use
 Cochrane review (2004) 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
History lesson
Those who do not learn the lessons of history
are bound to repeat them…..
1957
Hyperventilation and asymptomatic
chronic asthma
Osborne et al Thorax 2000
 Studied patterns of breathing in 23 currently asymptomatic stable
asthmatics, occasional reliever use, normal lung function, AHR to
methacholine and 17 matched controls, no asthma
 Asthmatics had
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No current symptoms
No clinical evidence of hyperventilation
Normal lung function (97.6% vs 101.7%, NS)
Lower PaCO2 (p<0.01) 4.96 vs 5.27 kPa
Lower PETCO2 (p<0.02) 4.89 vs 5.28 kPa
Reduced PaCO2 correlated with PD20M (r = 0.56, p<0.01), but not with
sputum eos, anxiety/depression or lung function
 More anxiety (p<0.02) but scores were within normal range
 NS differences in ventilatory or respiratory pattern between asthma and
controls
Prevalence of dysfunctional breathing in
patients treated for asthma in primary care:
cross-sectional survey
Thomas et al BMJ 2001;322:1098
 Evidence links dysfunctional breathing with asthma and
respiratory disorders (Howell Thorax 1990)
 Hyperventilation common in specialist respiratory clinics (Carr
et al J Pschysom Res 1998)
 Link between asthma and symptomatic hyperventilation in
several studies (Demeter AJM 1986)
 42% of patients in hospital clinic showed evidence of
hyperventilation disorder (McLean AJRCCM 1999)
 Hyperventilation may complicate and compound asthma
presentation (Han AJRCCM 1999)
Nijmegen questionnaire
for dysfunctional breathing
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Chest pain
Feeling tense
Blurred vision
Dizziness
Confusion or loss of touch
with reality
Fast or deep breathing
Shortness of breath
Tightness across chest
Bloated
Tingling in fingers and hand
Difficulty taking deep breath
Stiffness or cramps in fingers
or hands
Tightness around mouth
Cold hands or feet
Palpitations
Anxiety
 Symptom measurement tool
 Score 0 (never) to 4 (very
often)
 Assists in identifying
dysfunctional breathing and
hyperventilation
 Total symptom score > 23
has sensitivity 91% and
specificity 95% as a
screening instrument in
patients with
hyperventilation syndrome
Prevalence of dysfunctional breathing in patients
treated for asthma in primary care: crosssectional survey
Thomas et al BMJ 2001;322:1098
 Sought to determine prevalence of dysfunctional
breathing in asthma patients in UK primary care
 7033 patients; 4381 aged 17 – 65, semi-rural GP
 307 (7% ) met criteria – all patients who had asthma
diagnosed on clinical grounds, who had received > 1 script in
past 12m for inhaled or oral BD or ICS
 Sent questionnaire to 307; response rate 74%
 No significant differences in severity of asthma
between high and low scores
 1/3 of women and 1/5 of men in had high scores on the
Nijmegen Q‟aire suggesting dysfunctional breathing
Prevalence of dysfunctional breathing in
patients treated for asthma in primary care:
cross-sectional survey
Thomas et al BMJ 2001;322:1098
RECOMMENDATIONS
 Dysfunctional breathing is frequently undiagnosed
 Recommend scrutiny to identify dysfunctional breathing
which should be addressed specifically rather than
increasing medication for asthma
 Need studies to identify the role of breathing retraining to
address high prevalence of dysfunctional breathing in
asthmatic patients
Types of breathing techniques and
exercises used in breathing retraining
Problems studying breathing
techniques in asthma
 RCT must involve blinding subject and observer
 Practitioners must not have a vested interest in outcome, nor
unregulated contact time with the patient
 Alternatively patients are taught through an arms length process
(eg video)
 Must standardise training period and practise periods
 Ideally active and control interventions must appear efficacious
to the subject
 Adequately powered studies
 Outcomes should be objective measures of asthma symptom
and disease control, and validated quality-of-life questionnaires
Yoga studies
Yoga (pranayama)
regularising and slowing the breathing
frequency by
 prolonging the expiratory phase
 enhancing abdominal/diaphragmatic breathing
 imposing resistance to inspiration and expiration
yogasanas and chanting which include
manoeuvres to control breathing aimed at
 slowing respiratory frequency
 reducing depth of breathing
Mimicking Pranayama yoga in clinical
trials of breathing techniques
 Slow breathing retraining exercises using Pink City
lung exerciser (Pink City represents Jaipur India)
 mouthpiece attached to a disc with a selection of
apertures of 2-5 mm, any one of which can be
selected, through which all inspired and expired air
must pass
 apertures carry a one-way valve which halves the
cross-sectional area of the aperture during expiration,
imposing a 1:2 ratio on the duration of inspiration and
expiration
 Smaller aperture  slower respiratory rate
RCT of two breathing exercises (Buteyko
and pranayama) in asthma
Cooper et al Thorax 2003;58:674
 90 patients with asthma
 Used a Pink City Lung Exerciser or placebo PCLE or
Butyeko (BBT) for 6 months
 Practised BD and used techniques during symptom
episodes
 No change on PD20M
 Symptoms reduced in BBT (p<0.003) by mean 3;
SABA use reduced by 2 puffs/day at 6m
 No change in FEV1, exacerbations, or ICS dose
reduction
Yoga studies
Vempati R. et al BMC Pul Med 2009; 9: 37
 Lifestyle modification based on yoga, versus wait-list
 intervention consisted of 2-wk supervised training in lifestyle
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modification and stress management based on yoga
followed by closely monitored continuation of the practices at
home for 6-wk
n=57
Control waitlisted – usual care
Outcome measures assessed at 0, 2, 4 & 8 wk
significant reduction in EIB in the yoga group
Improved lung function, exercise challenge QoL vs control
Improved rescue use in both groups
No change in inflammatory markers
Yoga for Breathing retraining
Yoga is taught in eight steps of which one,
pranayama deals explicitly with control of
breathing
Pranayama has four objectives
 a stepwise reduction in breathing frequency
 attainment of a 1:2 ratio for duration of inspiration
and expiration
 a breath holding period at the end of inspiration
that lasts twice the length of expiration
 mental concentration on breathing
Buteyko Breathing Technique
 Aims to reduce hyperventilation through periods of
controlled reduction in breathing, known as „slow
breathing‟ and „reduced breathing‟
 Combined with periods of breath holding, known as
„control pauses‟ and „extended pauses‟
 emphasis is on self-monitoring using the pulse rate
and the pauses as objective measures of outcome
 Longer pauses = better breathing control
 Includes advice and training on the benefits of nasal
breathing over oral breathing
Common features in Buteyko breathing,
yoga and deep diaphragmatic breathing
 Practising a series of exercises which help reduce
the depth and frequency of respiration
 Learned mastery over breathing rate and depth
 Breath “holding” ability at end expiration during
normal respiration used to monitor progress
 May also involve
 Physical Relaxation
 Thought control
 Nasal route of breathing
Rationale for Buteyko
breathing
 People with asthma hyperventilate  tachypnea,
bronchoconstriction, low airway CO2 and arterial CO2  more
stimulus to increase respiratory rate
 Increased respiratory rate  cooling and drying of airways 
bronchoconstriction
 β2 agonists  sympathetic overdrive  tachypnea and overbreathing  hypocapnia bronchoconstriction
 Promoting nasal breathing over oral breathing warms, filters
and humidifies air  less bronchoconstriction
 Deep inspiration and deep breaths are counter effective, hence
must avoid performing PEF and spirometry
= Asthma control can be learned
Breathing exercises for asthma
Holloway & Ram Cochrane Library 2004
Assessed evidence the efficacy of breathing
retraining in the treatment of asthma
42 full text papers  35 studies excluded
 Most of small size, 2 studies show significant reductions in
reliever use
 3 studies showed reductions in acute exacerbations
 2 studies showed improvements in QoL
 Overall benefits only in isolated outcome measures, in single
studies
Buteyko breathing techniques in
asthma
Bowler et al MJA 1998;169:575
Prospective blinded randomized study compared BBT
with control relaxation classes
 39 subjects with asthma, aged 12 – 70
 Median daily SABA use 900 mcgs, ICS 1500 mcgs
 Mean FEV1 75% predicted, end tidal CO2 33.0
At 3m, BBT group had median reduction of 904 mcg
SABA vs 54mcgs (controls)
 Daily ICS dose fell 49% BBT vs 0 (p = 0.06)
 Improvement in QoL (p< 0.4)
 Reduction in SABA use (p < 0.008)
 NS improvement in am PEF (16.7L/min)
Study Design
Group A video and exercises daily
ICS dose stable
Run-in

ICS dose reduction
Group B video and exercises daily
Week
PEF
-2
0
V1 V2
ICS dose reduction
PEF
PEF
Washout
ICS dose stable
PEF
*
*
22
6
12
14 16
V3
V4
V5 V6
* ICS 
V7
28 30
V8 V9
Baseline Characteristics
Variable
Group A (n=28)
Group B (n=29)
Gender (M:F)
11 : 17
14 : 15
Smoking Hx (Never: Former)
19 : 9
23 : 6
Atopy (non-atopic: atopic)
2 : 23
4 : 23
OCS Use % (past year)
42.9
27.6
80.8%
(74.5-87.0%)
78.9%
(72.5-85.4%)
2.2
(1.4-3.9)
2.9
(1.3-4.4)
AQLQ
(mean)
0.77
(0.57-0.96)
0.54
(0.43-0.65)
ACQ-7
(mean)
1.5
(1.22-1.70)
1.4
(1.16-1.58)
Daytime Symptom Intensity
Score (mean)
2.00
(1.00-3.00)
2.00
(1.50-2.00)
FEV1% pred.
Reliever Use
(median, puffs/day)
Video intervention
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Active video teaching hypoventilation, prolonged expiration
and nasal breathing techniques
• Nasal route of breathing (“gentle breathing”)
• Hypoventilation (“awareness of reduced breath”)
• Breath hold at FRC (“breath check”)
Control video teaching non-specific exercises :
• Forward curl, arm raise, good posture and relaxation

Each video included a demonstrated exercise session of 20
minutes which subjects watched daily and performed the
exercises for 20 minutes twice daily during the whole
treatment period (weeks 0 to 30)

Advised to use the exercises as needed for the relief of
symptoms in place of reliever medication. If the exercises did
not relieve symptoms, reliever medication was to be used
Daily Asthma Symptom Score
Symptom Score, mean (SD)
(1=None- 5=Severe)
NS
p=0.04
NS
NS
4
NS
p=0.01
3
2
1
Week 0
Week 12
Group A
Group B
Week 28
Reliever Use
Puffs/24 hours
p=0.0005
NS
p<0.0001
p=0.0003
NS
p=0.0007
Reliever use, median (IQR)
(puffs/24 hrs)
8
7
6
5
4
3
2
1
0
Week 0
Week 12
Group A
Group B
Week 28
2.5
RESULTS
: Median
Daily
Reliever Use
Median
Daily
Reliever
Group A
Group B
Use
2
1.5
1
0.5
Week 30
Week 28
Week 22
Week 16
Week 14
Week 12
Week 6
0
ACQ score, mean (SD)
(range 0-6)
Asthma Control Questionnaire
NS
3
NS
p=0.0056
p=0.03
NS
p=0.0014
2
1
0
Week 0
Week 12
Group A
Group B
Week 28
Results
Quality of life: no difference between groups
Symptom scores: small improvement in both groups
Reliever use: 86% reduction in both groups!
ICS dose: halved in both groups
Physiological or inflammatory outcomes: No difference
Physician assessment: similar improvement in both groups
Qualitative feedback from patients
•Sense of personal control
•Breathing exercises good for mild/moderate symptoms
•Not effective for symptoms due to colds, allergy or
exercise
Breathing techniques
In this study, either abdominal & upper body breathing
techniques, or shallow nasal breathing exercises
Reduced SABA use
Enabled ICS dose reduction
Maintained or improved symptom scores
Maintained or improved ACQ
Benefits were not affected by PF monitoring
Breathing Exercises
Study Participation
Regular monitoring
Increased awareness
Being in control
Increased compliance
Calm & relaxed
Less reliant on medication
Fewer side effects
Perception of improved control & exercise efficacy
Patients’ comments
The exercises were described as being
 “Initially not a great advantage, but as the study continued I have
been able to „breathe‟ myself out of many situations”
 “Extremely useful, even if it wasn‟t enough it gave the space to
wait before medicating without the desperate panicky feeling”
 “Not very useful. Symptoms mean shortness of breath, so deep,
relaxed breathing is very difficult….”
BUT the exercises were
 “No match for URTI, dust, vigorous exercise, animal response”
 “The exercises did not work when I had viral illnesses (e.g. cold,
sinusitis) or when I was doing „dusty‟ housework”
When asked if they would use the
exercises in future
For mild symptoms, 86% would try the
exercises first
For moderate symptoms, 52% would try the
exercises first followed by reliever
if there was insufficient effect
For severe symptoms, 0% would try the
exercises first
Using breathing techniques as a behavioural
experiment (CBT)
 Patient tests preconception (asthma will worsen) of an alternative
behaviour (breathing technique) in place of maladaptive behaviour
(over-use of rescue medication)
Belief
Alternative
perspective
Experiment
Specific
Results
prediction
Conclusion
I need to take
my Ventolin
every time I
feel breathless
otherwise I‟ll
have an
asthma attack
My
breathlessness
may improve by
doing breathing
techniques. I
wont always
need to use
Ventolin
When feeling
breathless I
do breathing
techniques
first and only
use Ventolin if
symptoms
persist
If I don‟t
take
Ventolin
when I am
breathless
my asthma
will get
worse
My
breathlessness
often improves
by using
breathing
techniques . I
don‟t always
need to use
Ventolin
Edelman 2007 AFP 36 (3)
On at least
half of the
occasions
my
breathlessness got
better with
breathing
techniques
alone
www.racgp.org.au/afp/200704
Breathing Exercises for Asthma : an RCT
Breathing
Exercises for Asthma : an RCT
Thomas et al Thorax 2009;64:55-61
 prospective, parallel group, single-blind RCT, n= 183
 89 patients with asthma and impaired QoL,randomised to
 3 sessions of physiotherapist-supervised breathing training (n=94)
or
 asthma nurse-delivered asthma education
 1 month post intervention : similar improvements in AQLQ
scores in both groups, trends (NS) to improved ACQ
 6 months : significant between-group difference favouring
breathing training - 0.38 units, 95% CI 0.08 to 0.68
 6-months : significant between-group differences in HAD anxiety
favouring breathing training (1.1,95% CI 0.2-1.9), HAD
depression (0.8, 95% CI 0.1-1.4) and Nijmegen scores(3.2, 95%
CI 1.0 to 5.4)
Breathing Exercises for Asthma : an RCT
Thomas et al Thorax 2009;64:55-61
How do patients take up new
practices?
 No single theory dominates research or practice in
health education
 Three theories predominate
 Health Belief Model
 Bandura‟s Social Learning Theory
 Ajzen and Fishbein‟s Theory of Reasoned Action
 These models presume that people are able and
willing to change their health behaviours if given
sufficient information, appropriate role models,
incentives and support
1.
2.
3.
4.
Bandura et al. 1990
Glanz, Lewis et al. Health Behaviour and Health Ed 1990
Eagar, Garrett et al. Health Planning Aust Perspectives 2001
Horne and Weinemn Psychol Health. 2002;17:17–32.
Conclusions
Breathing techniques COMPRISING DIFFERENT
SETS OF UPPER BODY MOVEMENTS and
RELAXATION EXERCISES or NASAL ROUTE OF
BREATHING and REDUCED RATE AND DEPTH OF
BREATHING, taught by video or health
professionals, and practiced regularly, may be useful
in the management of symptomatic patients with
mild-moderate asthma