case study of asthma for physiotherapy

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Effects of physiotherapy treatment in patients with bronchial asthma: A systematic review

Affiliation.

• 1 Faculty of Physical Therapy, Universidade de Vigo, Spain.
• PMID: 32515632
• DOI: 10.1080/09593985.2020.1772420

Background : Bronchial asthma is a chronic inflammatory disease of the respiratory tract. Its physiotherapy treatment aims to reduce the frequency of asthmatic spells and the intensity of symptoms. The methods employed act mainly through the education of the patient in the correct handling of the asthma attacks and the improvement of the pulmonary elasticity. Objective : The objective of this review was to critically evaluate the available evidence on the effectiveness of different physiotherapy interventions in asthmatic patients. Methods : To achieve this, the search was focused on scientific databases with the key words Physiotherapy and Asthma. The search was limited to studies that evaluated the effects of a physiotherapy intervention in patients diagnosed with bronchial asthma. Results : 1794 articles were located and after the inclusion and exclusion criteria were applied, 12 studies were analyzed. Of these, 5 evaluated a respiratory reeducation intervention, 4 manual therapy techniques, 2 interventions based on therapeutic exercise and 1 relaxation techniques. Conclusions : The results obtained revealed that physiotherapy provides a wide range of treatment options for bronchial asthma and all of them provide positive results against the exclusive application of pharmacological treatment.

Keywords: Physical therapy modalities; asthma; pulmonary medicine.

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The role of physiotherapy in chronic asthma

To coincide with World Asthma Day 2022, Sonia Cheng and Mitchell Taylor from the APA Cardiorespiratory national group present five discussion points about the role of physiotherapists in the management of chronic asthma.

1. The treatable traits approach improves patient outcomes in chronic asthma

Identifying the treatable traits of a patient with chronic asthma through a comprehensive assessment improves outcomes. 

The treatable traits model is a new paradigm in the management of chronic asthma.

Rather than using a one-size-fits-all treatment approach, clinicians should undertake a comprehensive patient assessment that aims to identify the individual’s treatable traits (McDonald et al 2019).

Several specific traits have been identified in asthma, including allergies, eosinophilia, upper airway disease, sarcopaenia, osteopaenia, dysfunctional breathing, depression and anxiety, poor inhaler technique, obesity, mucus hypersecretion and low confidence with exercise.

Some treatable traits are best managed by a respiratory physician (eg, eosinophilia), while other traits require involvement from physiotherapists and the wider multidisciplinary team.

The use of a treatable traits model in severe asthma has been shown to improve health-related quality of life and asthma control and to reduce healthcare use (McDonald et al 2020).

2. Sarcopaenia and osteopaenia can be addressed with regular exercise and physical activity

Sarcopaenia, activity limitation and low confidence to engage in physical activity (PA) are common extrapulmonary treatable traits in chronic asthma.

This population is at higher risk of osteopaenia due to prolonged use of inhaled corticosteroids (Kumarathas et al 2020), which may lead to osteoporotic fractures.

Obesity is also an important risk factor and disease modifier in asthma.

Obesity increases the risk of developing asthma and people with asthma who are also obese have more frequent and severe exacerbations and reduced response to several medications (Peters et al 2018).

Pulmonary rehabilitation is the optimal setting for addressing sarcopaenia and osteopaenia and promoting weight loss.

Aerobic training should be performed at ≥60 per cent of peak work rate in an incremental exercise test for 20–30 minutes, 3–5 times a week, to increase endurance capacity and reduce dyspnoea (Nici et al 2006).

Resistance training involving the major muscle groups should be performed at 8–10 repetitions for a maximum 2–3 times a week (Ries et al 2007).

People with asthma should be supported through PA counselling and the provision of feedback on objectively measured PA to adhere to current PA recommendations, which include 150–300 minutes a week of moderate-intensity aerobic PA, and PA that emphasises functional balance and muscle strengthening activities at least three times a week to reduce falls risk (World Health Organization 2020).

Resistance and balance training in conjunction with bisphosphonate therapies are recommended to increase bone strength (RACGP & Osteoporosis Australia 2017).

3. Dysfunctional breathing is a common, but often undiagnosed, treatable trait

Dysfunctional breathing, or breathing pattern disorders, occurs when a change in breathing mechanics manifests itself as self-perpetuating respiratory symptoms such as breathlessness, chest pain and an inability to get a satisfying breath.

Physiotherapy management of dysfunctional breathing, which has a significant overlap with chronic asthma, can improve symptoms and quality of life. 

Dysfunctional breathing was thought to be a differential diagnosis to asthma; however, recent research has highlighted the significant overlap between the two conditions, with poorly controlled asthma often being a driver of the development of dysfunctional breathing.

The prevalence of dysfunctional breathing in chronic asthma is estimated to be 29–64 per cent, with a higher prevalence in those with severe asthma (Courtney et al 2017).

People with chronic asthma who develop dysfunctional breathing may have symptoms of breathlessness disproportionate to their underlying disease and symptoms that do not respond to traditional therapies (Veidal et al 2017).

Regular screening for dysfunctional breathing in severe asthma is important to improve early identification and onward referral to appropriately trained physiotherapists for breathing retraining exercises (RACGP & Osteoporosis Australia 2017).

Physiotherapy and breathing retraining are at the core of dysfunctional breathing management, which has been shown to improve symptoms and health-related quality of life (Courtney et al 2017).

4. Ensuring good inhaler technique is everyone’s responsibility

Inhaled corticosteroid-based preventers are the foundation of medical management for asthma and are prescribed for all adults who report asthma symptoms twice or more during the past month, waking due to asthma symptoms once or more during the past month or an asthma flare-up in the previous 12 months (National Asthma Council Australia 2020).

Inhaler technique should be reviewed by all health professionals treating chronic asthma, including physiotherapists, to ensure patients are using inhalers correctly. 

There has been a recent shift away from an over-reliance on relievers containing a rapid-onset beta2-agonist.

Use of reliever medications alone is associated with an increased risk of severe flare-ups in the absence of inhaled corticosteroids or with poor adherence to inhaled corticosteroids (Mauer & Taliercio 2020).

It is critical to train patients in how to use their inhaler correctly, including the use of a spacer, via physical demonstrations or videos.

Poor adherence with inhalers and inhaler technique errors significantly undermine the efficacy of these medications.

Up to 87 per cent of patients make at least one technique error when using their inhalers (Castel-Branco et al 2017).

Current guidelines recommend reviewing inhaler technique at all points of contact with health professionals, including with physiotherapists (Mauer & Taliercio 2020).

Lung Foundation Australia and National Asthma Council Australia have a range of resources to assist physiotherapists in reviewing inhaler device polypharmacy and poor inhaler technique, including the Asthma and COPD Medications Chart , inhaler technique checklists , demonstration videos and asthma action plans .

5. The need for airway clearance should be assessed in all patients with chronic asthma

Mucus hypersecretion is a common treatable trait in chronic asthma and may lead to retained secretions and an increased risk of respiratory infections.

An estimated 30 per cent of people with chronic asthma develop bronchiectasis (Padilla-Galo et al 2018), which can further worsen mucus hypersecretion and mucus stasis in the lungs.

Patients identified with mucus hypersecretion, defined as the production of >25 ml of sputum per day, should be referred to an appropriately trained physiotherapist for prescription of an airway clearance routine.

Patients should be provided with a range of airway clearance techniques to identify the most practical and effective strategy with high compliance (Belli et al 2021).

The forced expiratory technique in an appropriate postural drainage position is recommended for all individuals with self-reported cough and sputum, and the active cycle of breathing and oscillatory positive expiratory pressure devices for those with bronchiectasis (Hill et al 2019).

Mucolytics, including humidification and saline nebulisation, may be beneficial for individuals with difficulty expectorating sputum.

Patients should be followed up within three months to assess the effectiveness of the airway clearance routine and to modify their routine if needed, including the addition of other techniques and increasing daily airway clearance frequency.

Click here for an infographic poster version of this article.

>> Mitchell Taylor APAM is the director and lead physiotherapist at Functional Lungs Respiratory Physiotherapy and deputy chair of the Cardiorespiratory New South Wales chapter committee. He is a clinical researcher in the Department of Respiratory Medicine at St George Hospital, Sydney and conducts a number of practitioner courses with a focus on cardiorespiratory physiotherapy in private practice.

>> Sonia Cheng APAM is a cardiorespiratory physiotherapist and lecturer with the Discipline of Physiotherapy at the University of Sydney . She is the chair of the APA Cardiorespiratory national group. Her research interests include the measurement and promotion of physical activity in people with chronic disease.

McDonald VM, Fingleton J, Agusti A, et al. Treatable traits: a new paradigm for 21st century management of chronic airway diseases: Treatable Traits Down Under International Workshop report. Eur Respir J. 2019 May 9;53(5):1802058. doi: 10.1183/13993003.02058-2018. McDonald VM, Clark VL, Cordova-Rivera L, et al. Targeting treatable traits in severe asthma: a randomised controlled trial. Eur Respir J. 2020 Mar 5;55(3):1901509. doi: 10.1183/13993003.01509-2019. Kumarathas I, Harsløf T, Andersen CU, et al. The risk of osteoporosis in patients with asthma. Eur Clin Respir J. 2020;7(1):1763612. Published 2020 May 19. doi:10.1080/20018525.2020.1763612. Peters U, Dixon AE, Forno E. Obesity and asthma. J Allergy Clin Immunol. 2018;141(4):1169-1179. doi:10.1016/j.jaci.2018.02.004. Nici L, Donner C, Wouters E, et al. American Thoracic Society/European Respiratory Society statement on pulmonary rehabilitation. Am J Respir Crit Care Med. 2006 Jun 15;173(12):1390-413. doi: 10.1164/rccm.200508-1211ST. Ries AL, Bauldoff GS, Carlin BW, et al. Pulmonary Rehabilitation: Joint ACCP/AACVPR Evidence-Based Clinical Practice Guidelines. Chest. 2007 May;131(5 Suppl):4S-42S. doi: 10.1378/chest.06-2418. WHO guidelines on physical activity and sedentary behaviour. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO. The Royal Australian College of General Practitioners and Osteoporosis Australia. Osteoporosis prevention, diagnosis and management in postmenopausal women and men over 50 years of age. 2nd edn. East Melbourne, Vic: RACGP, 2017. Courtney R. Breathing training for dysfunctional breathing in asthma: taking a multidimensional approach. ERJ Open Res. 2017;3(4):00065-2017. Published 2017 Dec 8. doi:10.1183/23120541.00065-2017. Veidal S, Jeppegaard M, Sverrild A, et al. The impact of dysfunctional breathing on the assessment of asthma control. Respir Med. 2017 Feb;123:42-47. doi: 10.1016/j.rmed.2016.12.008. Epub 2016 Dec 18. National Asthma Council Australia. Australian Asthma Handbook, Version 2.1. National Asthma Council Australia, Melbourne, 2020. Website. Available from: http://www.asthmahandbook.org.au . Castel-Branco MM, Fontes A, Figueiredo IV. Identification of inhaler technique errors with a routine procedure in Portuguese community pharmacy. Pharm Pract (Granada). 2017 Oct-Dec;15(4):1072. doi: 10.18549/PharmPract.2017.04.1072. Epub 2017 Dec 18. Mauer Y, Taliercio RM. Managing adult asthma: The 2019 GINA guidelines. Cleve Clin J Med. 2020 Aug 31;87(9):569-575. doi: 10.3949/ccjm.87a.19136. Padilla-Galo A, Olveira C, Fernández de Rota-Garcia L, et al. Factors associated with bronchiectasis in patients with uncontrolled asthma; the NOPES score: a study in 398 patients. Respir Res. 2018;19:43. doi: 10.1186/s12931-018-0746-7. Belli S, Prince I, Savio G, et al. Airway Clearance Techniques: The Right Choice for the Right Patient. Front Med (Lausanne). 2021;8:544826. Published 2021 Feb 4. doi:10.3389/fmed.2021.544826. Hill AT, Sullivan AL, Chalmers JD, et al. British Thoracic Society Guideline for bronchiectasis in adults. Thorax 2019;74:1-69. doi: 10.1136/thoraxjnl-2018-212463.

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Breathing exercises for adults with asthma

Breathing exercises have been widely used worldwide as a non‐pharmacological therapy to treat people with asthma. Breathing exercises aim to control the symptoms of asthma and can be performed as the Papworth Method, the Buteyko breathing technique, yogic breathing, deep diaphragmatic breathing or any other similar intervention that manipulates the breathing pattern. The training of breathing usually focuses on tidal and minute volume and encourages relaxation, exercise at home, the modification of breathing pattern, nasal breathing, holding of breath, lower rib cage and abdominal breathing.

To evaluate the evidence for the efficacy of breathing exercises in the management of people with asthma.

Search methods

To identify relevant studies we searched The Cochrane Library, MEDLINE, Embase, PsycINFO, CINAHL and AMED and performed handsearching of respiratory journals and meeting abstracts. We also consulted trials registers and reference lists of included articles.

The most recent literature search was on 4 April 2019.

Selection criteria

We included randomised controlled trials of breathing exercises in adults with asthma compared with a control group receiving asthma education or, alternatively, with no active control group.

Data collection and analysis

Two review authors independently assessed study quality and extracted data. We used Review Manager 5 software for data analysis based on the random‐effects model. We expressed continuous outcomes as mean differences (MDs) with confidence intervals (CIs) of 95%. We assessed heterogeneity by inspecting the forest plots. We applied the Chi 2 test, with a P value of 0.10 indicating statistical significance, and the I 2 statistic, with a value greater than 50% representing a substantial level of heterogeneity. The primary outcome was quality of life.

Main results

We included nine new studies (1910 participants) in this update, resulting in a total of 22 studies involving 2880 participants in the review. Fourteen studies used Yoga as the intervention, four studies involved breathing retraining, one the Buteyko method, one the Buteyko method and pranayama, one the Papworth method and one deep diaphragmatic breathing. The studies were different from one another in terms of type of breathing exercise performed, number of participants enrolled, number of sessions completed, period of follow‐up, outcomes reported and statistical presentation of data. Asthma severity in participants from the included studies ranged from mild to moderate, and the samples consisted solely of outpatients. Twenty studies compared breathing exercise with inactive control, and two with asthma education control groups. Meta‐analysis was possible for the primary outcome quality of life and the secondary outcomes asthma symptoms, hyperventilation symptoms, and some lung function variables. Assessment of risk of bias was impaired by incomplete reporting of methodological aspects of most of the included studies. We did not include adverse effects as an outcome in the review.

Breathing exercises versus inactive control

For quality of life, measured by the Asthma Quality of Life Questionnaire (AQLQ), meta‐analysis showed improvement favouring the breathing exercises group at three months (MD 0.42, 95% CI 0.17 to 0.68; 4 studies, 974 participants; moderate‐certainty evidence), and at six months the OR was 1.34 for the proportion of people with at least 0.5 unit improvement in AQLQ, (95% CI 0.97 to 1.86; 1 study, 655 participants). For asthma symptoms, measured by the Asthma Control Questionnaire (ACQ), meta‐analysis at up to three months was inconclusive, MD of ‐0.15 units (95% CI −2.32 to 2.02; 1 study, 115 participants; low‐certainty evidence), and was similar over six months (MD −0.08 units, 95% CI −0.22 to 0.07; 1 study, 449 participants). For hyperventilation symptoms, measured by the Nijmegen Questionnaire (from four to six months), meta‐analysis showed less symptoms with breathing exercises (MD −3.22, 95% CI −6.31 to −0.13; 2 studies, 118 participants; moderate‐certainty evidence), but this was not shown at six months (MD 0.63, 95% CI −0.90 to 2.17; 2 studies, 521 participants). Meta‐analyses for forced expiratory volume in 1 second (FEV1) measured at up to three months was inconclusive, MD −0.10 L, (95% CI −0.32 to 0.12; 4 studies, 252 participants; very low‐certainty evidence). However, for FEV 1 % of predicted, an improvement was observed in favour of the breathing exercise group (MD 6.88%, 95% CI 5.03 to 8.73; five studies, 618 participants).

Breathing exercises versus asthma education

For quality of life, one study measuring AQLQ was inconclusive up to three months (MD 0.04, 95% CI ‐0.26 to 0.34; 1 study, 183 participants). When assessed from four to six months, the results favoured breathing exercises (MD 0.38, 95% CI 0.08 to 0.68; 1 study, 183 participants). Hyperventilation symptoms measured by the Nijmegen Questionnaire were inconclusive up to three months (MD −1.24, 95% CI −3.23 to 0.75; 1 study, 183 participants), but favoured breathing exercises from four to six months (MD −3.16, 95% CI −5.35 to −0.97; 1 study, 183 participants).

Authors' conclusions

Breathing exercises may have some positive effects on quality of life, hyperventilation symptoms, and lung function. Due to some methodological differences among included studies and studies with poor methodology, the quality of evidence for the measured outcomes ranged from moderate to very low certainty according to GRADE criteria. In addition, further studies including full descriptions of treatment methods and outcome measurements are required.

Plain language summary

Breathing exercises for asthma

Asthma is a lung disease. Asthma works in two ways. It that causes the airways to become inflamed (the body's response to injury and infection) and it causes the small tubes of the airways to tighten (called airway obstruction). The tightening of the tubes can happen in response to asthma triggers, such as animal fur or feathers, dust or pollen.

Asthma is very common worldwide and is a major public health problem due to the high healthcare costs associated with hospitalisation and medication. Breathing exercises have been used to treat people with asthma as a way of controlling the symptoms of asthma without medication. People use various breathing techniques to change their breathing pattern.

Review question

We wanted to find out how effective breathing exercises are for adults with asthma. We were most interested to know if breathing exercises improved people's quality of life (our primary outcome), and also if they helped improve asthma symptoms, hyperventilation (over‐breathing), and lung function (our secondary outcomes).

Key results

We searched for randomised controlled trials. This means people were selected at random to try either breathing exercises or a control. We included education about asthma or usual asthma care as the controls.

We found 22 studies involving 2880 adults with mild to moderate asthma. The studies used different breathing exercises. Fourteen studies used yoga, four studies used breathing retraining, one study used Buteyko method, one study used Buteyko method and pranayama, one study used Papworth method and one study used deep diaphragmatic breathing. Twenty studies compared breathing exercises with normal asthma care and two compared breathing exercises with asthma education. Studies assessed quality of life, asthma symptoms and hyperventilation symptoms, number of acute exacerbations (flare‐ups), lung function (breathing tests), and general practitioner (GP) appointments.

Several studies looked at our primary outcome, quality of life. The results showed an improvement in quality of life after three months in the breathing‐exercises group. We found that breathing exercises probably did not help to improve asthma symptoms. However, breathing exercises did improve hyperventilation symptoms, when measured from four months after starting the exercises to six months. One lung function test, percentage of predicted FEV1 (the amount of air you can force from your lungs in one second) showed some improvement in the people who did breathing exercises.

Certainty of the evidence

We are moderately certain about the benefits of breathing exercises. However, we found some differences between the studies in terms of type of breathing exercises performed, number of participants enrolled, number and duration of sessions completed, outcomes reported and statistical presentation of data.

Breathing exercises may have positive effects on quality of life, hyperventilation symptoms, and lung function in adults with mild to moderate asthma.

The evidence is current to April 2019.

Summary of findings

Summary of findings for the main comparison.

a Downgraded one level because one study was high risk of bias for selective reporting. b Downgraded one level because we included only one study with a small sample size in the analysis. c Downgraded one level because of the small sample size and wide confidential interval presented. d Graded as very low due to the impossibility of pooling the data into meta‐analysis. e Downgraded two levels because the included studies showed in general a high risk of bias and one level because of small sample size.

Description of the condition

Asthma is a chronic airway inflammatory disorder of the lungs that can lead to structural and functional changes, resulting in bronchial hyperresponsiveness and airflow obstruction ( Zhang 2010 ; Brightling 2012 ; GINA 2018 ). Symptoms of asthma include recurrent episodes of wheeze, cough, breathlessness and chest tightness, together with episodes of marked worsening of symptoms, known as exacerbations ( Zhang 2010 ; Brightling 2012 ; GINA 2018 ). Exacerbations can be fatal and they are more frequent and more serious in high‐risk patients or patients with uncontrolled asthma ( GINA 2018 ). Factors such as viral infections, allergens, tobacco smoke, physical exercise, stress, certain medications (non‐steroidal anti‐inflammatory drugs and beta‐blockers) may trigger or worsen asthma symptoms ( GINA 2018 ; WHO 2018 ). Some phenotypes are already identified, such as allergic asthma, non‐allergic asthma, and late‐onset asthma ( GINA 2018 ).

The diagnosis of asthma is based on the individual's medical history, physical examination findings and lung function and laboratory test results ( Sveum 2012 ; National Asthma Council Australia 2016 ; Gillis 2017 ). Measurement of lung function provides an assessment of the severity of airflow limitation. These measures yield complementary information about different aspects of asthma control and are obtained by spirometry and by peak expiratory flow measurement ( GINA 2018 ). Assessment of airway responsiveness to factors that can cause asthma symptoms, evaluation of airway inflammation and measurement of allergic status may facilitate the diagnosis and management of people with asthma ( GINA 2018 ).

Asthma is a serious public health problem that is a major cause of disability and health resource utilisation for those affected, which may need emergency care including hospital admission ( Bateman 2008 ; Eisner 2012 ; To 2012 ; Nunes 2017 ). Asthma affects around 1% to 18% of the population worldwide. Annually, the number of asthma deaths is about 180,000 with a wide variation between age, economic groups, continents and regions ( GINA 2018 ; WHO 2018 ).

Some chronic respiratory diseases, such as asthma, have been commonly associated with dysfunctional breathing patterns ( Veidal 2017 ). The prevalence of dysfunctional breathing in people with asthma was reported as ranging from 29% to 64% ( Courtney 2017 ). Some of the mechanisms regarding the dysfunctional breathing include multiple dimensions. These dimensions are biochemical, biomechanical and psychophysiological and refer to hyperventilation, to breathing pattern disorders and to interactions of physiology with cognitive and emotional factors, respectively ( Courtney 2017 ). Dysfunctional breathing may occur in different forms, with hyperventilation syndrome one of the most well known forms, affecting a third of people with asthma ( Grammatopoulou 2014 ; Boulding 2016 ; Vidotto 2019 ). One of the major symptoms is breathlessness that may occur associated with hyperventilation and respiratory alkalosis. However, the breathlessness is not always caused only by hyperventilation or the presence of an abnormal breathing pattern. The changes in breathing pattern are a result of a physiological response ( Thomas 2001 ; Morgan 2002 ). In addition, psychological symptoms may interfere with the severity of the respiratory symptoms and may influence patients' quality of life ( Rimington 2001 ; Juniper 2004 ; Lavoie 2005 ). Thus, an important component of asthma management is identifying individual issues that impair health‐related quality of life and treating them ( Rimington 2001 ; Juniper 2004 ). So, the control of asthma may be achieved by an individualised plan, considering the factors that contribute to attaining and maintaining asthma control ( Braido 2013 ).

Description of the intervention

Although no cure for asthma is known, there are various pharmacological and non‐pharmacological interventions that may help people control their asthma symptoms ( GINA 2018 ; Beasley 2016 ). For example, avoiding triggers (such as pollen or cold temperatures) and asthma education can also help people to control their asthma symptoms ( Burgess 2011 ; Welsh 2011 ; Kew 2016 ; GINA 2018 ).

Medications to treat asthma can be broadly divided into long‐term controllers and short‐term relievers ( Arun 2012 ). Controller medications are taken daily on a long‐term basis, and the relievers are used to rapidly decrease bronchoconstriction and relieve its symptoms ( GINA 2018 ). Such treatment can be administered in different ways (by inhalation, orally or parenterally; GINA 2018 ).  

Non‐pharmacological interventions have gained attention in the treatment of asthma. Those interventions include breathing exercises, physical activity, and other strategies such as cessation of smoking, avoidance of occupational exposure and indoor allergens, and weight reduction, among others ( GINA 2018 ). Another approach comprises complementary and alternative medicine that includes non‐conventional therapies such as homeopathy, acupuncture, aromatherapy, reflexology, massage, hypnotherapy, dietary supplements, and Alexander technique ( Blanc 2001 ; Torres‐Llenza 2010 ; Dennis 2012 ; Mark 2015 ). Breathing exercises have been used by physiotherapists and other professionals to control the symptoms of asthma ( Bruton 2005 ; James 2016 ) and can be performed as the Papworth method, Buteyko breathing technique, yoga or any other similar intervention that manipulates the breathing pattern ( Ram 2003 ; Denehy 2016 ).

How the intervention might work

In people with asthma, the presence of dysfunctional breathing independently of hyperventilation can contribute to dyspnoea. Breathing exercises are a commonly used approach for correcting dysfunctional breathing. The breathing retraining programme aims to help people with asthma in their daily life or when experiencing dyspnoea by teaching them to breathe using a better breathing pattern. The protocols for training of breathing usually pay attention to tidal and minute volume and encourage relaxation, exercise at home, the modification of breathing pattern, nasal breathing, holding of breath, and lower rib cage and abdominal breathing ( Courtney 2017 ; Sankar 2018 ). Breathing training is usually a multi‐component intervention that aims at behavioural change and involves many different methods and techniques of breathing exercises such as Buteyko method, yogic breathing, Papworth method and deep diaphragmatic breathing ( Bailey 2016 ). When breathing retraining appropriately targets the biochemical, biomechanical or psychophysiological dimensions of dysfunctional breathing, asthma control, medication usage, dysfunctional breathing symptoms and quality of life can be improved ( Courtney 2019 ). The biochemical and biomechanical dimensions can respond to breathing protocols when they target hyperventilation, control of breathing volume, relaxation of hypertonic respiratory muscles, and teach patients to adopt a more normal breathing pattern, whether they have dyspnoea or not. Regarding the psychophysiological dimension of dysfunctional breathing, breathing retraining can cover important aspects involving relaxation techniques, and emotional and mental self‐regulations tools to decrease hyperarousal and anxiety ( Courtney 2017 ; Courtney 2019 ).

Why it is important to do this review

The worldwide high prevalence of asthma has become a public health problem because of the high healthcare costs resulting from hospitalisation and medication. It causes a high number of missed work days and can result in early permanent disability and premature death. In general, asthma‐related costs are very high ( Giavina‐Bianchi 2010 ; Nunes 2017 ). Breathing exercises have been widely used as an adjunct therapy in the treatment of people with asthma, generating considerable interest among researchers to develop studies that seek to show evidence of the effectiveness of this intervention.

This is an update of a review last published in 2013, in which the review authors concluded that no conclusive evidence was provided to support or refute the benefits of breathing exercises in people with asthma. Since 2013, new studies have been conducted to evaluate the effects of breathing exercises on quality of life, symptom control and lung function in people with asthma. Thus, within this review update, we aim to summarise and assess evidence from randomised controlled trials (RCT) showing the efficacy of breathing exercises in the treatment of adults with asthma.

Criteria for considering studies for this review

Types of studies.

RCTs of breathing exercises in adults with asthma.

Types of participants

Adults with physician‐diagnosed asthma or diagnosis by internationally established criteria, or both: American Thoracic Society (ATS), European Respiratory Society (ERS) or British Thoracic Society (BTS). Participants may be either community‐ or hospital‐based.

To operationalise the age criteria, the mean age of the participants should be over 18 years old.

Types of interventions

Intervention: adults with asthma who have been assigned to treatment comprising breathing retraining

Comparison: control group receiving asthma education or, alternatively, no active control group (e.g. waiting list control)

Types of outcome measures

Primary outcomes.

• Quality of life

Secondary outcomes

• Asthma symptoms and hyperventilation symptoms (e.g. measures of dyspnoea or breathlessness with Borg score or visual analogue scale)
• Number of acute exacerbations (mean number and number of participants experiencing one or more exacerbations)
• Inpatient hospitalisation episodes
• Physiological measures: lung function and functional capacity
• General practitioner (GP) or hospital outpatient appointments or both
• Days off work
• Participant's subjective evaluation of the intervention

Search methods for identification of studies

Electronic searches.

We identified studies from the Cochrane Airways Trials Register, which is maintained by the Information Specialist for the Group. The Cochrane Airways Trials Register contains studies identified from several sources:

• monthly searches of the Cochrane Central Register of Controlled Trials (CENTRAL), through the Cochrane Register of Studies;
• weekly searches of MEDLINE Ovid SP 1946 to date;
• weekly searches of Embase Ovid SP 1974 to date;
• Monthly searches of PsycINFO Ovid SP 1967 to date;
• Monthly searches of CINAHL EBSCO (Cumulative Index to Nursing and Allied Health Literature) 1937 to date;
• Monthly searches of AMED EBSCO (Allied and Complementary Medicine) all years to date;
• handsearches of the proceedings of major respiratory conferences.

Studies contained in the Trials Register are identified through search strategies based on the scope of Cochrane Airways. Details of these strategies, as well as a list of handsearched conference proceedings are in Appendix 2 . See Appendix 3 for search terms used to identify studies for this review.

For the previous version of this review ( Freitas 2013 ), searches were conducted up to January 2013. For this version, the literature search has been updated to 4 April 2019. This review update includes searches conducted in April 2003, February 2012, January 2013, December 2016, December 2017, and April 2019.

Searching other resources

We looked for additional studies by consulting reference lists of relevant articles found by the above methods. We searched the US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov (www.clinicaltrials.gov), and the World Health Organization International Clinical Trials Registry Platform (apps.who.int/trialsearch), to look for planned, ongoing and unpublished studies.

Selection of studies

Two review authors (KMPPM and TAS) independently assessed studies for the possibility of inclusion in this review. We retrieved full‐text articles and reviewed them to determine eligibility. We resolved final decisions and disagreements by consultation with a third review author (DAF). We recorded the selection process in sufficient detail to complete a PRISMA flow diagram ( Moher 2009 ), and ' Characteristics of excluded studies ' table.

Data extraction and management

Two review authors (KMPPM and GAAF) independently extracted data into Review Manager 5 ( Review Manager 2014 ), by using a standard data collection form. According to methods described in the Cochrane Handbook for Systematic Reviews of Interventions ( Higgins 2011 ), we collected information from the studies, including the following.

• Methods (design, method of randomisation, method of allocation concealment, outcome assessor blinding, withdrawal and dropouts)
• Participants (country, health status, mean age, gender, total sample and exclusion criteria)
• Interventions (methods and types of intervention, including number and duration of sessions and methods used for control group comparisons)
• Outcomes (improvement in quality‐of‐life indices, asthma symptoms, number of acute exacerbations, inpatient hospitalisation episodes, etc)

We resolved disagreements by discussion and consensus with a third review author (GSSC).

Assessment of risk of bias in included studies

Two review authors (KMPPM and TAS) independently assessed the risk of bias using the Cochrane tool for assessing risk of bias, which includes the following items: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting and other sources of bias. We classified risk of bias as high, low or unclear, according to the methods described in Chapter 8 of the Cochrane Handbook for Systematic Reviews of Interventions ( Higgins 2017 ). We resolved disagreements by discussion and consensus with a third review author (GSSC).

Measures of treatment effect

We expressed continuous outcomes as mean difference (MD) with 95% confidence interval (CI) when outcome measurements were performed on the same scale. We planned to use standardised mean difference (SMD) with 95% CI if studies assessed an outcome by using different methods. We expressed dichotomous outcomes as odds ratio (OR) with 95% CI.

We used intention‐to‐treat (ITT) analyses where they are reported instead of per‐protocol/completer analyses.

Unit of analysis issues

We did not include studies with a cross‐over or cluster‐randomised design in the review.

Dealing with missing data

We wrote to authors of included studies to request additional data as required.

Assessment of heterogeneity

We assessed heterogeneity by inspecting the forest plots to detect non‐overlapping CIs, while applying the Chi 2 test with a P value of 0.10 indicating statistical significance. We also implemented the I 2 statistic, with a value of 50% denoting moderate levels of heterogeneity and above 50% indicating a substantial level of heterogeneity ( Deeks 2017 ).

Assessment of reporting biases

If we had been able to meta‐analyse sufficient data (10 studies or more), we planned to assess reporting bias among the studies using the funnel plot method discussed in the Cochrane Handbook for Systematic Reviews of Interventions ( Sterne 2017 ). If asymmetry was noted, we planned to explore possible causes, including publication bias, poor methodological quality and true heterogeneity.

Data synthesis

We used Cochrane's statistical package, Review Manager 5, to combine outcomes when possible ( Review Manager 2014 ). We used the random‐effects method, which considers that different studies are estimating different, yet related, intervention effects ( DerSimonian 1986 ). For studies with more than two arms, we split the control group to avoid double counting.

Subgroup analysis and investigation of heterogeneity

If we were able to combine sufficient data and identify substantial heterogeneity (an I 2 statistic value greater than 50%), we planned to conduct the following subgroup analyses.

• Degree of asthma severity
• Age groups (adult versus elderly)
• Duration of treatment
• Type of breathing exercise

Sensitivity analysis

If we had been able to combine sufficient data, sensitivity analysis would have been performed to explore the influence on the results of the following factors.

• Study quality (RCTs with poor methodology)
• Study size (stratified by sample size)
• Allocation concealment (high risk of bias versus low risk of bias versus unclear risk of bias)
• Assessor blinding (high risk of bias versus low risk of bias versus unclear risk of bias)

Summary of findings and assessment of the certainty of the evidence

We created a 'Summary of findings' table that included the following outcomes, according to the methods described in Chapter 11 of the Cochrane Handbook for Systematic Reviews of Interventions : change in quality of life measured by the Asthma Quality of Life Questionnaire (AQLQ), change in asthma symptoms measured by the Asthma Control Questionnaire (ACQ), change in hyperventilation symptoms measured by the Nijmegen Questionnaire, number of acute exacerbations, inpatient hospitalisation episodes, and lung function (Forced Expiratory Volume in 1 second (FEV 1 )), and days off work.

We determined the quality of the evidence using the GRADE approach and GRADEproGDT software ( GRADEpro GDT ). We justified all decisions to downgrade the quality of studies in footnotes, and made comments to aid readers' understanding of the review where necessary.

Description of studies

Results of the search.

The previous version of the review ( Freitas 2013 ), included 13 studies ( Nagarathna 1985 ; Girodo 1992 ; Fluge 1994 ; Vedanthan 1998 ; Thomas 2003 ; Holloway 2007 ; Sodhi 2009 ; Thomas 2009 ; Vempati 2009 ; Grammatopoulou 2011 ; Bidwell 2012 ; Singh 2012 ; Prem 2013 ). For this 2019 update, the most recent search was 4 April 2019. The database searching returned 245 references, resulting in 176 references after removing duplicates. Four additional references were obtained by searching other sources, resulting in 180 references. Of these, we identified 19 as potentially relevant, and we retrieved the full‐text articles for closer inspection. We added 11 of these (relating to nine studies) as new additions in the 2019 update ( Aggarwal 2013 ; Gupta 2015 ; Prasanna 2015 ; Agnihotri 2016 ; Satpathy 2016 ; Thomas 2017 ; Agnihotri 2018 ; Malarvizhi 2018 ; Pushpa 2018 ). See ' Figure 1 ' for full details on the results of the search.

Study flow diagram

Included studies

In total, 22 studies are included in this review ( Nagarathna 1985 ; Girodo 1992 ; Fluge 1994 ; Vedanthan 1998 ; Thomas 2003 ; Holloway 2007 ; Sodhi 2009 ; Thomas 2009 ; Vempati 2009 ; Grammatopoulou 2011 ; Bidwell 2012 ; Singh 2012 ;  Aggarwal 2013 ; Prem 2013 ; Gupta 2015 ; Prasanna 2015 ; Agnihotri 2016 ; Satpathy 2016 ; Thomas 2017 ; Agnihotri 2018 ; Malarvizhi 2018 ; Pushpa 2018 ). Of these, two included studies have one additional report that was collected under a single study ID ( Sodhi 2009 ; Thomas 2017 ). Therefore, we included 22 studies reported in 24 reports. We included 14 studies in the quantitative synthesis ( Vedanthan 1998 ; Holloway 2007 ; Sodhi 2009 ; Thomas 2009 ; Vempati 2009 ; Grammatopoulou 2011 ; Bidwell 2012 ; Singh 2012 ; Aggarwal 2013 ; Prem 2013 ; Gupta 2015 ; Agnihotri 2016 ; Thomas 2017 ; Pushpa 2018 ). See ' Characteristics of included studies ' for full details on each study and Table 2 for an overview of the characteristics of the included studies.

a Range across treatment arms reported where overall data were not reported. b Median and IQR.

Setting and populations

Thirteen studies were conducted in India ( Nagarathna 1985 ; Sodhi 2009 ; Vempati 2009 ; Singh 2012 ;  Aggarwal 2013 ; Prem 2013 ; Gupta 2015 ; Prasanna 2015 ; Agnihotri 2016 ; Satpathy 2016 ; Agnihotri 2018 ; Malarvizhi 2018 ; Pushpa 2018 ), one in Canada ( Girodo 1992 ), one in Germany ( Fluge 1994 ), four in the UK ( Thomas 2003 ; Holloway 2007 ; Thomas 2009 ; Thomas 2017 ), two in the USA ( Vedanthan 1998 ; Bidwell 2012 ) and one in Greece ( Grammatopoulou 2011 ). All papers were written in English with the exception of Fluge 1994 , which was written in German. Seven studies were conducted between 2014 and 2019, 11 studies were conducted between 2003 and 2013, three were conducted between 1992 and 1998 and one was conducted in 1985. The studies varied in size from 17 to 655 participants. Participants in the included studies were older than 18 years of age, with the exception of Nagarathna 1985 (aged 9 to 47), Thomas 2003 (aged 17 to 65) and Holloway 2007 and Thomas 2017 (aged 16 to 70), Agnihotri 2016 and Agnihotri 2018 (aged 12 to 60). We included all studies as the mean age was over 18.

Interventions and control groups

In fourteen studies ( Nagarathna 1985 ; Fluge 1994 ; Vedanthan 1998 ; Sodhi 2009 ; Vempati 2009 ; Bidwell 2012 ; Singh 2012 ; Aggarwal 2013 ; Gupta 2015 ; Agnihotri 2016 ; Satpathy 2016 ; Agnihotri 2018 ; Malarvizhi 2018 ; Pushpa 2018 ), participants undertook yoga exercises that involved pranayama breathing exercises as the major component, and the control groups did not undergo yoga training but continued taking their usual medication. In Nagarathna 1985 , participants in the intervention group underwent training for two weeks and were told to practise these exercises for 65 minutes daily. In Fluge 1994 , participants underwent 15 yoga sessions over three weeks. In Vedanthan 1998 , yoga sessions were performed three times a week over 16 weeks. In Sodhi 2009 , each yoga training session was of 45 minutes' duration per week with a trained instructor for a period of eight weeks. In Vempati 2009 , the intervention consisted of two‐week supervised training in lifestyle modification and stress management based on yoga followed by closely monitored continuation of these practices at home for six weeks. In Bidwell 2012 , yoga training consisted of two, one‐hour supervised yoga sessions per week for 10 weeks. In Singh 2012 , participants attended yoga training provided by a yoga expert for five to six days. Thereafter, participants were told to practise yoga for an average of 40 to 50 minutes daily at home for two months. Participants were called to the yoga centre regularly (about every seven days) so investigators could see whether they were doing the yoga exercises properly. In Aggarwal 2013 and Gupta 2015 , participants performed yoga for three months. In Satpathy 2016 , participants in intervention group performed yogic exercises daily early in the morning under the guidance of a yoga instructor over four months. In Agnihotri 2016 and Agnihotri 2018 , participants performed yoga sessions for 30 minutes per day, five days a week over six months. In Malarvizhi 2018 , participants received 30 minutes of yoga training for a week under a trained yoga teacher and were advised to practise at home daily once a day for six months. In Pushpa 2018 , participants practised yoga exercises for 45 minutes a day over two weeks and were instructed to practise at home for 45 minutes twice daily, regularly for the remaining six weeks and were instructed to maintain a diary record of each day of yoga practice.

In the Girodo 1992 study, participants undertook a 16‐week programme of deep diaphragmatic breathing exercises and were compared against a group of controls that were on a waiting list. Thomas 2003 compared participants who completed three short breathing retraining sessions (total contact time 75 minutes), taught by a physiotherapist, with a control group that received asthma education from a nurse. In Holloway 2007 , the intervention group completed five 60‐minute individual sessions on the Papworth method provided by a respiratory physiotherapist. The control group received no additional treatment. In Thomas 2009 , the breathing training group attended three sessions (one small group session and two individual sessions) that provided an explanation of normal breathing and possible effects of abnormal 'dysfunctional breathing'. During individual sessions, participants were taught diaphragmatic and nasal breathing techniques and were encouraged to practise these exercises for at least 10 minutes per day. The control group received three sessions of nurse‐provided asthma education. The intervention group in the Grammatopoulou 2011 study received 12 individual breathing retraining sessions, and the control group received usual asthma care. Prem 2013 divided 120 participants into three groups: Buteyko, yoga and control. Participants assigned to Buteyko or yoga groups received three to five days of sessions totaling 60 minutes each day. Participants in the control group followed routine physician care involving pharmacological management. Prasanna 2015 instructed participants to perform Buteyko breathing exercises at least twice a day for a period of two months, and the control group used only inhaled corticosteroids. Thomas 2017 divided participants into three groups: breathing retraining group using DVD and booklet format, face‐to‐face physiotherapy and a usual care group.

The primary outcome in seven studies ( Holloway 2007 ; Thomas 2009 ; Bidwell 2012 ; Prem 2013 ; Thomas 2017 ; Agnihotri 2018 ; Malarvizhi 2018 ), was quality of life, although the studies used different instruments (SGRQ in Holloway 2007 and Bidwell 2012 , AQLQ in Thomas 2009 , Prem 2013 , Thomas 2017 , and Malarvizhi 2018 , and MiniAQLQ in Agnihotri 2018 ). Asthma symptoms as measured by the Asthma Control Test (ACT) score were the main outcome in Grammatopoulou 2011 . In Vempati 2009 , pulmonary function was the primary outcome.

Lung function was the secondary outcome for Holloway 2007 , Thomas 2009 , Grammatopoulou 2011 , and Thomas 2017 . Asthma symptoms measured by the Asthma Control Questionnaire (ACQ) were a secondary outcome in Thomas 2009 and Thomas 2017 . In addition, Thomas 2003 , Thomas 2009 , Holloway 2007 and Thomas 2017 assessed hyperventilation symptoms by the Nijmegen Questionnaire. Grammatopoulou 2011 and Vempati 2009 assessed quality of life as a secondary outcome, measured by the Short Form (SF)‐36 v2 Health Survey and by the AQLQ, respectively.

The other included studies did not specify primary and secondary outcomes, but the study authors reported several main outcome measures, including pulmonary function ( Fluge 1994 ; Aggarwal 2013 ; Gupta 2015 ; Agnihotri 2016 ; Pushpa 2018 ), asthma symptoms ( Girodo 1992 ), number of acute exacerbations and pulmonary function ( Nagarathna 1985 ), quality of life and asthma symptoms ( Thomas 2003 ), asthma symptoms and lung function ( Vedanthan 1998 ; Prasanna 2015 ), and lung function and quality of life ( Sodhi 2009 ; Singh 2012 ).

Excluded studies

After we had retrieved the full text of potentially eligible studies, we excluded a total of 48 studies from the review. Two previously included studies had been excluded in the 2012 update ( Bowler 1998 ; Opat 2000 ). We have described reasons for exclusion in the Characteristics of excluded studies .

Risk of bias in included studies

Full details of 'Risk of bias' judgments can be found in Characteristics of included studies and in Figure 2 .

'Risk of bias' summary: review authors' judgements about each 'Risk of bias' item for each included study

Nine studies reported adequate sequence generation and we judged them to have low risk of bias ( Thomas 2003 ; Holloway 2007 ; Sodhi 2009 Grammatopoulou 2011 ; Prem 2013 ; Agnihotri 2016 ; Thomas 2017 ; Agnihotri 2018 ; Malarvizhi 2018 ).

Thomas 2003 recruited individuals with high Nijmegen Questionnaire scores who were currently being treated for asthma at a general practice. They assigned volunteers randomly by numbering them alphabetically and using random number tables to assign them to study groups. Holloway 2007 , undertook randomisation by a computer‐generated number sequence that assigned consecutive participant ID numbers a 1 or a 2 to denote intervention or a control condition. Sodhi 2009 randomised participants in two groups (Yoga and control) using permuted block randomisation. Grammatopoulou 2011 undertook random allocation with sealed envelopes. Prem 2013 assigned participants to three groups (Buteyko, yoga and control) through block randomisation. Agnihotri 2016 and Agnihotri 2018 undertook randomisation by a computer‐generated random number table. Thomas 2017 used the web based Tenalea randomisation system. Malarvizhi 2018 randomised participants by using a random allocation software.

Thirteen studies reported that they were randomised but gave no description of the methods used, and we therefore judged them to be at unclear risk of bias ( Nagarathna 1985 ; Girodo 1992 ; Fluge 1994 ; Vedanthan 1998 ; Thomas 2009 ; Vempati 2009 ; Bidwell 2012 ; Singh 2012 ; Aggarwal 2013 ; Gupta 2015 ; Prasanna 2015 ; Satpathy 2016 ; Pushpa 2018 ).

Only four studies described adequate allocation concealment and we judged them to have low risk of bias ( Grammatopoulou 2011 ; Prem 2013 ; Thomas 2017 ; Malarvizhi 2018 ). Grammatopoulou 2011 concealed allocation with sealed envelopes, and Prem 2013 concealed allocation in sequentially numbered, sealed, opaque envelopes. Thomas 2017 randomly allocated participants to one of the three study arms by using a telephone call service. Malarvizhi 2018 randomly allocated participants to one of the two study arms by using random allocation software. The other eighteen studies gave no description of the methods of allocation concealment used and we therefore judged them to have unclear risk of bias ( Nagarathna 1985 ; Girodo 1992 ; Fluge 1994 ; Vedanthan 1998 ; Thomas 2003 ; Holloway 2007 ; Thomas 2009 ; Vempati 2009 ; Sodhi 2009 ; Bidwell 2012 ; Singh 2012 ; Aggarwal 2013 ; Gupta 2015 ; Prasanna 2015 ; Agnihotri 2016 ; Satpathy 2016 ; Agnihotri 2018 ; Pushpa 2018 ).

Blinding of the investigator and the participant involved is not possible or practical in these studies. Participants in these studies must know whether or not they are undertaking breathing training or asthma education, as compliance is critical to the study; therefore we judged these studies to have a high risk of bias. However, it is possible to blind the assessor who is analysing the results of the study. One study reported that participants were blinded, however due to the type of intervention used in the study arms, it is likely that the blinding could have been broken. We therefore judged this study to have a high risk of bias ( Malarvizhi 2018 ).

Only one study reported blinded outcome assessment, however the outcome was patient‐rated, which could introduce high risk of detection bias ( Malarvizhi 2018 ). Six studies said that blinding was not possible; we judged these studies to have a high risk of bias, as we determined that the outcomes may have been influenced by the lack of blinding ( Thomas 2003 ; Holloway 2007 ; Thomas 2009 ; Vempati 2009 ; Grammatopoulou 2011 ; Thomas 2017 ). Nine studies did not describe blinding and we considered the assessed outcomes to be patient‐rated, so we judged them to have a high risk of bias ( Girodo 1992 ; Vedanthan 1998 ; Sodhi 2009 ; Bidwell 2012 ; Singh 2012 ; Prem 2013 ; Prasanna 2015 ; Satpathy 2016 ; Agnihotri 2018 ). Six studies did not report any procedures intended to blind the participants and outcome assessors ( Nagarathna 1985 ; Fluge 1994 ; Aggarwal 2013 ; Gupta 2015 ; Agnihotri 2016 ; Pushpa 2018 ), so we judged them to have unclear risk of bias.

Incomplete outcome data

Seven studies did not describe the occurrence of withdrawals and dropouts and we judged them to be at unclear risk of bias ( Girodo 1992 ; Sodhi 2009 ; Aggarwal 2013 ; Gupta 2015 ; Prasanna 2015 ; Satpathy 2016 ; Pushpa 2018 ). Nagarathna 1985 affirmed that in total 25 participants dropped out of the study, however, we judged this study to have an unclear risk of bias because it did not describe the reasons, nor how many participants dropped out of the study in each group (intervention and control). Three studies did not report any withdrawals or dropouts; we judged these studies to have a low risk of bias ( Vedanthan 1998 ; Grammatopoulou 2011 ; Bidwell 2012 ). Seven studies described withdrawals and dropouts and we judged them to have a low risk of bias too, because the missing outcome data were balanced in numbers across intervention groups and the reasons were similar ( Thomas 2003 ; Holloway 2007 ; Thomas 2009 ; Thomas 2017 ) or because the reasons for missing outcome data were unlikely to be related to true outcomes ( Fluge 1994 ; Singh 2012 ; Prem 2013 ). Four studies described withdrawals and dropouts. However, the reasons for missing outcome data were not clearly described. Thus, we judged them to be at unclear risk of bias ( Vempati 2009 ; Agnihotri 2016 ; Agnihotri 2018 ; Malarvizhi 2018 ).

Selective reporting

Two studies were registered on clinicaltrials.gov, another one on ISRCTN register, and all of the prespecified primary and secondary outcomes were reported in the prespecified way ( Holloway 2007 ; Vempati 2009 ; Thomas 2017 ). We judged these studies to have a low risk of selective reporting bias. Thirteen studies adequately reported outcome data for all outcomes as listed in the methods and were therefore assessed as low risk of bias, although none of the protocols for these studies are available ( Nagarathna 1985 ; Thomas 2003 ; Sodhi 2009 ; Thomas 2009 ; Grammatopoulou 2011 ; Singh 2012 ; Aggarwal 2013 ; Gupta 2015 ; Agnihotri 2016 ; Satpathy 2016 ; Agnihotri 2018 ; Malarvizhi 2018 ; Pushpa 2018 ). We judged six studies to be at high risk of bias because they reported one or more outcomes of interest in the review incompletely ( Girodo 1992 ; Fluge 1994 ; Vedanthan 1998 ; Bidwell 2012 ; Prem 2013 ; Prasanna 2015 ).

Other potential sources of bias

We were unable to identify any other potential biases in five studies ( Thomas 2003 ; Holloway 2007 ; Grammatopoulou 2011 ; Prem 2013 ; Thomas 2017 ). We judged 17 studies to be at unclear risk of bias, as they did not provide sufficient information to allow assessment of whether an important risk of bias is present ( Nagarathna 1985 ; Girodo 1992 ; Fluge 1994 ; Vedanthan 1998 ; Sodhi 2009 ; Thomas 2009 ; Vempati 2009 ; Bidwell 2012 ; Singh 2012 ; Aggarwal 2013 ; Gupta 2015 ; Prasanna 2015 ; Agnihotri 2016 ; Satpathy 2016 ; Agnihotri 2018 ; Malarvizhi 2018 ; Pushpa 2018 ).

Effects of interventions

See: Table 1

The included studies had different durations, with multiple time points. So, to deal with methodological differences, we performed the meta‐analysis for the assessed outcomes by pooling the available data by the last time point of assessments after their baseline. For all outcomes, we pooled data at up to three months, from four to six months, and over six months.

Primary outcome: quality of life

Ten studies involving 1706 participants reported quality of life ( Holloway 2007 ; Sodhi 2009 ; Vempati 2009 ; Grammatopoulou 2011 ; Bidwell 2012 ; Singh 2012 ; Prem 2013 ; Thomas 2017 ; Agnihotri 2018 ; Malarvizhi 2018 ). We included six of these studies in meta‐analysis ( Holloway 2007 ; Vempati 2009 ; Bidwell 2012 ; Prem 2013 ; Thomas 2017 ; Agnihotri 2018 ).

For the outcome 'Change in AQLQ', which included Vempati 2009 , Prem 2013 , Thomas 2017 and Agnihotri 2018 , meta‐analysis showed significant differences favouring the intervention group (MD 0.42, 95% CI 0.17 to 0.68; 4 studies, 974 participants; Analysis 1.1 ; Figure 3 ), however we observed substantial heterogeneity (Chi 2 = 20.85, df = 5 (P = 0.0009); I 2 = 76%). Thomas 2017 reported that 64.4% of participants in the physiotherapy group, 61.7% in the DVD group and 55.7% in the control group reported a clinically significant improvement on AQLQ assessment after six months, higher than the minimal clinically important difference (MCID) of 0.5 ( Juniper 2004 ). However, due to an improvement in both the intervention and control groups, there was uncertainty in the between‐group difference (OR 1.34, 95% CI 0.97 to 1.86, P = 0.07; 1 study, 655 participants; Analysis 1.2 ; Figure 4 ).

Forest plot of comparison 1. Breathing exercises versus inactive control, outcome 1.1: change in AQLQ (up to 3 months)

Forest plot of comparison 1. Breathing exercises versus inactive control, outcome 1.2: change in AQLQ (over 6 months)

Comparison 1 Breathing exercises versus inactive control, Outcome 1 Change in AQLQ (up to 3 months).

Comparison 1 Breathing exercises versus inactive control, Outcome 2 Number of people who improved scores in AQLQ (over 6 months).

Thomas 2017 also reported the number needed to treat for one participant to have a clinically relevant improvement (NNTB: number needed to treat for an additional beneficial outcome) in quality of life of 7 and 8 for the physiotherapy and DVD arm, respectively, compared with the usual‐care arm.

The outcome 'Change in SGRQ', included Holloway 2007 and Bidwell 2012 in two different time points (six months and three months, respectively). However, due to the high heterogeneity, we could not pool data. Higher scores in SGRQ indicate worse quality of life and a change of 4 units was established as a MCID ( Jones 2002 ). In Bidwell 2012 , the mean score change after three months from baseline was very large and was higher than the MCID (16.01 units in the breathing exercises group and 31.85 units in the control group). In order to visualise the data, we included the second time point of 12 months, evaluated in Holloway 2007 , in the graphic and it shows a tendency to an improvement of quality of life favouring the breathing exercises group ( Analysis 1.3 ).

Comparison 1 Breathing exercises versus inactive control, Outcome 3 Change in SGRQ.

We were not able to include the other four studies in the meta‐analysis ( Sodhi 2009 ; Grammatopoulou 2011 ; Singh 2012 ; Malarvizhi 2018 ). Of these, Sodhi 2009 found improvement in three domains (symptoms, activities and environment) and in total scores of the AQLQ in the yoga group compared with the control group (P < 0.01). Grammatopoulou 2011 showed that the group that performed breathing exercises improved the physical component of the SF‐36 quality‐of‐life questionnaire compared with controls in all assessments (two, three and six months after intervention, with P value of 0.003, 0.0002 and 0.066, respectively). Singh 2012 observed a significant difference favouring the group submitted to the intervention, with P < 0.001 for all four domains of the AQLQ. Agnihotri 2018 reported AQLQmini at six months as well as three months, but we could not combine data from Agnihotri 2018 with Thomas 2017 at six months. Agnihotri 2018 found an improvement between breathing exercise and control group (mean 5.72 (standard deviation (SD) 0.38) and mean 5.43 (SD 0.34) respectively). Finally, we could not include Malarvizhi 2018 in the meta‐analysis due to a discrepancy between the graphical presentation and the data provided by correspondence.

Secondary outcome: asthma symptoms and hyperventilation symptoms

Six studies involving 1055 participants reported asthma symptoms ( Girodo 1992 ; Vedanthan 1998 ; Prem 2013 ; Prasanna 2015 ; Satpathy 2016 ; Thomas 2017 ). Of these, two studies used the Asthma Control Questionnaire (ACQ) ( Prem 2013 ; Thomas 2017 ), and we included them in the meta‐analysis. Three studies involving 780 participants reported hyperventilation symptoms ( Holloway 2007 ; Grammatopoulou 2011 ; Thomas 2017 ), by using the Nijmegen Questionnaire.

For the outcome 'Change in ACQ', we performed meta‐analysis including data from up to three months and over six months. However, we included only one study for each analysis ( Prem 2013 and Thomas 2017 , respectively); note that each study has three arms. The differences between the intervention and control groups from up to three months (MD −0.15, 95% CI −2.32 to 2.02; 1 study, 115 participants; Analysis 1.4 ), and over six months (MD −0.08, 95% CI −0.22 to 0.07; 1 study, 449 participants; Analysis 1.5 ) were both uncertain.

Comparison 1 Breathing exercises versus inactive control, Outcome 4 Change in ACQ (up to 3 months).

Comparison 1 Breathing exercises versus inactive control, Outcome 5 Adjusted change in ACQ (over 6 months).

For the outcome 'Change in Nijmegen', we performed meta‐analysis including data from four to six months ( Holloway 2007 ; Grammatopoulou 2011 ), and over six months ( Holloway 2007 ; Thomas 2017 ). Meta‐analysis showed differences favouring the intervention group for hyperventilation symptoms from baseline to four to six months (MD −3.22, 95% CI −6.31 to −0.13; 2 studies, 118 participants; Analysis 1.6 ). For over six months, improvement was not shown (MD 0.63, 95% CI −0.90 to 2.17; 2 studies, 521 participants; Analysis 1.7 ).

Comparison 1 Breathing exercises versus inactive control, Outcome 6 Nijmegen (4 to 6 months).

Comparison 1 Breathing exercises versus inactive control, Outcome 7 Adjusted change in Nijmegen (over 6 months).

Four studies ( Girodo 1992 ; Vedanthan 1998 ; Prasanna 2015 ; Satpathy 2016 ), did not report sufficient data to enter the meta‐analysis. Of these, one study reported no clear difference in asthma symptoms between yoga and control groups mean 7.0 (SD 10.16) and mean 1.75 (SD 24.24); P > 0.05 ( Vedanthan 1998 ). Girodo 1992 did not observe significant changes in frequency of symptoms on the Asthma Symptom Checklist in any group. Prasanna 2015 reported improvement of asthma symptoms between the intervention and control groups (P < 0.05). Satpathy 2016 showed a difference in the proportion of participants, in both groups, who presented lower frequency of asthma symptoms assessed by the Asthma Symptom Score.

Secondary outcome: number of acute exacerbations

Four studies reported this outcome ( Nagarathna 1985 ; Sodhi 2009 ; Satpathy 2016 ; Thomas 2017 ), however they did not report sufficient data to enter the meta‐analysis. Nagarathna 1985 showed a decrease in the number of exacerbations per week between intervention and control groups, with mean 0.83 (SD 2.49) and mean 2.1 (SD 2.7), (P < 0.005). Sodhi 2009 found a decrease in the number of acute exacerbations per week between intervention and control groups from baseline up to eight weeks, with mean 0.38 (SD 0.48) and mean 0.58 (SD 0.53); P < 0.05. Satpathy 2016 showed a decrease (P < 0.01) in the number of participants who had acute exacerbation between baseline and four months post‐intervention in the intervention group. Thomas 2017 assessed asthma exacerbations by the use of oral corticosteroids. Results from Thomas 2017 showed no statistically significant difference between the intervention and control groups. In Thomas 2017 , the percentage of participants of the physiotherapy, DVD and control groups that showed more than one oral corticosteroid courses (asthma exacerbations) after 12 months was 11.36%, 9.20% and 14.89%, respectively.

Secondary outcome: physiological measures

Sixteen studies involving 1951 participants assessed lung function ( Nagarathna 1985 ; Fluge 1994 ; Vedanthan 1998 ; Holloway 2007 ; Sodhi 2009 ; Vempati 2009 ; Grammatopoulou 2011 ; Bidwell 2012 ; Singh 2012 ; Aggarwal 2013 ; Prem 2013 ; Gupta 2015 ; Prasanna 2015 ; Agnihotri 2016 ; Thomas 2017 ; Pushpa 2018 ). Of these, we included 11 studies in meta‐analysis ( Vedanthan 1998 ; Holloway 2007 ; Sodhi 2009 ; Vempati 2009 ; Singh 2012 ; Aggarwal 2013 ; Prem 2013 ; Gupta 2015 ; Agnihotri 2016 ; Thomas 2017 ; Pushpa 2018 ). Five studies did not report sufficient data to enter the meta‐analysis ( Nagarathna 1985 ; Fluge 1994 ; Grammatopoulou 2011 ; Bidwell 2012 ; Prasanna 2015 ).

For FEV 1 (L) measured at up to three months, we observed no clear difference between intervention and control groups (MD −0.10 L, 95% CI −0.32 to 0.12; I 2 = 61%; 4 studies, 252 participants; Analysis 1.8 ). Although the MCID in FEV 1 has not been rigorously established for asthma, the magnitude of the MD found of 0.1 L is likely to have a clinical relevance ( Enright 2004 ; Tepper 2012 ). For FEV 1 % of predicted, we found a difference favouring the intervention group (MD 6.88 % predicted, 95% CI 5.03 to 8.73; 5 studies, 618 participants; Analysis 1.9 ). When measured at over six months, no clear differences were observed in FEV 1 in litres (MD −0.02 L, 95% CI −0.08 to 0.04; 2 studies, 491 participants; Analysis 1.10 ), and in % of predicted (MD 0.49 % predicted, 95% CI −2.48 to 3.46; 1 study, 424 participants; Analysis 1.11 ).

Comparison 1 Breathing exercises versus inactive control, Outcome 8 Lung function (FEV1 in litres; up to 3 months).

Comparison 1 Breathing exercises versus inactive control, Outcome 9 Lung function (FEV1 % of predicted; up to 3 months).

Comparison 1 Breathing exercises versus inactive control, Outcome 10 Adjusted change in lung function (FEV1 in litres; over 6 months).

Comparison 1 Breathing exercises versus inactive control, Outcome 11 Adjusted change in lung function (FEV1 % of predicted; over 6 months).

For the outcome peak expiratory flow rate, measured at up to three months, we observed a difference favouring the intervention group, however there was substantial heterogeneity among the studies ( Analysis 1.12 ). We were able to perform a meta‐analysis including two studies with data measured at over six months ( Holloway 2007 ; Thomas 2017 ). Results from this analysis showed no clear difference favouring the intervention group comparing to control group (MD −1.07, 95% CI −14.89 to 12.74; 2 studies, 491 participants; Analysis 1.13 ).

Comparison 1 Breathing exercises versus inactive control, Outcome 12 Lung function (PEFR; up to 3 months).

Comparison 1 Breathing exercises versus inactive control, Outcome 13 Adjusted change in lung function (PEFR; over 6 months).

Two studies also assessed capnography ( Holloway 2007 ; Grammatopoulou 2011 ). Holloway 2007 did not find differences between intervention and control groups regarding end‐tidal carbon dioxide. However, values for relaxed breathing rate over a 10‐minute period, in breaths per minute (bpm), showed better results in the intervention group than in the control group: mean 10.0 bpm (SD 3.0) and mean 15.3 bpm (SD 2.4); P < 0.001, at six months post‐baseline, respectively; and mean 9.6 bpm (SD 3.7) and mean 15.3 bpm (SD 2.7); P < 0.001 at 12 months post‐baseline assessment, respectively. In Grammatopoulou 2011 , the intervention group compared with the control group showed increased end‐tidal carbon dioxide (mean 37.95 mmHg (SD 2.70) and mean 34.90 mmHg (SD 2.91); P = 0.002 for one month post baseline; mean 38.50 mmHg (SD 1.88) and mean 35.15 mmHg (SD 2.58); P < 0.0001 for two months post‐baseline; and mean 37.90 mmHg (SD 3.54) and mean 34.60 mmHg (SD 2.91); P = 0.003 for six months post‐baseline. The intervention group showed a decreased respiratory rate compared with the control group (P < 0.0001) in all time point assessments.

One study ( Thomas 2017 ), also assessed airway inflammation by the fraction of exhaled nitric oxide (FeNO) measured in parts per billion (ppb). In Thomas 2017 , there was no clear difference in the comparison between physiotherapy and control groups regarding baseline and 12‐month values (P = 0.28; median 19 ppb (interquartile range (IQR) 13 to 33) and median 20 ppb (IQR 13 to 31). However, a small difference was observed between DVD and control groups (P = 0.02; median 20 ppb (IQR 13 to 33) and median 20 ppb (IQR 13 to 31), respectively).

Secondary outcomes: general practitioner (GP) appointments

Only one study ( Thomas 2017 ), assessed GP appointments, from baseline to a 12‐month follow‐up. Thomas 2017 found no clear difference in consultation rates between the physiotherapy intervention group (P = 0.87) or the DVD intervention group than the control group (P = 0.69).

Secondary outcomes: inpatient hospitalisation episodes, days off work and subjective evaluation of the intervention

None of the included studies reported these outcomes.

Two studies involving 216 participants assessed this outcome ( Thomas 2003 ; Thomas 2009 ). Both studies had follow‐up periods of one and six months.

Thomas 2003 showed that the median (IQR) changes in overall asthma quality‐of‐life score at one month were 0.6 (IQR 0.05 to 1.12) and 0.09 (IQR −0.25 to 0.26) for the breathing retraining and education groups, respectively (P = 0.018) after one month. After six months, only the improvement in the activities domain of the AQLQ was clearly greater in the breathing retraining than in the education group (0.83 (IQR −0.10 to 1.71) and −0.05 (IQR −0.74 to 0.34), P = 0.018).

Thomas 2009 showed no clear between‐group differences in four subdomains, symptoms (MD 0.18, 95% −0.19 to 0.55, P = 0.34), activities (MD 0.10, 95% CI −0.22 to 0.43, P = 0.53), emotion (MD −0.07, 95% CI −0.46 to 0.32, P = 0.72), and environment (MD −0.10, 95% CI −0.46 to 0.25, P = 0.56), and for the total score of the AQLQ at up to three months' assessment (MD 0.04, 95% CI −0.26 to 0.34; 1 study, 183 participants; Analysis 2.1 ). From four to six months, there were greater improvements in the intervention group in terms of the subdomains of symptoms (P = 0.01), activities (P = 0.01) and emotions (P = 0.05) but not in the environment subdomain (P = 0.40) compared with controls, with a between‐group difference favouring the intervention group (P = 0.01) for the total score (MD 0.38, 95% CI 0.08 to 0.68; 1 study, 183 participants; Analysis 2.2 ).

Comparison 2 Breathing exercises versus asthma education, Outcome 1 Change in AQLQ (up to 3 months).

Comparison 2 Breathing exercises versus asthma education, Outcome 2 Change in AQLQ (4 to 6 months).

One study involving 183 participants assessed asthma symptoms ( Thomas 2009 ). Thomas 2009 carried out assessment of symptoms at baseline and one month and six months after the intervention which was inconclusive for the ACQ (MD −0.17, 95% CI −0.38 to 0.04, P = 0.12).

Two studies, involving 216 participants, used the Nijmegen Questionnaire to assess hyperventilation symptoms ( Thomas 2003 ; Thomas 2009 ). In Thomas 2003 , the between‐group difference favouring the intervention was statistically significant only after six months (median −9.50 (IQR −11.75 to 0), 1.00 (IQR −5.75 to 2), P = 0.01, breathing exercise and education group, respectively). We could not use data from Thomas 2003 in the meta‐analysis because only median and interquartile range were available. Thomas 2009 found no clear difference favouring the intervention group up to three months (MD −1.24, 95% CI −3.23 to 0.75; 1 study, 183 participants; Analysis 2.3 ), whereas a difference favoured the intervention group from four to six months (MD −3.16, 95% CI −5.35 to −0.97; 1 study; 183 participants; Analysis 2.4 ).

Comparison 2 Breathing exercises versus asthma education, Outcome 3 Nijmegen (up to 3 months).

Comparison 2 Breathing exercises versus asthma education, Outcome 4 Nijmegen (4 to 6 months).

Only one study assessed spirometric values ( Thomas 2009 ). This study assessed FEV 1 (L) and found no clear difference (MD −0.06 L, 95% CI −0.13 to 0.00; P = 0.07) between the intervention and control groups.

Thomas 2009 also assessed resting end‐tidal carbon dioxide concentration, showing that values for this outcome were uncertain within and between groups (MD 0.08 mmHg, 95% CI −0.15 to 0.30; P = 0.51).

Secondary outcomes: numbers of acute exacerbations, inpatient hospitalisation episodes, general practice (GP) appointments, days off work, and subjective evaluation of the intervention

Neither of these two studies reported these outcomes.

Summary of main results

This Cochrane Review assessed available evidence for the efficacy of breathing exercises in the treatment of adults with asthma. A total of 22 studies involving 2880 participants satisfied the inclusion criteria. Although these studies met the inclusion criteria, they differed in terms of intervention characteristics, such as type of breathing exercise, number of participants, number and duration of sessions, reported outcomes and statistical presentation of data. These differences limited the inclusion of several studies in our meta‐analyses.

We found a probable effect favouring the breathing exercises over inactive control in quality of life assessed by AQLQ up to three months. The mean difference for AQLQ showed in this review was slightly lower than the MCID of 0.5 ( Juniper 2004 ). For asthma symptoms, we found no clear difference between the breathing exercises and control group. However, the very large confidence interval includes both clinically relevant benefits and harm. We also found a probable effect for the breathing exercises over inactive control and asthma education in symptoms of hyperventilation, measured by the Nijimegen Questionnaire from four to six months. However, the MCID has not been established for the Nijmegen Questionnaire ( van Dixhoorn 2015 ). For lung function parameter, we found a possible effect for the breathing exercises over inactive control in FEV 1 % of predicted up to three months. No clear effect was found between breathing exercises and inactive control in FEV 1 (L) up to three months.

Overall completeness and applicability of evidence

Despite the broad spectrum of breathing exercises, the findings of this review were based on the techniques that were used in the included studies, which were some of the most commonly used techniques. Those studies included the Papworth method, Buteyko, diaphragmatic breathing, yoga and breathing retraining exercises. We found that breathing exercises showed some probable improvements in quality of life and hyperventilation symptoms. The types of delivery differed between face‐to‐face or by using an audio‐visual media self‐guided programme. The self‐guided programme is convenient and low‐cost ( Arden‐Close 2017 ). Some included studies involved group sessions in which participants were able to talk to each other and share their experiences. This can also be considered as a therapeutic procedure that may affect the sensation of well‐being ( Evans 1993 ). Awareness of participation in the study, the sensation of increased care and cure and the specialists' recommendations to continue regular asthma medication, and educational approaches are characteristics that must be considered when the findings of an experimental study are interpreted ( Grammatopoulou 2011 ).

Moreover, asthma severity of participants from the included studies ranged from mild to moderate, so it was not possible to assess the effects of breathing exercises on participants with severe asthma. The samples from studies consisted solely of outpatients. Besides that, three of the eight outcomes proposed by this review were not addressed: inpatient hospitalisation episodes, days off work and participants' subjective evaluation of the intervention.

The certainty of the evidence ranges from moderate to very low according to GRADE criteria and we have presented our GRADE judgements in the 'Summary of findings' table. We downgraded the evidence for quality of life due to one study being at high risk of bias for selective reporting. For the outcome asthma symptoms, we downgraded the certainty of evidence because we included in the analysis only one study with a small sample size, and that we considered to be at high risk of bias for selective reporting. We downgraded the certainty of evidence for symptoms of hyperventilation due to the small sample size and wide confidence interval presented. For the outcome lung function, we downgraded the certainty of evidence because the included studies showed in general a high risk of bias and small sample size.

Potential biases in the review process

Although we attempted to apply a systematic process for including and excluding studies in this review, alongside following the criteria prespecified in the protocol, with robust methods for data collection and 'Risk of bias' assessment, final decisions are open to interpretation or criticism. It is also not clear whether some of the participants in Agnihotri 2016 were included in the quality of life reporting in Agnihotri 2018 , so although there is no risk of double counting individuals for the outcomes, the total number of individuals studied may have been overstated.

Incomplete outcome data may be considered a potential source of bias of this review. It is difficult to quantify the impact of this potential bias as we were unable to enter the data from these studies into a meta‐analysis. Also related to meta‐analysis, sensitivity analysis was not possible because we were unable to obtain sufficient data. This would have allowed us to investigate possible effect modifiers such as degree of asthma severity, age groups and duration of treatment. Moreover, sensitivity analysis could have identified the influence of some factors (such as study quality and study size) on the results; thus, revealing the source of the substantial heterogeneity that we found among studies on quality of life and lung function.  

Agreements and disagreements with other studies or reviews

The current review update included nine new RCTs. Although there is a large number of available studies on this topic, it is important to emphasise that we found no recent or updated systematic review. A previous review performed by Bruurs 2013 assessed the effectiveness of breathing exercises as physiotherapy in the treatment of people with asthma. The outcomes assessed by Bruurs 2013 were based on those measures used in the Cochrane Reviews, Dennis 2000 and Holloway 2004 , which they classified as subjective and objective patient‐relevant outcomes for asthma. Bruurs 2013 reported improvement in quality of life and symptoms, and reduction of medication use, but the breathing exercises did not affect lung function. The findings of this current review update, based on meta‐analysis results, are consistent with the improvement in asthma symptoms favouring the breathing exercises groups. However, the review of Bruurs 2013 presented some methodological differences, regarding the age of participants and the inclusion of other types of physiotherapy, such as inspiratory muscle training, physical exercises, and airway clearance techniques. Moreover, Bruurs 2013 did not assess the risk of bias, perform meta‐analysis or assess the quality of the evidence. One Cochrane Review that assessed the effects of yoga in people with asthma analysed data from 15 RCTs, where five of them included yogic breathing alone and the other studies assessed yoga interventions that included breathing exercises, posture, and meditation ( Yang 2016 ). Similar to our findings, despite the limitations in the quality of the included studies, Yang 2016 found improvements in quality of life and symptoms of asthma.

Implications for practice

Breathing exercises may have positive effects on quality of life, hyperventilation symptoms, and lung function. Due to some methodological differences among included studies and studies with poor methodology, the certainty of evidence for the measured outcomes ranged from moderate to very low according to GRADE criteria. In addition, no data are available regarding the effects of breathing exercises on inpatient hospitalisation episodes, days off work and participants' subjective evaluation of the intervention.

Implications for research

Well conducted randomised controlled trials are still needed to assess the clinical benefit of breathing exercises in the management of asthma, including people with severe asthma, and those outcomes that were not assessed by the studies included in this review such as inpatient hospitalisation episodes, days off work and participants' subjective evaluation of the intervention. It is also important to emphasise the need for studies with a clear report of the sample age, asthma severity, and a specific description of the breathing exercise used rather than the combined interventions. As the Nijimegen Questionnaire is an important outcome‐reported measurement instrument to assess hyperventilation symptoms, further research is needed to determine a minimal clinically important difference for this questionnaire in people with asthma.

Researchers are encouraged to conduct studies to investigate in the asthma population the effects of other interventions that were not covered in this review, such as pursed‐lip breathing. The effects of the breathing exercises on different mechanisms (hyperventilation, breathing pattern disorders, cognitive and emotional factors related to biochemical, biomechanical and psychophysiological dimensions of dysfunctional breathing in asthma) should also be investigated. Furthermore, in the future, much more attention needs to be paid to good reporting and high‐quality study design, including items such as adequate random sequence generation and allocation concealment, blinding of outcome assessor and determination of the study sample size before the study is begun.

Protocol first published: Issue 4, 1998 Review first published: Issue 3, 2000

Acknowledgements

The review authors would like to thank Emma Dennett (the Managing Editor of Cochrane Airways) for providing assistance throughout the review process and Elizabeth Stovold (the Information Specialist of Cochrane Airways) for performing the search. We acknowledge the assistance of Christopher Cates in relation to the statistical support.

We would also like to thank all the study authors who responded to our enquiries.

The current review authors would like to thank Elizabeth Holloway for the development of the original review and her clinical expertise, and Selma S Bruno for her previous input into the development of the 2013 update of this review.

The review authors and Cochrane Airways editorial team are grateful to the following peer reviewers for their time and comments:

Amanda Roberts, UK (consumer);

Eleanor Fairbank, UK (consumer);

Negar Jamshidi, RMIT University, Australia (consumer);

Johannes C van der Wouden, Amsterdam UMC, Vrije Universiteit, The Netherlands; and

Alice Jones, The University of Sydney and The University of Queensland, Australia.

The Background and Methods sections of this review are based on a standard template used by Cochrane Airways.

This project was supported by the National Institute for Health Research (NIHR), via Cochrane Infrastructure funding to Cochrane Airways. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, NHS, or the Department of Health.

Appendix 1. Description of terms

Buteyko method is a breathing exercise that uses a combination of slow and reduced‐volume breathing with breath control and breath‐holding exercises to normalise the breathing pattern ( Bruton 2005 ; Courtney 2008 ). This method aims to help people normalise their breathing patterns and to avoid their tendency to hyperventilate ( Austin 2013 ; Chaitow 2014 ).

Diaphragmatic breathing emphasises the contraction of the diaphragm, expansion of the belly, and a deep inhale and exhale of breath ( Ma 2017 ). Initially, people should be trained in this technique by 'tactile stimulation' by placing the therapist's (or patient's) hand over the patient's abdomen and on the upper chest, and by 'visual stimulation' by looking at abdominal and chest movement. The patient should be in a comfortable and appropriate position, and the therapist must tell the patient to breathe deeply, and then exhale. During the inhale, the hand placed on the abdomen should rise. In the exhale, the patient should be instructed to actively contract their abdominal muscles. Pursed‐lip breathing can be included during the exhalation. Diaphragmatic breathing aims to improve ventilation and decrease the activity of the respiratory muscle by minimising the work of breathing ( Watchie 2010 ; Bandy 2012 ). This technique is also referred to as belly, deep or abdominal breathing ( Varvogli 2011 ; Ma 2017 ).

Papworth method is focused on a sequence of components that includes integrated breathing and relaxation exercises combined with education. This method aims to improve breathing patterns and minimise hyperventilation by using diaphragmatic breathing, with a slow nasal expiration ( Holloway 2007 ).

Spirometry is a non‐invasive physiological test that measures the maximal volume of air inspired and expired with maximal effort ( Graham 2019 ). The test can be performed by using a spirometer with different techniques. The person is asked to take a complete breath in, press their lips around a mouthpiece, then perform a full fast expiration, and follow with an inspiration. To ensure no air escape, a nose clip must be used. The spirometry test has been used to assess ventilatory function and as a tool to detect the presence of lung disease ( Barreiro 2004 ; Moore 2012 ). The forced vital capacity (FVC) is the total volume of air exhaled during a forced and complete expiration. The expiratory volume in the first second (FEV 1 ) is the volume of air exhaled in the first second under force after a maximal inhalation. The percentage of the FVC expired in one second is expressed as FEV 1 /FVC. The vital capacity (VC) is the total volume of air that can be exhaled as fast as possible. The forced expiratory flow (FEF), also known as mid‐expiratory flow, is the average flow that can be recorded at 25%, 50% and 75% of the FVC ( Graham 2019 ).

Yoga has been described as techniques used for relaxation and is known as therapy for mind and body improvements ( Bernardi 2000 ). Yoga includes a combination of body postures (asanas), breathing exercises (pranayamas or yogic breathing exercises), and meditation (dhyana) ( Riley 2004 ; Hakked 2017 ). Many yoga breathing exercises have been described in the literature. These exercises can have different pace (rate and depth of respiration), alteration of nostrils or breath‐hold, and they also combine abdominal, thoracic and clavicular breathing phases ( Muktibodhananda 2002 ; Lopes 2018 ).

Appendix 2. Sources and search methods for the Cochrane Airways Specialised Register (CAGR)

Electronic searches: core databases.

Handsearches: core respiratory conference abstracts

MEDLINE search strategy used to identify studies for the Cochrane Airways Specialised Register

Asthma search.

1. exp Asthma/

2. asthma$.mp.

3. (antiasthma$ or anti‐asthma$).mp.

4. Respiratory Sounds/

5. wheez$.mp.

6. Bronchial Spasm/

7. bronchospas$.mp.

8. (bronch$ adj3 spasm$).mp.

9. bronchoconstrict$.mp.

10. exp Bronchoconstriction/

11. (bronch$ adj3 constrict$).mp.

12. Bronchial Hyperreactivity/

13. Respiratory Hypersensitivity/

14. ((bronchial$ or respiratory or airway$ or lung$) adj3 (hypersensitiv$ or hyperreactiv$ or allerg$ or insufficiency)).mp.

15. ((dust or mite$) adj3 (allerg$ or hypersensitiv$)).mp.

16. or/1‐15

Filter to identify randomised controlled trials

1. exp "clinical trial [publication type]"/

2. (randomised or randomised).ab,ti.

3. placebo.ab,ti.

5. randomly.ab,ti.

6. trial.ab,ti.

7. groups.ab,ti.

8. or/1‐7

9. Animals/

10. Humans/

11. 9 not (9 and 10)

12. 8 not 11

The MEDLINE strategy and randomised controlled trial filter are adapted to identify studies in other electronic databases.

Appendix 3. Search strategy to identify relevant studies from the Cochrane Airways Specialised Register

Via the cochrane register of studies (crs).

#1 AST:MISC1 #2 MeSH DESCRIPTOR Asthma Explode All #3 asthma*:ti,ab #4 #1 or #2 or #3 #5 MeSH DESCRIPTOR Breathing Exercises #6 (breath*) NEAR5 (technique* or exercise* or re‐train* or train* or re‐educat* or educat* or physiotherap* or "physical therapy" or "respiratory therapy") #7 buteyko or "qigong yangsheng" or pranayama* OR yoga* #8 "breathing control" #9 #5 or #6 or #7 or #8 #10 #4 and #9

In search line #1, MISC1 denotes the field in the record where the reference has been coded for condition, in this case, asthma.

New search for studies and content updated (conclusions changed)

Data and analyses

Comparison 1.

Comparison 2

Characteristics of studies

Characteristics of included studies [ordered by study id].

ACT: Asthma Control Test; QOL: Asthma Quality of Life; AQLQ: Asthma Quality of Life Questionnaire; ATS: American Thoracic society; CNS: central nervous system; COPD: chronic obstructive airway disease; FEF25‐75: forced expiratory flow averaged over the middle portion of forced vital capacity; FENO: fraction of exhaled nitric oxide; FEV1: forced expiratory volume during the first second; FVC: forced vital capacity; GINA: global initiative for asthma; GP: general practitioner; HADS: Hospital Anxiety and Depression Scale; ICMR: Indian Council of Medical Research; ICS: inhalational corticosteroids; MMV: maximum voluntary ventilation; NAEPP: National Asthma Education and Prevention Program; NHS: National Health Service; NQ: Nijmegen (Hyperventilation) Questionnaire; PEFR: peak expiratory flow rate; QoL: quality of life; R&D: research and development; RCT: randomised controlled trial; SF‐36: 36‐Item Short Form; SGRQ: St George's Respiratory Questionnaire; SVC: slow vital capacity; TB: tuberculosis; VC: vital capacity

Characteristics of excluded studies [ordered by study ID]

COPD: chronic obstructive pulmonary disease; FET: forced expiratory technique; RCT: randomised controlled trial

Characteristics of studies awaiting assessment [ordered by study ID]

QoL: quality of life; RCT: randomised controlled trial

Characteristics of ongoing studies [ordered by study ID]

ACQ: Asthma Control Questionnaire; AQLQ: Asthma Quality of Life Questionnaire; ARCIM: Institute of Academic Research in Complementary and Integrative Medicine; ASF: Asthma Short Form; FEV1: forced expiratory volume in first second; GPE: Global perceived effect; HADS: Hospital Anxiety and Depression Scale: NQ: Nijmegen (Hyperventilation) Questionnaire; QoL: quality of life; RCT: randomised controlled trial; STAI: State‐Trait Anxiety Inventory

Differences between protocol and review

For the 2019 update, we have included one new author in the current version of this review. We have amended the 'Type of interventions' description, to make clearer that all participants assigned to treatment comprising breathing retraining were included. We included studies with participants with a mean age of over 18 years old, rather than studies enrolling only people aged over 18 years. We felt that the studies were reflective of a relevant, adult population. We have included an additional description regarding the age in the 'Type of participants' section. We have introduced the type of breathing exercise as a subgroup analyses criteria.

We included the change in asthma symptoms measured by asthma control questionnaire (ACQ), change in hyperventilation symptoms measured by the Nijmegen Questionnaire in the 'Summary of findings' table. We have added 'hyperventilation symptoms' as a complementary information to the original secondary outcome 'asthma symptoms'.

We initially stated that we used a fixed‐effect model unless there was substantial heterogeneity and for this 2019 update we used the random‐effects method, which considers that different studies are estimating different, yet related, intervention effects. We included a statement to make clearer that we used intention‐to‐treat analyses instead of per‐protocol/completer analyses, when both were reported.

Contributions of authors

Thayla Santino: selected the studies, assessed the risk of bias, entered data into Review Manager 5, interpreted data and drafted the final review.

Gabriela Chaves: extracted data, assessed the risk of bias, entered data into Review Manager 5, carried out the analysis, interpreted data and drafted the final review.

Diana Freitas: selected the studies, entered data into Review Manager 5, carried out the analysis, interpreted data and drafted the final review.

Guilherme Fregonezi: extracted data

Karla Mendonça: co‐ordinated the review, made an intellectual contribution, extracted data, assessed the risk of bias, interpreted data and drafted the final review.

Contributions of editorial team

Rebecca Fortescue (Co‐ordinating Editor): edited the review. Chris Cates (Co‐ordinating Editor) checked the data entry prior to the full write‐up of the review, advised on methodology, interpretation and content; approved the final review prior to publication. Anne Holland (Editor): edited the review; advised on methodology, interpretation and content. Emma Dennett (Managing Editor): co‐ordinated the editorial process; advised on interpretation and content; edited the review. Emma Jackson (Assistant Managing Editor): conducted peer review; edited the Plain language summary and reference sections of the protocol and the review. Elizabeth Stovold (Information Specialist): designed the search strategy; ran the searches; edited the search methods section.

Sources of support

Internal sources.

• The review authors declare that no such funding was received for this systematic review, Other.

External sources

TAS is a PhD scholarship holder funded by CAPES (Finance Code 001).

Declarations of interest

TAS: none known GSSC: none known DAF: none known GAFF: none known KMPPM: none known

References to studies included in this review

Aggarwal 2013 {published data only}.

• Aggarwal T, Khatri A, Siddiqui SS, Hasan SN, Deepankar, Kulshreshtha M, et al. Pranayama has additive beneficial effects along with medication in bronchial asthma patients . Journal of Physiology and Pharmacology Advances 2013; 3 ( 12 ):292‐7. [ Google Scholar ]

Agnihotri 2016 {published data only}

• Agnihotri S, Kant S, Kumar S, Mishra RK, Mishra SK. The assessment of effects of yoga on pulmonary functions in asthmatic patients: a randomized controlled study . Journal of Medical Society 2016; 30 ( 2 ):98‐102. [ Google Scholar ]

Agnihotri 2018 {published data only}

• Agnihotri S, Kant S, Mishra SK, Verma A. Assessment of significance of yoga on quality of life in asthma patients: a randomized controlled study . Ayu Journal 2017; 38 :28‐32. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Bidwell 2012 {published data only}

• Bidwell AJ, Yazel B, Davin D, Fairchild TJ, Kanaley JA. Yoga training improves quality of life in women with asthma . Journal of Alternative and Complementary Medicine 2012; 18 ( 8 ):749‐55. [ PubMed ] [ Google Scholar ]

Fluge 1994 {published data only}

• Fluge T, Ritcher H, Fabel H, Zysno E, Wehner E, Wagner IU. Long term effects of breathing exercises and yoga in patients with asthma [Langzeiteffekte von atemgymnastik und yoga bei patienten mit asthma bronchiale]. Pneumologie 1994; 48 :485‐90. [ PubMed ] [ Google Scholar ]

Girodo 1992 {published data only}

• Girodo M, Ekstrand KA, Metiver GJ. Deep diaphragmatic breathing: rehabilitation exercises for the asthmatic patient . Archives of Physiology, Medicine and Rehabilitation 1992; 73 :717‐20. [ PubMed ] [ Google Scholar ]

Grammatopoulou 2011 {published data only}

• Grammatopoulou EP, Skordilis EK, Stavrou N, Myrianthefs P, Karteroliotis K, Baltopoulos G, et al. The effect of physiotherapy‐based breathing retraining on asthma control . Journal of Asthma 2011; 48 ( 6 ):593‐601. [ PubMed ] [ Google Scholar ]

Gupta 2015 {published data only}

• Gupta N, Kumar A, Joshi HS, Sharma D. Effect of yoga on spirometric value in bronchial asthma patients . Global Journal for Research Analysis 2015; 4 ( 7 ):231‐3. [DOI: 10.15373/22778160] [ CrossRef ] [ Google Scholar ]

Holloway 2007 {published data only}

• Holloway EA, West RJ. Integrated breathing and relaxation training (the Papworth method) for adults with asthma in primary care: a randomised controlled trial . Thorax 2007; 62 ( 12 ):1039–42. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Malarvizhi 2018 {published data only}

• Malarvizhi M, Maheshkumar K, Bhavani H, Hariprasadd B. Effect of 6 months of yoga practice on quality of life among patient with asthma: a randomized control trial . Advances in Integrative Medicine 2018; 6 ( 4 ):163‐6. [ Google Scholar ]

Nagarathna 1985 {published data only}

• Nagarathna R, Nagendra HR. Yoga for bronchial asthma: a controlled study . British Medical Journal 1985; 291 :1077‐9. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Prasanna 2015 {published data only}

• Prasanna KB, Sowmiya KR, Dhileeban CM. Effect of Buteyko breathing exercise in newly diagnosed asthmatic patients . International Journal of Medicine and Public Health 2015; 5 ( 1 ):77‐81. [ Google Scholar ]

Prem 2013 {published data only}

• Prem V, Sahoo RC, Adhikari P. Comparison of the effects of Buteyko and pranayama breathing techniques on quality of life in patients with asthma: a randomized controlled trial . Clinical Rehabilitation 2013; 27 ( 2 ):133‐41. [ PubMed ] [ Google Scholar ]

Pushpa 2018 {published data only}

• Pushpa K, Sharma D. Yoga as a complementary therapy improves pulmonary functions in patients of bronchial asthma: a randomized controlled trial . National Journal of Physiology, Pharmacy and Pharmacology 2018; 8 ( 12 ):1704‐08. [ Google Scholar ]

Satpathy 2016 {published data only}

• Satpathy S, Kar A, Purohit KC, Manik R. A comparative study of effect of Yoga on symptoms and drug use in bronchial asthma . IOSR Journal of Dental and Medical Sciences 2016; 15 ( 8 ):41‐4. [DOI: 10.9790/0853-1508074144] [ CrossRef ] [ Google Scholar ]

Singh 2012 {published data only}

• Singh S, Soni R, Singh KP, Tandon OP. Effect of yoga practices on pulmonary function tests including transfer factor of lung for carbon monoxide (TLCO) in asthma patients . Indian Journal of Physiology and Pharmacology 2012; 56 ( 1 ):63‐8. [ PubMed ] [ Google Scholar ]

Sodhi 2009 {published and unpublished data}

• Sodhi C, Singh S, Bery A. Assessment of the quality of life in patients with bronchial asthma, before and after yoga: a randomised trial . Iranian Journal of Allergy, Asthma and Immunology 2014; 13 ( 1 ):55‐60. [ PubMed ] [ Google Scholar ]
• Sodhi C, Singh S, Dandona PK. A study of the effect of yoga training on pulmonary functions in patients with bronchial asthma . Indian Journal of Physiology and Pharmacology 2009; 53 ( 2 ):169‐74. [ PubMed ] [ Google Scholar ]

Thomas 2003 {published data only}

• Thomas M, McKinley RK, Freeman E, Foy C, Prodger P, Price D. Breathing retraining for dysfunctional breathing in asthma: a randomised controlled trial . Thorax 2003; 58 ( 2 ):110‐5. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Thomas 2009 {published data only}

• Thomas M, McKinley RK, Mellor S, Watkin G, Holloway E, Scullion J, et al. Breathing exercises for asthma: a randomised controlled trial . Thorax 2009; 64 ( 1 ):55‐61. [ PubMed ] [ Google Scholar ]

Thomas 2017 {published data only}

• Bruton A, Lee A, Yardley L, Raftery J, Arden‐Close E, Kirby S, et al. Physiotherapy breathing retraining for asthma: a randomised controlled trial . Lancet Respiratory Medicine 2017; 6 ( 1 ):19‐28. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Thomas M, Bruton A, Little P, Holgate S, Lee A, Yardley L, et al. A randomised controlled study of the effectiveness of breathing retraining exercises taught by a physiotherapist either by instructional DVD or in face‐to‐face sessions in the management of asthma in adults . Health Technology Assessment 2017; 21 ( 53 ):1‐162. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Vedanthan 1998 {published data only}

• Vedanthan PK, Kasavalu LN, Mutthy KC, Duvall K, Hall MJ, Baker S, et al. Clinical study of yoga techniques in university students with asthma: a controlled study . Allergy and Asthma Proceedings 1998; 19 ( 1 ):3‐9. [ PubMed ] [ Google Scholar ]

Vempati 2009 {published data only}

• Vempati R, Bijlani RL, Deepak KK. The efficacy of a comprehensive lifestyle modification programme based on yoga in the management of bronchial asthma: a randomized controlled trial . BMC Pulmonary Medicine 2009; 30 ( 9 ):10.1186/1471‐2466‐9‐37. [ PMC free article ] [ PubMed ] [ Google Scholar ]

References to studies excluded from this review

Aleksandrov 1990 {published data only}.

• Aleksandrov OV, Struchkov PV, Fedechkin VV, et al. The use of a respiratory regulator in the combined therapy of obstructive lung diseases . Terapevticheskii Arkhiv 1990; 62 :73‐75. [ PubMed ] [ Google Scholar ]

Anonymous 1968 {published data only}

• Anonymous. Hypnosis for asthma . British Medical Journal 1968; 4 :71‐6. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Asher 1990 {published data only}

• Asher MI, Douglas C, Airy M, Andrews D, Trenholme A. Effects of chest physical therapy on lung function in children recovering from acute severe asthma . Pediatric Pulmonology 1990; 3 ( 9 ):146‐51. [ PubMed ] [ Google Scholar ]

Berlowitz 1995 {published data only}

• Berlowitz D, Denehy L, Johns DP, Bish RM, Walters EH. The Buteyko asthma breathing technique [letter] . Medical Journal of Australia 1995; 162 ( 1 ):53. [ PubMed ] [ Google Scholar ]

Bobokhodzhaev 1984 {published data only}

• Bobokhodzhaev II, Rudoi DG, Bobkhodzhaev OI, Kovaleva IF, Vlasova IF. Effectiveness of the early inclusion of physical methods in the combined therapy of bronchial asthma [Russian]. Voprosy Kurortologii, Fizioterapii i Lechebnoi Fizicheskoi Kultury 1984; 1 :58‐9. [ PubMed ] [ Google Scholar ]

Bowler 1998 {published data only}

• Bowler SD, Green A, Mitchell CA. Buteyko breathing techniques in asthma: a blinded randomised controlled trial . Medical Journal of Australia 1998; 169 ( 11‐12 ):575‐8. [ PubMed ] [ Google Scholar ]

Cambach 1997 {published data only}

• Cambach W, Chadwick‐Straver RV, Wagenaar RC, Keimpema AR, Kemper HC. The effects of a community‐based pulmonary rehabilitation programme on exercise tolerance and quality of life: a randomized controlled trial . European Respiratory Journal 1997; 10 :104‐13. [ PubMed ] [ Google Scholar ]

Cambach 1999 {published data only}

• Cambach W, Wagenaar RC, Koelman TW, Keimpema T, Kemper HC. The long‐term effects of pulmonary rehabilitation in patients with asthma and chronic obstructive pulmonary disease: a research synthesis . Archives of Physical Medicine Rehabilitation 1999; 80 :103‐11. [ PubMed ] [ Google Scholar ]

Coll 1994 {published data only}

• Coll R, Tello A. Yoga in bronchial asthma letter [Yoga en el asma bronquial]. Archivos de Bronconeumologia 1994; 30 ( 7 ):369. [ PubMed ] [ Google Scholar ]

Cooper 2003 {published data only}

• Cooper S, Oborne J, Newton S, Harrison V, Thompson Coon J, Lewis S, et al. Effect of two breathing exercises (Buteyko and pranayama) in asthma: a randomised controlled trial . Thorax 2003; 58 ( 8 ):674‐9. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Cowie 2008 {published data only}

• Cowie RL, Conley DP, Underwood MF, Reader PG. A randomised controlled trial of the Buteyko technique as an adjunct to conventional management of asthma . Respiratory Medicine 2008; 102 ( 5 ):726‐32. [ PubMed ] [ Google Scholar ]

Emtner 1998 {unpublished data only}

• Emtner M. Rehabilitation of adults with asthma: a quantitative and qualitative Study (comprehensive summaries of Uppsala dissertations from the Faculty of Medicine) . Acta Universitatis Upsaliensis (1998), 1998. [ Google Scholar ]

Erskine 1979 {published data only}

• Erskine J, Schonell M. Relaxation therapy in bronchial asthma . Journal of Psychosomatic Research 1979; 23 :131‐9. [ PubMed ] [ Google Scholar ]

Falkenbach 1993 {published data only}

• Falkenbach A, Kirchner P, Richter R, Kaiser C, Schultze‐Werninghaus G, Meier‐Sydow J. The influence of a comprehensive respiratory therapy and educational program on the symptoms during metacholine‐induced acute airway obstruction in asthmatic adults . European Journal of Physical Medicine and Rehabilitation 1993; 3 ( 3 ):95‐100. [ Google Scholar ]

Gallefoss 1999 {published data only}

• Gallefoss F, Bakke PS, Kjaersgaard P. Quality of life assessment after patient education in a randomised controlled study on asthma and chronic obstructive pulmonary disease . American Journal of Respiratory and Critical Care Medicine 1999; 159 :812‐7. [ PubMed ] [ Google Scholar ]

Gosselink 1993 {published data only}

• Gosselink HA, Wagenaar RC. Efficacy of breathing exercises in chronic obstructive pulmonary disease and asthma . Journal of Rehabilitation Sciences 1993; 6 :66‐79. [ Google Scholar ]

Hoang 2015 {published data only}

• Hoang KA, Nguyen HM. The effectiveness of practicing pranayama yoga on some respiratory indicators in patients suffering from bronchial disease . International Journal of Science Culture and Sport 2015; 3 ( 2 ):6‐12. [ Google Scholar ]

Holmes 1990 {published data only}

• Holmes P. An air of hope . Nursing Times 1990; 86 ( 33 ):21. [ PubMed ] [ Google Scholar ]

Johansson 2017 {published data only}

• Johansson EL, Ternestén‐Hasseus E, Olsén MF, Millgvist E. Physical therapy treatment impaired chest mobility in patients with airway sensory hyperreactivity . Physiotherapy Research International 2017; 22 ( 2 ):e1658. [ PubMed ] [ Google Scholar ]

Joseph 1999 {published data only}

• Joseph CL, Foxman B, Leickly FE, Peterson E, Ownby D. Sensitivity and specificity of asthma definitions and symptoms used in a survey of childhood asthma . Journal of Asthma 1999; 36 ( 7 ):565‐73. [ PubMed ] [ Google Scholar ]

Karam 2017 {published data only}

• Karam M, Kaur BP, Baptist AP. A modified breathing exercise program for asthma is easy to perform and effective . Journal of Asthma 2017; 54 ( 2 ):217‐22. [ PubMed ] [ Google Scholar ]

Khanam 1996 {published data only}

• Khanam AA, Sachdevaq U, Guleria R, Deepak KK. Study of pulmonary and autonomic functions of asthma patients after yoga training . Indian Journal of Physiology and Pharmacology 1996; 40 ( 4 ):318‐24. [ PubMed ] [ Google Scholar ]

Kotses 1978 {published data only}

• Kotses H, Glaus KD, Bricel SK, Edwards JE, Crawford PL. Operant muscular relaxation and peak expiratory flow rate in asthmatic children . Journal of Psychosomatic Research 1978; 22 :17‐23. [ PubMed ] [ Google Scholar ]

Kurabayashi 1998 {published data only}

• Kurabayashi H, Machida I, Handa H, Akiba T, Kubota K. Comparison of three protocols for breathing exercises during immersion in 38C water for chronic obstructive pulmonary disease . American Journal of Physical Medicine Rehabilitation 1998; 77 ( 2 ):145‐8. [ PubMed ] [ Google Scholar ]

Lacasse 1997 {published data only}

• Lacasse Y, Guyatt GH, Goldstein RS. The components of a respiratory rehabilitation program . Chest 1997; 111 :1077‐88. [ PubMed ] [ Google Scholar ]

Loew 1996 {published data only}

• Loew TH, Siegfried W, Martus P, Tritt K, Hahn EG. 'Functional relaxation' reduces acute airway obstruction in asthmatics as effectively as inhaled terbutaline . Psychotherapy and Psychosomatics 1996; 65 :124‐8. [ PubMed ] [ Google Scholar ]

Manocha 2002 {published data only}

• Manocha R, Marks GB, Kenchington P, Peters D, Salome CM. Sahaja yoga in the management of moderate to severe asthma: a randomised controlled trial . Thorax 2002; 57 :110‐5. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Mass 1991 {published data only}

• Mass R, Harden H, Leplow B, Wessel M, Richter R, Dahme B. A device for functional residual capacity controlled biofeedback of respiratory resistance [Ein messaufbau zur ruckmeldung des atemwiderstandes unter kontrolle der funktionellen residualkapazitat]. Biomedizinische Technik 1991; 36 ( 4 ):78‐85. [ PubMed ] [ Google Scholar ]

McFadden 1986 {published data only}

• McFadden ER Jr, Lenner KA, Strohl KP. Postexertional airway rewarming and thermally induced asthma . Journal of Clinical Investigation 1986; 78 :18‐25. [ PMC free article ] [ PubMed ] [ Google Scholar ]

McHugh 2003 {published data only}

• McHugh P, Aitcheson F, Duncan B, Houghton F. Buteyko breathing technique for asthma: an effective intervention . New Zealand Medical Journal 2003; 116 ( 1187 ):U710. [ PubMed ] [ Google Scholar ]

Mussell 1986 {published data only}

• Mussell MJ. Trachea noise biofeedback device to help reduce bronchospasm in asthmatics . Journal of Biomedical Engineering 1986; 8 :341‐4. [ PubMed ] [ Google Scholar ]

Opat 2000 {published data only}

• Opat AJ, Cohen MM, Bailey MJ, Abramson MJ. A clinical trial of the Buteyko breathing technique in asthma as taught by a video . Journal of Asthma 2000; 37 ( 7 ):557‐64. [ PubMed ] [ Google Scholar ]

Paleev 1988 {published data only}

• Paleev NR, Tsar Kova LN, Chenko VA. Anti‐recurrence treatment of bronchial asthma and chronic bronchitis [Russian]. Klinicheskaia Meditsina 1988; 66 ( 12 ):15‐21. [ PubMed ] [ Google Scholar ]

Pryor 1979 {published data only}

• Pryor J, Webber BA. An evaluation of the forced expiration technique as an adjunct to postural drainage . Physiotherapy 1979; 65 ( 10 ):304‐7. [ PubMed ] [ Google Scholar ]

Raghavendra 2016 {published data only}

• Raghavendra P, Shetty P, Shetty S, Manjunath NK, Saoji AA. Effect of high‐frequency yoga breathing on pulmonary functions in patients with asthma . Annals of Allergy, Asthma and Immunology 2016; 117 ( 5 ):550–1. [ PubMed ] [ Google Scholar ]

Redchits 1986 {published data only}

• Redchits IV, Treumova SI. Effectiveness of the differential treatment of bronchial asthma patients on the southern coast of the Crimea . Voprosy Kurortologii, Fizioterapii, i Lechebnoi Fizicheskoi Kultury 1986; 4 :54‐6. [ PubMed ] [ Google Scholar ]

Sabina 2005 {published data only}

• Sabina AB, Williams A‐L, Wall HK, Bansal S, Chupp G, Katz DL. Yoga intervention for adults with mild‐to‐moderate asthma: a pilot study . Annals of Allergy, Asthma and Immunology 2005; 94 ( 5 ):543‐8. [ PubMed ] [ Google Scholar ]

Saxena 2009 {published data only}

• Saxena T, Saxena M. The effect of various breathing exercises (pranayama) in patients with bronchial asthma of mild to moderate severity . International Journal of Yoga 2009; 2 ( 1 ):22‐5. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Schulze 2000 {published data only}

• Schulze J, Riel B, Fischer S, Lecheler J, Hofmann D. Improvement of the quality of life by asthma training [Verbesserung der Lebensqualität durch Asthmaschulung]. Pravent‐Rehabil 2000; 12 ( 3 ):91‐8. [ Google Scholar ]

Shaw 2011 {published data only}

• Shaw BS, Shaw I. Static standing posture and pulmonary function in moderate‐persistent asthmatics following aerobic and diaphragmatic breathing training . Pakistan Journal of Medical Sciences 2011; 27 ( 3 ):549‐52. [ Google Scholar ]

Singh 1987 {published data only}

• Singh V. Effect of respiratory exercises on asthma . Journal of Asthma 1987; 24 ( 6 ):355‐9. [ PubMed ] [ Google Scholar ]

Singh 1990 {published data only}

• Singh V, Wisniewski A, Britton J, Tattersfield A. Effect of yoga breathing exercises (pranayama) on airway reactivity in subjects with asthma . Lancet 1990; 335 :1381‐3. [ PubMed ] [ Google Scholar ]

Slader 2006 {published data only}

• Slader CA, Reddel HK, Spencer LM, Belousova EG, Armour CL, Bosnic‐Anticevich SZ, et al. Double blind randomised controlled trial of two different breathing techniques in the management of asthma . Thorax 2006; 61 ( 2 ):651‐6. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Smyth 1999 {published data only}

• Smyth JM, Soeffer MH, Hurewitz A, Stone AA. The effect of tape recorded relaxation training on well being symptoms, and peak expiratory flow rate in adult asthmatics: a pilot study . Psychology and Health 1999; 14 :487‐501. [ Google Scholar ]

Tandon 1978 {published data only}

• Tandon MK. Adjunct treatment with yoga in chronic severe airways obstruction . Thorax 1978; 33 :514‐7. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Van der Schans 1997 {published data only}

• Schans CP, Jong W, Vries G, Postma DS, Koeter GH, Mark TW. Respiratory muscle activity and pulmonary function during acutely induced airways obstruction . Physiotherapy Research International 1997; 2 ( 3 ):167‐94. [ PubMed ] [ Google Scholar ]

Weiner 1992 {published data only}

• Weiner MD, Azgad Y, Ganem R, Weiner M. Inspiratory muscle training in patients with bronchial asthma . Chest 1992; 102 ( 5 ):1357‐61. [ PubMed ] [ Google Scholar ]

Wilson 1975 {published data only}

• Wilson AF, Honsberger R, Chiu JT, Novey HS. Transcendental meditation and asthma . Respiration 1975; 32 :74‐80. [ PubMed ] [ Google Scholar ]

References to studies awaiting assessment

Agnihotri 2013 {published data only}.

• Agnihotri S. Significance of yoga in asthma management to improve the status of quality of life . European Journal of Allergy and Clinical Immunology. Conference: European Academy of Allergy and Clinical Immunology and World Allergy Organization World Allergy and Asthma Congress 2013 . Milan, Italy, 2013; Vol. 68:378.

Divya 2013 {published data only}

• Divya, Kusumadevi MS, Veeriah S. Effect of yoga training on airway resistance and specific airway conductance in patients of bronchial asthma . Indian Journal of Physiology and Pharmacology. Conference: 59th Annual Conference of Association of Physiologists and Pharmacologists of India, APPI 2013 . Bengaluru, India, 2013; Vol. 57 (5 SUPPL. 1):126‐127.

Kant 2013 {published data only}

• Kant K, Agnihotri S. Asthma diagnosis and treatment – 1029. Yoga as an adjuvant therapy in asthma management . World Allergy Organization Journal 2013; 6 ( 1 ):P28. [ Google Scholar ]

References to ongoing studies

Andreasson 2017 {unpublished data only}.

• Andreasson KH, Bødtger U, Skou ST, et al. Breathing Exercises in Asthma Targeting Dysfunctional Breathing . Clinical Trials 2017.

Elahi 2016   {unpublished data only}

• Elahi N. Effect of breathing exercises on indicators of clinical,spirometric parameters and quality of life of patientswith asthma reffered to Allergic Asthma clinic ofImam Khomeini in Ahwaz. . Iranian Registry of Clinical Trials 2016.

Murthy 2010 {unpublished data only}

• Murthy. Effect of naturopathy interventions in bronchial asthma . 2010.

Vagedes 2017 {unpublished data only}

• Vagedes J. Effectiveness of a Buteyko‐based Breathing Technique for Asthma Patients . Clinical Trials 2017.

Additional references

Arden‐close 2017.

• Arden‐Close E, Yardley L, Kirby S, Thomas M, Bruton A. Patients' experiences of breathing retraining for asthma: a qualitative process analysis of participants in the intervention arms of the BREATHE trial . NPJ Primary Care Respiratory Medicine 2017; 27 ( 1 ):56. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Arun JJ, Lodha R, Kabra SK. Bronchodilatory effect of inhaled budesonide/formoterol and budesonide/salbutamol in acute asthma: a double‐blind, randomized controlled trial . BMC Pediatrics 2012; 12 :21. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Austin 2013

• Austin G. Buteyko technique use to control asthma symptoms . Nursing Times 2013; 109 ( 16 ):16‐7. [ PubMed ] [ Google Scholar ]

Bailey 2016

• Bailey NW, Bridgman TK, Marx W, Fitzgerald PB. Asthma and mindfulness: an increase in mindfulness as the mechanism of action behind breathing retraining techniques? . Mindfulness 2016; 7 ( 6 ):1249–55. [ Google Scholar ]
• Bandy WD, Sanders B. Therapeutic exercise for physical therapy assistants: techniques for intervention . 3. Philadelphia: Wolters Kluwer: Lippincott Williams & Wilkins, 2012. [ Google Scholar ]

Barreiro 2004

• Barreiro TJ, Perillo I. An approach to interpreting spirometry . American Family Physician 2004; 69 ( 5 ):1107‐14. [ PubMed ] [ Google Scholar ]

Bateman 2008

• Bateman ED, Hurd SS, Barnes PJ, Bousquet J, Drazen JM, FitzGerald M. Global strategy for asthma management and prevention: GINA executive summary . European Respiratory Journal 2008; 31 ( 1 ):143‐78. [ PubMed ] [ Google Scholar ]

Beasley 2016

• Beasley R, Hancox RJ, Harwood M, Perrin K, Poot B, Pilcher J, et al. Asthma and respiratory foundation NZ adult asthma guidelines: a quick reference guide . New Zealand Medical Journal 2016; 129 ( 1445 ):83‐102. [ PubMed ] [ Google Scholar ]

Bernardi 2000

• Bernardi L, Wdowczyk‐Szulc J, Valenti C, Castoldi S, Passino C, Spadacini G, et al. Effects of controlled breathing, mental activity and mental stress with or without verbalization on heart rate variability . Journal of the American College of Cardiology 2000; 35 ( 6 ):1462‐9. [ PubMed ] [ Google Scholar ]
• Blanc PD, Trupin L, Earnest G, Katz PP, Yelin EH, Eisner MD. Alternative therapies among adults with a reported diagnosis of asthma or rhinosinusitis: data from a population‐based survey . Chest 2001; 120 ( 5 ):1461‐7. [ PubMed ] [ Google Scholar ]

Boulding 2016

• Boulding R, Stacey R, Niven R, Fowler SJ. Dysfunctional breathing: a review of the literature and proposal for classification . European Respiratory Review 2016; 25 ( 141 ):287‐94. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Braido 2013

• Braido F. Failure in asthma control: reasons and consequences . Hindawi Scientifica 2013; 2013 :549252. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Brightling 2012

• Brightling CE, Gupta S, Gonem S, Siddiqui S. Lung damage and airway remodelling in severe asthma . Clinical and Experimental Allergy 2012; 42 ( 5 ):638‐49. [ PubMed ] [ Google Scholar ]

Bruton 2005

• Bruton A, Lewith GT. The Buteyko breathing technique for asthma: a review . Complementary Therapies in Medicine 2005; 13 ( 1 ):41‐6. [ PubMed ] [ Google Scholar ]

Bruurs 2013

• Bruurs ML, Giessen LJ, Moed H. The effectiveness of physiotherapy in patients with asthma: a systematic review of the literature . Respiratory Medicine 2013; 107 ( 4 ):483‐94. [ PubMed ] [ Google Scholar ]

Burgess 2011

• Burgess J, Ekanayake B, Lowe A, Dunt D, Thien F, Dharmage SC. Systematic review of the effectiveness of breathing retraining in asthma management . Expert Review of Respiratory Medicine 2011; 5 ( 6 ):789‐807. [ PubMed ] [ Google Scholar ]

Chaitow 2014

• Chaitow L, Gilbert C, Morrison D. Recognizing and treating breathing disorders: a multidisciplinary approach . 2nd Edition. Elsevier Health Sciences, 2014. [ Google Scholar ]

Courtney 2008

• Courtney R. Strengths, weaknesses, and possibilities of the Buteyko breathing method . Biofeedback 2008; 36 ( 2 ):59‐63. [ Google Scholar ]

Courtney 2017

• Courtney R. Breathing training for dysfunctional breathing in asthma: taking a multidimensional approach . ERJ Open Research 2017; 3 ( 4 ):00065‐2017. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Courtney 2019

• Courtney R, Biland G, Ryan A, Grace S, Gordge R. Improvements in multi‐dimensional measures of dysfunctional breathing in asthma patients after a combined manual therapy and breathing retraining protocol: a case series report . International Journal of Osteopathic Medicine 2019; 31 :36‐43. [ Google Scholar ]
• Deeks JJ, Higgins JP, Altman DG (editors), on behalf ofthe Cochrane Statistical Methods Group. Chapter 9: Analysing data and undertaking meta‐analyses. In: Higgins JPT, Churchill R, Chandler J, Cumpston MS (editors), Cochrane Handbook for Systematic Reviews of Interventions version 5.2.0 (updated June 2017), Cochrane, 2017 . Available from www.training.cochrane.org/handbook .

Denehy 2016

• Denehy L, Main E. Cardiorespiratory physiotherapy: adults and paediatrics . 5th Edition. Elsevier, 2016. [ Google Scholar ]

Dennis 2000

• Dennis JA, Cates CJ. Alexander technique for chronic asthma . Cochrane Database of Systematic Reviews 2000, Issue 2 . [DOI: 10.1002/14651858.CD000995] [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Dennis 2012

• Dennis JA, Cates CJ. Alexander technique for chronic asthma . Cochrane Database of Systematic Reviews 2013, Issue 9 . [DOI: 10.1002/14651858.CD000995.pub2] [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

DerSimonian 1986

• DerSimonian R, Laird N. Meta‐analysis in clinical trials . Controlled Clinical trials 1986; 7 ( 3 ):177‐88. [ PubMed ] [ Google Scholar ]

Eisner 2012

• Eisner MD, Yegin A, Trzaskoma B. Severity of asthma score predicts clinical outcomes in patients with moderate to severe persistent asthma . Chest 2012; 141 ( 1 ):58‐65. [ PubMed ] [ Google Scholar ]

Enright 2004

• Enright PL, Beck K, Sherrill DL. Repeatability of spirometry in 18,000 adult patients . American Journal of Respiratory and Critical Care Medicine 2004; 169 ( 2 ):235‐8. [ PubMed ] [ Google Scholar ]
• Evans D. To help patients control asthma the clinician must be a good listener and teacher . Thorax 1993; 48 ( 7 ):685‐7. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Giavina‐Bianchi 2010

• Giavina‐Bianchi P, Aun MV, Bisaccioni C, Agondi R, Kalil J. Difficult‐to‐control asthma management through the use of a specific protocol . Clinics 2010; 65 ( 9 ):905‐18. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Gillis 2017

• Gillis RM, Van Litsenburg, Balkom WR, Muris JW, Smeenk FW. The contribution of an asthma diagnostic consultation service in obtaining an accurate asthma diagnosis for primary care patients: results of a real‐life study . NPJ Primary Care Respiratory Medicine 2017; 27 ( 1 ):35. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention 2018 . ginasthma.org/ (accessed 2 April 2018).

GRADEpro GDT [Computer program]

• McMaster University (developed by Evidence Prime). GRADEpro GDT . Version accessed 01 August 2018. Hamilton (ON): McMaster University (developed by Evidence Prime).

Graham 2019

• Graham BL, Steenbruggen I, Miller MR, Barjaktarevic IZ, Cooper BG, Hall GL, et al. Standardization of spirometry 2019 update. An official American Thoracic Society and European Respiratory Society technical statement . American Journal of Respiratory and Critical Care Medicine 2019; 200 ( 8 ):e70‐e88. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Grammatopoulou 2014

• Grammatopoulou EP, Skordilis EK, Georgoudis G, Haniotou A, Evangelodimou A, Fildissis G, et al. Hyperventilation in asthma: a validation study of the Nijmegen Questionnaire‐‐NQ . Journal of Asthma 2014; 51 ( 8 ):839‐46. [ PubMed ] [ Google Scholar ]

Hakked 2017

• Hakked CS, Balakrishnan R, Krishnamurthy MN. Yogic breathing practices improve lung functions of competitive young swimmers . Journal of Ayurveda and Integrative Medicine 2017; 8 ( 2 ):99‐104. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Higgins 2011

• Higgins JP, Deeks JJ. Chapter 7: Selecting studies and collecting data. In: Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011 . www.cochrane‐handbook.org .

Higgins 2017

• Higgins JP, Altman DG, Sterne JA (editors). Chapter 8: Assessing risk of bias in included studies. In: Higgins JPT, Churchill R, Chandler J, Cumpston MS (editors), Cochrane Handbook for Systematic Reviews of Interventions version 5.2.0 (updated June 2017), Cochrane, 2017 . Available from www.training.cochrane.org/handbook .
• James DR, Lyttle MD. British guideline on the management of asthma: SIGN Clinical Guideline . Archives of Disease in Childhood: Education & Practice 2016; 101 ( 6 ):319‐22. [ PubMed ] [ Google Scholar ]
• Jones PW. Interpreting thresholds for a clinically significant change in health status in asthma and COPD . European Respiratory Journal 2002; 19 ( 3 ):398‐404. [ PubMed ] [ Google Scholar ]

Juniper 2004

• Juniper EF, Wisniewski ME, Cox FM, Emmett AH, Nielsen KE, O'Byrne PM. Relationship between quality of life and clinical status in asthma: a factor analysis . European Respiratory Journal 2004; 23 ( 2 ):287‐91. [ PubMed ] [ Google Scholar ]

Juniper 2005

• Juniper EF, Svensson K, Mork AC, Stahl E. Measurement properties and interpretation of three shorted versions of the asthma control questionnaire . Respiratory Medicine 2005; 99 ( 5 ):553‐8. [ PubMed ] [ Google Scholar ]
• Kew KM, Cates CJ. Home telemonitoring and remote feedback between clinic visits for asthma . Cochrane Database of Systematic Reviews 2016, Issue 8 . [DOI: 10.1002/14651858.CD011714.pub2] [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Lavoie 2005

• Lavoie KL, Cartier A, Labrecque M, Bacon SL, Lemière C, Malo JL, et al. Are psychiatric disorders associated with worse asthma control and quality of life in asthma patients? . Respiratory Medicine 2005; 99 ( 10 ):1249‐57. [ PubMed ] [ Google Scholar ]
• Lopes CP, Danzmann LC, Moraes RS, Vieira PJ, Meurer FF, Soares DS. Yoga and breathing technique training in patients with heart failure and preserved ejection fraction: study protocol for a randomized clinical trial . Trials 2018; 19 ( 1 ):405. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Ma X, Yue ZQ, Gong ZQ, Zhang H, Duan NY, Shi YT, et al. The effect of diaphragmatic breathing on attention, negative affect and stress in healthy adults . Frontiers in Psychology 2017; 8 :874. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Mark JD, Chung Y. Complementary and alternative medicine in pulmonology . Current Opinion in Pediatrics 2015; 27 ( 3 ):334‐40. [ PubMed ] [ Google Scholar ]
• Moher D, Liberati A, Tetzlaff J, Altman DG. The PRISMA Group. Preferred reporting items for systematic reviews and meta‐analyses: the PRISMA Statement . BMJ 2009; 339 :b2535. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Moore VC. Spirometry: step by step . Breathe 2012; 8 ( 3 ):232‐40. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Morgan 2002

• Morgan MD. Dysfunctional breathing in asthma: is it common, identifiable and correctable? . Thorax 2002; 57 ( Suppl II ):ii31‐ii35. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Muktibodhananda 2002

• Muktibodhananda S. Hatha yoga pradipika: light on hatha yoga . 2. Bihar: Yoga Publication Trust, 2002. [ Google Scholar ]

National Asthma Council Australia 2016

• National Asthma Council Australia. Australian Asthma Handbook . www.asthmahandbook.org.au/diagnosis/adults (accessed 21 August 2018).
• Nunes C, Pereira AM, Morais‐Almeida M. Asthma costs and social impact . Asthma Research and Practice 2017; 3 :1. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• Ram FS, Holloway EA, Jones PW. Breathing retraining for asthma . Respiratory Medicine 2003; 97 ( 5 ):501‐7. [ PubMed ] [ Google Scholar ]

Review Manager 2014 [Computer program]

• Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager 5 (RevMan 5) . Version 5.3. Copenhagen: Nordic Cochrane Centre, The Cochrane Collaboration, 2014.
• Riley D. Hatha yoga and the treatment of illness . Alternative Therapies in Health and Medicine 2004; 10 ( 2 ):20‐1. [ PubMed ] [ Google Scholar ]

Rimington 2001

• Rimington LD, Davies DH, Lowe D, Pearson MG. Relationship between anxiety, depression, and morbidity in adult asthma patients . Thorax 2001; 56 ( 4 ):266‐71. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Sankar 2018

• Sankar J, Das RR. Asthma ‐ a disease of how we breathe: role of breathing exercises and pranayama . Indian Journal of Pediatrics 2018; 85 ( 10 ):905‐10. [ PubMed ] [ Google Scholar ]

Sterne 2017

• Sterne JA, Egger M, Moher D, Boutron I (editors). Chapter 10: Addressing reporting biases. In: Higgins JPT, Churchill R, Chandler J, Cumpston MS (editors), Cochrane Handbook for Systematic Reviews of Interventions version 5.2.0 (updated June 2017), Cochrane, 2017 . Available from www.training.cochrane.org/handbook .
• Sveum R, Bergstrom J, Brottman G, Hanson M, Heiman M, Johns K, et al. Institute for Clinical Systems Improvement. Diagnosis and management of asthma. Updated July 2012 . www.icsi.org/_asset/rsjvnd/Asthma‐Interactive0712.pdf (accessed 23 September 2013).

Tepper 2012

• Tepper RS, Wise RS, Covar R, Irvin CG, Kercsmar CM, Kraft M, et al. Asthma outcomes: pulmonary physiology . Journal of Allergy Clinical Immunology 2012; 129 ( 30 ):S65–S87. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Thomas 2001

• Thomas M, McKinley RK, Freeman E, Foy C. Prevalence of dysfunctional breathing in patients treated for asthma in primary care: cross sectional survey . BMJ 2001; 322 ( 7294 ):1098‐100. [ PMC free article ] [ PubMed ] [ Google Scholar ]
• To T, Stanojevic S, Moores G, Gershon AS, Bateman ED, Cruz AA, et al. Global asthma prevalence in adults: findings from the cross‐sectional world health survey . BMC Public Health 2012; 12 :204. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Torres‐Llenza 2010

• Torres‐Llenza V, Bhogal S, Davis M, Ducharme F. Use of complementary and alternative medicine in children with asthma . Canadian Respiratory Journal 2010; 17 ( 4 ):183–9. [ PMC free article ] [ PubMed ] [ Google Scholar ]

van Dixhoorn 2015

• Dixhoorn J, Folgering H. The Nijmegen Questionnaire and dysfunctional breathing . ERJ Open Research 2015; 1 ( 1 ):00001‐2015. [DOI: 10.1183/23120541.00001-2015] [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Varvogli 2011

• Varvogli L, Darviri C. Stress management techniques: evidence‐based procedures that reduce stress and promote health . Health Science Journal 2011; 5 ( 2 ):74‐89. [ Google Scholar ]

Veidal 2017

• Veidal S, Jeppegaard M, Sverrild A, Backer V, Porsbjerg C. The impact of dysfunctional breathing on the assessment of asthma control . Respiratory Medicine 2017; 123 :42‐7. [ PubMed ] [ Google Scholar ]

Vidotto 2019

• Vidotto LS, Carvalho CR, Harvey A, Jones M. Dysfunctional breathing: what do we know? . Jornal Brasileiro de Pneumologia 2019; 45 ( 1 ):e20170347. [ PMC free article ] [ PubMed ] [ Google Scholar ]

Watchie 2010

• Watchie J. Cardiovascular and pulmonary physical therapy: a clinical manual . 2. Saunders Elsevier, 2010. [ Google Scholar ]
• Welsh EJ, Hasan M, Li P. Home‐based educational interventions for children with asthma . Cochrane Database of Systematic Reviews 2011, Issue 10 . [DOI: 10.1002/14651858.CD008469.pub2] [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• World Health Organization. Asthma fact sheets . www.who.int/en/news‐room/fact‐sheets/detail/asthma (accessed 2 April 2018).
• Yang ZY, Zhong HB, Mao C, Yuan JQ, Huang YF, Wu XY, et al. Yoga for asthma . Cochrane Database of Systematic Reviews 2016, Issue 4 . [DOI: 10.1002/14651858.CD010346] [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]
• Zhang X, Köhl J. A complex role for complement in allergic asthma . Expert Review of Clinical Immunology 2010; 6 ( 2 ):269‐77. [ PMC free article ] [ PubMed ] [ Google Scholar ]

References to other published versions of this review

Freitas 2013.

• Freitas DA, Holloway EA, Bruno SS, Chaves GS, Fregonezi GA, Mendonça KM. Breathing exercises for adults with asthma . Cochrane Database of Systematic Reviews 2013, Issue 10 . [DOI: 10.1002/14651858.CD001277.pub3] [ PubMed ] [ CrossRef ] [ Google Scholar ]

Holloway 2004

• Holloway E, Ram FS. Breathing exercises for asthma . Cochrane Database of Systematic Reviews 2004, Issue 1 . [DOI: 10.1002/14651858.CD001277.pub2] [ PubMed ] [ CrossRef ] [ Google Scholar ]

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The Effect of Cardiopulmonary Physiotherapy and Sports Physiotherapy on Asthma Control: Case Study

Theeb Naif S Alsalem 1* , Faisal Saadoon F Alenzy 2 and Turki Menwer J Almuhaid 3

1 Physiotherapist, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia

2 Physiotherapist, Prince Sultan Military Medical City, Riyadh, Saudi Arabia

3 Physiotherapist, Prince Mohammed Bin Abdulaziz Hospital, Riyadh, Saudi Arabia

* Corresponding author:  Theeb Naif S Alsalem, Physiotherapist, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia.

Citation: Alsalem TNS, Alenzy FSF, Almuhaid TMJ. (2022) The Effect of Cardiopulmonary Physiotherapy and Sports Physiotherapy on Asthma Control: Case Study. J Neurol Sci Res. 2(2):1-26.

Received: June 02, 2022 | Published: June 20, 2022

Copyright ©️ 2022 genesis pub by Alsalem TNS, et al.  CC BY-NC-ND 4.0 DEED. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives 4.0  International License. This allows others distribute, remix, tweak, and build upon the work, even commercially, as long as they credit the authors for the original creation.

DOI:  http://doi.org/10.52793/JNSR.2022.2(2)-16

Introduction: The World Health Organization estimations show 235 million people who currently suffer from asthma, and the numbers of asthma deaths are increasing in the next 10 years. Asthma is a chronic disease characterized by intermittent attacks of breathlessness that is triggered by the allergies and cold air commonly. Asthma is well known disease to restrict physical activity, although exercising is one of the ways to manage the disease and minimize the symptoms and attacks. Methods: Twelve weeks program and each week consist of aerobic training twice, a swimming session, Inspiratory Muscle Training session, breathing exercises and Yoga session in every second week, the patient was introduced to Buteyko Technique as home exercises. The patient was asked to avoid all the allergies (Triggers). The patient was assessed on baseline and on the end of the program using the lung function test and Asthma Control Questionnaires (ACQ). Discussion: The patient completed the entire program chosen for him and the baseline assessment showed that the patient suffered from symptoms such as coughing and chest tightness especially at night. The lung function test showed improvement on the FEV1 predicted from the baseline (85%) and after the program assessment (92%) with an increase of 7%. The asthma control questionnaires showed also an improvement as the score at the baseline was 2.28 and after the program it is 1.14, which considered as borderline of adequate asthma control. Conclusion: Twelve-week supervised program of interventions can lead to improvement of lung function test parameter, control and quality of life in asthmatic motivated patients. From the findings a well-structured program influenced from the patient hobbies will keep the patient motivated and will increase the patient physical activities without any restrictions.

Introduction

Asthma is very common disease and the idea of helping patient to manage it and push away as far as possible all the restriction on physical activity and sport is by itself the biggest motivation for me, imagining the patient life with limited sports activity motivate me as well. And by educating the patient to the view of physiotherapy to this disease and the ability to manage it by training programs is my goal. By managing the disease the patient productivity will increase in the levels of work, his or her favorite sports or even simple task of the day like using the stairs. And to give an example there are athletes who have asthma like the American football star player named Jerome Bettis. If they can do it so any patient can. First of all the asthma as defined on WHO (World Health Organization) is “a disease characterized by recurrent attacks of breathlessness and wheezing, which vary in severity and frequency from person to person. In an individual, they may occur from hour to hour and day to day”. Asthma is a widely common disease among almost every society and the numbers are getting higher every year, internationally an estimated 300 million patient who suffer of asthma with an annual 25000 deaths, and by 2025 the number will increase 100 million, And studies shows the increase in the incidence of asthma over the last 20-30 years.  And as far as I was growing up in my hometown the majority of the people think the treatment is only by inhalers. The risk factors of asthma are Genetics or environmental and the Causes of the symptoms are facing the patient in everyday life and the patient need to manage it to provide the patient much easier, happy and symptoms free life. To achieve that we as physiotherapist have to convince the patient that by exercising (which is a trigger) will improve controlling the symptoms.

The topic is physiotherapy management of asthmatic patients in an adult age, physiotherapy approach to the lung diseases is sufficient by all level and it can manage and decrease the symptoms such as coughing, wheezing, shortness of breath, chest tightening and trouble in sleeping. The leading causes of symptoms are the infections, allergies, smoking (primary of even secondary), air pollutions and Exercises. By controlling asthma the patient should have few or no symptoms and minimal usage of medications.

The objectives are to achieve well-controlled asthma the patient has to go through training program and control by spirometer it every week for 10 supervised weeks and 2 unsupervised weeks. By the end of the program my patient should have the characteristics of the well-controlled asthma. And gradually returns to his favorite hobbies and sports. Respiratory diseases are common because of the higher rates of pollutions in the air. Asthma and heart disease have a relationship according to a study found that a patients who have to take daily medications are 60% more likely to have a heart attack in 10 years. So by treating and managing asthmatic patients it is already preventing the patients from having heart problems in the future. In this research these question will answered precisely and detailed:

• What is asthma?
• What is the different between asthmatic lung and healthy lung?
• What is the pathophysiology of the asthma?
• What are the signs and symptoms of asthma?
• What are the diagnostic methods?
• What are the classifications between the asthmatic patients?
• What are the risk factors and the triggers?
• Is there relationship between asthma and other disease?
• What are the pharmacological treatment options for the patients?
• How can the physiotherapist help the patient reduce the symptoms?

The levels of asthma control are less than what it should, a research was done on 12 weeks showed that there is a significant effect on the patients symptoms, as measured and controlled by the Asthma Control Questionnaire (ACQ) in the beginning and at the end of the program, and it led to improve the quality of life and motivate even more patients to control their symptoms. I will follow up this research on a patient who has a mild asthma done by the same methods and questionnaires and hopefully it will have the same results [1].

Theoretical Background

The thoracic wall is formed from the spinal column and twelve thoracic vertebrae from the posterior side and from the anterior side the sternum and twelve pairs of ribs and costal cartilages. From the anterior side the first seven pairs of ribs are connected to sternum, and from the 8 th to the 10 th are connected to each other by the costal cartilage, and the 11 th and 12 th ribs are floating ribs to allow the full chest expansion.

Figure 1: The thoracic wall [2].

The main blood supply to the sternum it supplied from the superior side by pair internal thoracic arteries that connecter with the lateral thoracic, the acromio-thoracic and the transverse cervical arteries. The internal thoracic artery is branched from the sub clavian artery and it goes posterior to the costal cartilage with the sternum. Ventral skin and muscles are supplied from the superior side by sub claivian vessels.

Figure 2: The main blood supply [2].

There is to mail groups of muscles in the chest wall, inspiratory and expiratory, and that classification comes from the functions. The inspiratory muscles (e.g. sternocleidomastoid and scalene muscles) expand the chest volume by pulling up the superior side of the rib cage. The Expiratory Muscles (e.g. rectus abdominis, internal oblique and external oblique muscles) decrease lung volumes pulling or narrowing the rib cage by downward motion. 

Figure 3: Muscles in the chest wall, Inspiratory and Expiratory [2].

 The diaphragm divides the thoracic and the abdominal cavities and it has a dome shape and supplied by the phrenic nerve. Pass through it the aorta, inferior vena cava, esophagus, vagus nerve and the gastric vessels. The diaphragm movements are concentric (by deep and slow inspiration) and controlled eccentric (exhaling “speaking”).

There are other muscles, which help the breathing and they are attached to the clavicle, scapula and the humarus such as pectoralis major, latissimus dorsi, serratus anterior and trapezius muscle. The movements of the thorax go on 3 planes: antero-posterior, supero-inferior and transversal. During the Inspiration there is trunk extension and during Expiration there is trunk flexion. During rest the diaphragm works (75%) and the intercostal (25%). The movements of the chest cavity seen in breathing during the inspiration and expiration. In inspiration, the inspiratory muscles contract and the diaphragm descends and that makes the rib cage elevate. Elevation of the rib cage increases the volume of thoracic cavity. With that the lung gets stretched and the intrapulmonary volume increases that makes the pressure drops to -1 mmHg. With that the air flows into the lungs until the intrapulmonary pressure equals to the atmospheric pressure, and that is the end of the inspiration and the start of the expiration which the muscles will act the opposite and relax so the diaphragm will raise and the rib cage will descend due the recoil of the costal cartilages. That will lead decreasing of the thoracic cavity volume and due that the intrapulmonary pressure raises to +1 mmHg. Then the air flow out of the lung until the intrapulmonary pressure is zero.

Upper and lower airways (23 generations). The upper starts from the nose until the larynx, and it consist of the nose (which warms and filters and humidifies the air) and sinuses, glottis, pharynx and larynx. The lower airways starts from the Trachea which is 16-20 cartilaginous c-shaped rings opened from the posterior side then 2 main bronchi then it branches more to 5 labor bronchi the top 10 segmental bronchi then to primary and terminal bronchioles which does not have cartilage, so far all the above is called the conducting system (1-16 generation) which has no gas exchange at all. After that comes the exchange surfaces (17-23 generations) which is the respiratory bronchioles and alveolar ducts and the alveolar sacs, and what connects the alveoli to another alveoli is called pores of kohn, and from alveoli to bronchioles is channels of Lambert. And a section of the airway walls consist of the epithelium, goblet cells, ciliated cells, glands, hyaline cartilage, smooth muscles and elastic fibers.

Figure 4: The lower airways [2].

The chest cavity consists of two lungs one on each side. The right lung has three lobes (upper, lower and middle) and the left lung has two lobes (upper and lower). The bronchopulmonary segments of the upper lobe (apical, posterior and anterior), the Right middles lobe (lateral and medial) and the left Lingular lobe (superior and inferior) and the Lower lobe (apical, anterior basal, posterior basal, lateral basal and subapical). The lungs are covered by the pleural cavity, which are two layers (visceral and parietal) to allow the negative pressure of breathing stay with no friction [2]. The respiratory system is where the exchange of the O 2 and CO 2 between the air lungs and blood in the pulmonary circulation (external respiration) and between the blood, cells and tissues (internal respiration) Figure 1 to Figure 4 [1-25].

Disorders of the Respiratory System

Restrictive Disorders: which means the restriction of the lung expansion resulting in decreasing of the lungs volumes (FVC, FEV 1 , TLC, VC, RV). And it localization is extrapulmonary (rib fracture, kyphoscoliosis and neuromuscular diseases) or Pleural (pleuritis and pleural disorder and effusion) or Parenchymal (pulmonary fibrosis, alveolar oedema and rheumatic diseases). Obstructive Disorders: it is characterized by abnormal low airflow. The airflow decreased always and volumes decreased frequently (FEV 1 and FEF25-75). Some examples of the disorders (Asthma, COPD, Bronchiolitis).

Is a chronic disease, which the pulmonary airways and the bronchioles are inflamed that lead to obstruction and usually the obstruction is reversible. The decreased bronchial flow after the bronchoprovocation is called bronchial hyperresponsiveness. And there is other triggers which provoke the airway obstruction such as cold air, exercise, infection, cigarette smoke and allergies. The pathology of asthmatic airways displays lung hyperinflation, smooth muscles hypertrophy and lamina reticularis thickening, mucosal edema, epithelial cell sloughing, cilia cell disruption and mucus glands hypersecretion [3]. Most attacks are short, without any symptoms between episodes. But airway inflammation is present in asymptomatic individuals. Asthma occurs in all ages, which nearly half of the patients develop asthma from childhood and the other third before the age 40, it has been estimated that 5% of adults have asthma and 7-10% of children in United states have asthma. Asthma Morbidity and mortality have risen in last two decades despite the increase number of antiasthma drugs. The etiology of asthma is believed to be genetic because asthma considered as familial disorder and that is strong evidence. Environmental factors also play a major role with the inherited factors to increase the risk of asthma and to cause bronchospasm attacks.

Childhood exposure to environment which has high levels of allergens, cigarette smoke, air pollution or respiratory viruses has increased chance to develop asthma, especially those children who has family history with asthma. The severity of the asthma acute attack is different from a patient to another, over time and the amount of exposure to inciting factors [4]. Asthma has two major components. When the immune system becomes sensitized to an allergen, usually through big exposure in childhood. The lungs became hyper reactive and this cause the muscles to contract making it very difficult to the patient to breath. The second component is inflammation, which makes the airway narrow, and swell and the cells produce more mucus. Asthma may be categorized as conventional asthma, occupational asthma, or exercise induced asthma. But the pathophysiology is the same; since the triggers and allergens are vary from a patient to another, each person react differently.

Asthma Classification

The classification of asthma is based on the severity, which can be seen in symptoms and the functional tests. Which are ?

• Intermittent mild asthma: without treatment the symptoms are (difficulty in breathing, wheezing, chest tightness and coughing), and occur less than two days a week and the symptoms do not interference the day activity life, and nighttime symptoms comes less than two days a month.
• Mild persistence asthma: without treatment the symptoms occur more than 2 days a week but not every day, the attacks happen in the daily life activity, nighttime symptoms happen 3-4 times a month.
• Moderate persistence asthma: without treatment the symptoms happen every day, nighttime symptom happen more than once a week but not every night.
• Sever persistence asthma: without treatment the symptoms happen every day and there is severing limitation of the daily physical activity, the nighttime symptoms happen often and some cases every night [5].

Asthma is a complex disease it comes with airway inflammation, hyper-responsiveness and variable obstructions of the airflow that may not all co-exist in many patients. The lung function test is done by Spirometry, which is a simple device can be used in the physician office and it provides the very important information about the relationship between the flow and volume. The test accuracy depends highly on the patient effort. The patient must listen and do exactly as the assessor coach and in the other hand the assessor must coach the patient with the correct understandable language and can identify the unacceptable effort as poorly performed maneuvers can lead to several of diseases patterns. There are more possible ways for diagnosis of asthma but the recommended approach in spirometry device is measuring the improvement in forced expiratory volume in 1s (FEV 1 ) of 12% and 200 ml after taking the bronchodilator challenge. The spirometry shows the increase of FEV 1 then it is a positive diagnosis, and if there is no increase it is a negative diagnosis.

Measurement of the peak expiratory flow rate (PEFR) is simple and convenient the patient can do it in the clinic or even in the house. PEFR has been linked with airway hyper-reactivity and it is useful diagnostic method. There are other methods such as Methacholine challenge, which is recommended for patient who has all the clinical features of asthma but normal spirometric testing measurements. Methacholine challenge testing (MCT) is in the beginning a safe test even on sever obstructed patients, MCT starts with inhaling methacholine, a substance that induce bronchoconstriction in susceptible airways, to their knowledge there were no deaths reported from MCT. And then measure the lung functions if the FEV 1 is decreased > 10% that’s a positive diagnosis. And in the other hand if there is no limitation (airflow limitation: FEV 1 <80%, FEV 1 /FVC<65%) after inhaling the bronchospasm provocation then it is a negative diagnosis.

Peak flow can be measured by the Peak flow meter and it is used to monitor the disease. It shows the peak expiratory flow (L/sec) and it should be used 2-3 times a day. It is not expensive and portable that makes it easier to check up everywhere and ever time. The diagnostic testing for patient who is over six years old is the same as adults, which is the lung function test and allergy tests. And for patients less than six years old it is difficult because they are not able to perform conventional lung function test [5].

Signs and Symptoms

Asthma signs and symptoms may vary from a patient to another but the most common ones are:

• Shortness of breath
• Chest tightness
• Trouble of sleeping

And there are causes to the symptoms (triggers) such as:

• Viral infections
• Allergens: dust mites, pet dander and pollen
• Tobacco smoke

Weather changes or cold air to monitor the patient severity the patient usually uses a timetable to check whenever he had the symptoms on each day in day or night. That helps with the management and check if the treatment option is suitable for the patient or the physician should change it to other option. And especially it is very helpful for the physiotherapist during the physical training treatment plan. Trying to avoid these causes is part from the treatment [6].

The goal is controlling the asthma. A well-controlled asthma must have minimal or no symptoms, few or no asthma flare-ups, no limitations in physical activity, minimal usage of medications and few or no side effects of medications. Drugs that are used as preventive medications or long-term medications (Long acting beta-agonists, immune modulator) are used for reducing the inflammation. Then the quick-relief (short acting beta-agonists, systemic corticosteroids) or rescue medication to quickly open the airways during the attacks (2-5 min). Allergy-desensitization or immunotherapy diminishes the symptoms in 3-5 years.

The physicians confuse often asthma control with asthma severity. The concept of asthma control has been always used in the treatment guidelines. There was a thought that the well-controlled asthma was the same concept as mild asthma, and the poorly controlled asthma like the severe asthma this concept is not correct. Severity is the intensity of the disease process before the treatment takes a place. For example patient with severe asthma if they were treated and managed appropriately can be controlled, and the opposite is true, patients with mild asthma if they did not follow the treatment plan they will have a poorly controlled asthma. The goals of treating and managing all levels of asthma are the same, but patients with severe asthma the treatment will be more difficult to achieve a controlled asthma. The meaning of controlled asthma requires the patient to have no symptoms in the daytime or the night-time, also a very infrequent rescue beta2-agonist use, and have no limitation in physical activity and lung function values close to normal. The Global Initiative for Asthma (GINA) suggests 5 steps for treatment. For each step there is a preffered option and other alternetive. Step 1 is rapid-acting inhaled beta2-agonist. The other 4 steps has other controlled options with the low-dose inhaled corticosteriods (ICSs) as the preffered option in Step 2 to long-acting inhaled beta2-agonist and high-dose of ICSs together and oral corticosteriods at Step 5. If the asthma is controlled the treattment should be reduced and consider other treatments to manage the disease. If the controling of asthma has not been established then the treatment advance to the next step. And the study suggest that the most effective control therapy for asthma is ICSs in low-doses in both children and adults.

Figure 5: The Global Initiative for Asthma [7].

     Other Therapy control options are well known such as:

• Breathing Exercises: the aim of these exercises is to normalize the breathing pattern by teaching the patient slower respiratory rate and longer expiration and reducing of hyperventilation and hyperinflation. And with the assumption that the asthmatic patients have an abnormal breathing pattern the physio should encourage the nasal breathing and diaphragmic breathing pattern.
• Inspiratory Muscle Training: the inspiratory muscles can be trained by external device to achieve strength and endurance. The reason for suggesting that exercising these muscles may reduce the intensity of the dyspnea and increase the exercise tolerance. It is possible that the effect of the corticosteroid treatment is to loss some muscles mass including the respiratory muscles.
• Physical Training: the fear of physical aerobic training as a treatment and the same time symptoms provocator inhibits many patients from taking part of this treatment option. The aim of the physical training programmes to improve physical fitness and neuromuscular coordination and self-confidence and it is the important component for a better management of asthma [8].

As a study shows which specific exercise is preferred for the asthmatic patients, between the fallowing (swimming, cycling, running). All the functional values were monitored, especially FEV 1 - FVC- FEV T%. This study confirms that the best results are seen in swimming. Because exercise-induced asthma present in swimming is less than running or cycling [9]. Therefore another study states that there are huge influences in the temperature of the air and also on the high interval exercises. The study results suggest that patients should avoid high intensity exercises (95% of Maximal heart rate) in the extremely low temperature (winter) and in extremely high temperature (summer) as a preventive option of exercise-induced asthma [10]. The study results suggest that patients should avoid high intensity exercises (95% of Maximal heart rate) in the extremely low temperature (winter) and in extremely high temperature (summer) as a preventive option of exercise-induced asthma [10]. The program was once in a week training on moderate intensity for 60 minutes. And doing the assessment before and after the 12 months by using questionnaires. The results showed that moderate intensity for long-term program could show clinical relevant improvements in exercise capability and the quality of life in the motivated adult patients [10]. As my opinion, every patient is different from another, by the age, gender, life-style, and even psychological factors are important. The physiotherapist should choose the best program depending on all the factors seen in the patient. 

For example asthmatic patient who loves swimming will be always motivated for the program that involve swimming, and in the other hand we must introduce new treatment exercise methods and without any restriction we prepare the patient for any sport the patient desires. After giving the program for patient and after adding his interests in it to keep him always motivated, the physiotherapists should explain always to carry his or her inhaler and when and how to use it. The period of the treatment is an important factor; if it’s a long periods the program should be moderate intensity and increasing gradually the intensity first and session time. The physiotherapist should encourage the patient to increase the quality and intensity of the exercises gradually, in order to adapt the body for the new training load. By doing all of that and making the preferred program for each patient and encouraging for higher intensity the patient can reach the well managed asthma with fewer asthma attacks and better life quality.

Physiotherapy Interventions  

Breathing Techniques

By using a big number of asthmatic patients to experiment the breathing techniques, a study had been done on the interventions of the physiotherapy in asthma. It was a systematic review to try the effectiveness of these interventions.  The study used interventions such as slow deep breathing with the Pink City Lung Exerciser 15 min a session and twice a week for the mild conditioned asthma patients. And another physiotherapy intervention for patient with acute sever cases which are hospitalized to establish chest physiotherapy after 6-24 the admission patients given the inhaled salbutamol comes after it physiotherapy breathing exercises. And some other stable conditioned patient with different intervention such as, a 16 weeks program strengthening the respiratory muscles to maximize the efficiency of the lung capacity, yoga breathing exercises; physiotherapy breathing exercises both of them 15 sessions of 3 hours over 3 weeks. The patients were monitored by lung function tests and spirometry values were taken before and after the programs for all the groups. And the results advice that on sever cases of acute asthma may not profit from physiotherapeutic breathing techniques. But in the other hand cases with mild-to-moderate may offer some assistance to the patient life. the breathing exercises and the strengthening of the respiratory muscles showed a significant result on mild-to-moderate asthmatic patients [10].

Swimming can improve the aerobic capacity to patients with asthma. That’s the results of several study on of them was done on Two groups. One group consists of eight patients, was training with 125% of the lactate threshold (LT), and monitored using a swimming ergometer. Another group with the same number of patients served as a control group subjects. As a result of the six weeks swimming training program, the patients showed a beneficial effect on the aerobic capacity (Matsumoto I. 2001). In this study they analyzed the effect of swimming on lung functions and (BHR) Bronchial hyperresponsiveness in mild asthmatic patients. The study was done on 70 mild persistent asthmatic patients selected according to GINA. The method was to have two sessions a week for one hour, for the following 6 months. There were two groups one had the asthma education and the swimming sessions and the other had drugs. The sessions were held on an indoor pool with natural warm water without chlorination. For assessment they measured the lung functions with spirometry, broncho provocative test and skin tests. The Conclusion was that patients with mild persistent asthma going to swim in non-chlorinated pools combined with asthma regular medicine and asthma education can cause better improvements of their parameters of the lung functional test. And more significant decrease of their airway hyperresponsiveness compared to traditionally treated patients with medicine [11].

Cart and Slow

Study experimenting on the raising of Pco2 level compared with slow breathing is linked with improvements in asthma control. The method of the study was testing one hundred twenty patients with asthma. With assigning the patients to Capnometry-Assisted Respiratory Training (CART) for raising Pco2 or Slow Breathing and Awareness Training (SLOW). Patients received five sessions a week and completed the home exercises over 4 weeks. Post-treatment and baseline assessments were made with monthly follow ups and measuring the pulmonary function tests such as spirometry, forced oscillations and quality of life and symptoms and drugs use. As a result improvements are seen in the lung function tests and quality of life and drugs use. The improvements were persistent on the 6 th month follow up [12]. This study was done on 33 patients between the ages of 17-65 years, with diagnosis of asthma and had at least one prescription for an inhaler or oral bronchodilator. They were managed by Nijmengen questionnaires and hit the score less than or equal to 23 to be diagnosed with dysfunctional breathing. The interventions of the physiotherapists were on groups of 4-5 patients for 45 minutes a session once or twice a week. In these sessions the physiotherapists explained the several symptoms such as breathlessness could be produced. The physiotherapists taught the patients diaphragmatic breathing exercise by using physiotherapy methodology. Emphasizing the slow and regular breathing is the main use of the diaphragmatic respiratory effort. The results and the data analyzing and the questionnaires showed that over the half of the asthmatic patients treated for dysfunctional breathing are clinically significant improvements in quality of life following the brief physiotherapy intervention. And this increased improvement is sustained in over 25% after 6 months of the interventions [13].

Pulmonary Rehabilitation

Patients with lung diseases are closer to present decreasing in the exercise tolerance and muscle strength, and the cause is the pulmonary limitations and the systematic repercussions of the pulmonary disease. The goals of this study are to evaluate and increase the physical capacity, peripheral muscle function, physical activity in daily life and the inflammatory markers after pulmonary rehabilitation. The study involved visits: the 1 st was Evaluation, in this visits they asked quality of life and asthma control questionnaires, lung function tests, blood inflammation, cardiopulmonary exercise test. The 2 nd visit was skeletal muscle function assessment. On the 3 rd visit they did incremental shuttle walk test and physical activity (accelerometer) and then divided and randomization to two groups on was intervention group, which was supervised rehabilitation program. The program was twice a week and the duration of each session was 60 minutes for 8 weeks. Each session includes of three parts: aerobic exercise (10 minutes warm up 20 minutes on target load and 5 minutes cool down), strength muscles exercises (40-70% of maximal repetition), and chest physiotherapy (Flutter will be used for 5 minutes). The second group is Control group. This program includes chest physiotherapy (Flutter for 10 minutes) and stretching exercises (for upper and lower limbs for 40 minutes) twice a week. Each session will be held for 60 minutes for 8 weeks. And after 8 weeks the study reevaluated the patients as the same method on the 1 st visit. And the results were both groups had controlled the asthma and with the evaluation and reassessment it can be seen in quality of life and the usage of drugs. Pulmonary rehabilitation is recommended for patients with chronic diseases with increased aerobic capacity [14].

Buteyko Technique

It is the most effective approach to management of asthma without using any drug, it can be applied to any age and any severity and it will give up quick and consistent results. Which emphasize the importance of nasal breathing? Nasal breathing humidify, warm, and clean the air which enters the lung. By encouraging the nasal breathing the night symptoms can improve. In that fact a study was made on the Buteyko technique to assess the effectiveness in asthmatic patient. A randomized controlled group of adult asthmatic patient did the buteyko technique, and other group was trained by physiotherapists to perform breathing and relaxing techniques. The measurements were composed by a score based on the Canadian asthma consensus reporting after six months of the intervention. And the results show both groups showed significant and similar improvements. And the Buteyko group the proportion with controlling the asthma increases from 40% to 70%. And in addition to the Buteyko group they showed a substantially reduced in their inhaled corticosteroid therapy comparing to the controlled group. As a conclusion of this study, after six months completing the intervention, a large majority of both groups showed control on their asthma with an additional benefit of reduction of the inhaled corticosteroids use in the Buteyko group. Therefore we may say that the Buteyko technique appear to provide benefits on adult asthmatic patient along with the chest physiotherapy in patients who are being treated with corticosteroid inhaled therapy [15].

Yoga treatment to improve the quality of life in asthmatic patients has its own popularity. Therefore a study was made to determine the effectiveness of yoga in patients with asthma. The study included 120 patients diagnosed with asthma. The patients were randomized to follow two groups. Group A was Yoga training group and group B was the control group. Group A included deep breathing exercises, Kapalabhati (cleaning breath), Bhastrika (rapid and deep respiratory movements), Ujjayi (loud sound producing pranayama) and sukha purvaka pranryama (easy comfortable breathing). The Yoga sessions were 24 minutes duration per week under supervision. And the patients were instructed to practice at home. Both groups had to answer the asthma quality of life Questionnaires (AQLQ) at baseline and 8 weeks after the baseline. The results were based on the (AQLQ), scores of Group B showed no significant changes from the baseline after eight weeks. Group A score showed an increase in the QOL after eight weeks. Means that the score of Group A was significantly higher than Group B score. From the results we know that Yoga may be beneficial for patients with asthma after practicing Yoga exercises [16].

Aerobic Exercises vs Breathing Exercises

Both of the exercises has major rule on management of asthmatic patients conditions. Therefore a study was done to compare the effectiveness of these treatments. The method was to choose randomly, comparative, blinded clinical trials with two groups will receive different interventions. Forty-eight patients with diagnosed asthma will be divided into two groups, Group A was the aerobic and Group B was the breathing exercises. First they evaluated the two groups on two visits; the first had clinical control, anxiety evaluation, hyperventilation syndrome, pulmonary and systematic inflammations and daily life physical activity. The second visit had the pulmonary function tests, maximal exercise capacity, thoracoabdominal kinematics and autonomic control. After their two visits the groups had two educational programs, which included pathophysiology, medical skills, medications skills, self-monitoring techniques, environmental control, avidness strategies and the use of the peak flow meter. After the educational programs the study randomized the two groups into aerobic training and breathing exercises. The aerobic training has been done on the treadmill with 60% of the maximum intensity and reaching to 80%. The breathing exercise group has been done yoga breathing techniques, nasal and diaphragmic breathing, increasing the expiratory time and slowing the respiratory flow. Breathing exercises had been divided into 3 phases lasting each phase one month. The study has showed a significant improvement on both groups in the functional respiratory. The aerobic exercises showed improvements in the daily life activity. And breathing exercises showed improvements in the peak expiratory flow and decrease anxiety and depressing and medical consumption. The study is undergoing and the data in being analyzed with encouraging improvements from the baseline tests. The results will show us the benefits of each intervention to optimize its effect to the asthmatic patients [17].

Inspiratory Muscles Trainings

A study was done to evaluate the effectiveness of Inspiratory Muscle Training (IMT) and respiratory exercises on the strength of muscles. The study was done on a randomized analytical including 50 patients of asthma. They were put in two groups: an IMT group, involving of 25 patients with a program includes an IMT and both education about asthma, treatment programs. The second group called a control group that includes also 25 patients, which had the usual monthly medical visits and education about asthma. The IMT was done by using a pressure threshold of 40% of the maximal inspiratory pressure. IMT was performed using of the threshold IMT (Respironics, Cedar Grove). The respiratory therapy includes IMT and breathing exercises, twice a week for a 50 minutes session, for 7 consecutive weeks. 25 minutes of it was IMT, during the first 20 minutes the IMT threshold used for sixty seconds of practice separated by sixty seconds of rest, in order to develop muscle strength. And on the last 5 minute, the equipment was used uninterruptedly to gain and develop the endurance.Both groups compared in terms of PEF and respiratory muscles strength and as well as the severity variables, by using equipment like Peak Flow device. The Conclusion of the study was: the program that involved IMT and respiratory exercises (IMT group) showed increase of the efficiency of the respiratory muscles, and in addition to improving of PEF and severity variables [18].

The estimates of the global burden of asthma of 2014 are rising to 334 million people suffer from asthma. An estimated 14% of the world’s children have symptoms of asthma and 8.6% of adults (18-45 years old) experience asthma symptoms. Asthma is the 14 th most important disorder in the world in terms of extent and duration of disability. As a result of that, it is highly recommended to do research, interventions and managing to decrease the asthma burden in the world [19]. Objectives of the research:

• Better understanding of management of asthma.
• Describe the Physiotherapy interventions towards asthmatic patients in details and the benefits.
• Improving the lung function measurements.
• Achieve the well-controlled asthma.
• Prevent asthma attacks or at least minimize it.
• Minimal usage of Medicine.
• Increase the quality of life and the physical activity of the patient so he/she can do whatever sport they like with no limitation.

In order to reach these objectives, the patients needs in the beginning the education about asthma and in most cases the physiotherapy approach about management of asthma and the variety of interventions it has to help the patient health and quality of life. After that the patient has to learn how to use the medicine giving as an inhaled substance in case the patient needs to use it during the physiotherapy interventions. Then the patient must do a lung function test (spirometry) and fill Questionnaires to assess how the interventions improving. To choose the best intervention for the patient is a matter of evidence-based treatment, although of that we should also choose the best intervention method to keep the patient motivated and encouraged to do more. Then we prepare the perfect specified program for the patient and in end of it we assess the same way as the baseline and we compare the results and hopefully we will reach all the objectives that we set with the patient.

There is no cure for asthma, in another hand pharmacological interventions showed a good improvement in symptoms. The physiotherapy interventions showed also substantial improvements in managing asthma. Poorly managed asthmatic patient have a very restrictive life, and with the physiotherapy interventions the patient will be free of the restrictions and can practice all the physical activities symptoms-free. Physical activity is widely known as the enemy of the asthmatic patients and by this research I will be able to prove that with physical activity the asthmatic patients well have a better life quality. So the physical activity is the subject I chose.

The literature review I have made about asthma and the different intervention and from all the articles I listed above that:

• I assume that the aerobic training will improve the lung functions parameters [20].
• I assume that with the swimming session the lung function parameter will increase [11,9].
• I assume that Yoga sessions will improve the quality of life to asthmatic patient.
• I assume that the Inspiratory Muscle Training (IMT) will improve the efficiency of the respiratory muscles and the PEF value.
• I assume by the breathing exercises the patient quality of life will improve.
• I assume that the breathing exercises will improve the patient’s anxiety.
• I assume that the Buteyko technique will help the patient to control the asthma and it will help also the patient’s night symptoms.
• I assume that every patient needs unique program depending on his hobbies to keep him motivated.

And to prove my hypotheses I will make a scientific-based program to an adult asthmatic patient.

Patient’s Clinical Findings

The patient is 29 years old and diagnosed with mild asthma through his physician. The lung function test showed a mild obstruction, and the patient did an allergy test as well to determine the triggers. He suffers from variety of symptoms. Symptoms seen in the patient:

• Cough, more than 2 days per week.
• Chest tightness especially at night, awakening symptoms 3 to 5 times per month.
• Minor limitation of daily activities.

The patient also did an allergy test that showed the inhaled triggers. The physician gave the patient the suitable medication and the patient has been advised to stay away from the triggers as much as possible to avoid the attacks. The patient has been educated about the relation between the triggers and the attacks [Appendix 3]. Patient’s triggers (Allergies):

• Dust mites, mugwort and ragweed.
• Pet dander specially dogs and cats.

The patient complained about tobacco smoke also leads to the attack.

Medications

The patient used for two years a medication (inhaler) named Seretide, twice a day.

Assessments

Before the patient starts the Treatment plan. I did a baseline assessment using the lung function test and Asthma Control Questionnaire 7 (ACQ-7).

Lung Functional (Spitometry) Test

The most important parameter of the spirometry for asthmatic patients is the FEV 1 expressed as percent of the predicted value [21]. Baseline assessment (appendix 1).

Appendix 1: Before treatment lung functional (Spitometry) baseline test.

Asthma Control Questionnaire 7 (ACQ-7)

All the guidelines in the world to treat asthma share the same goal of asthma management that is the patient will obtain control on asthma. That is why Asthma Control Questionnaire 7 (ACQ-7) was established to evaluate if the patient has a well-controlled asthma or poor-controlled asthma. It measures both capability of asthma control and the change of asthma control, which happens unexpectedly or a result of treatment program. The patient asked these questions and sum up the points and divide it on 7 and the score will determine if the patient has a controlled asthma or not. The patients who have score less than 1.0 will have a well-controlled asthma and the patients who have above 1.0 will have poor-controlled asthma. However there is a grey area between 0.75-1.25 where the patients are in the borderline of adequate control [22]. The patient had answered these questionnaires weekly. And the score for his baseline assessment (before the program started) was 2.28 which means poor-controlled asthma (Appendix 2).

Treatment Plan

Inspiratory Muscle Training

The patient had the breathing exercises once on every second week. The duration was 45 minutes per session. During this session I taught the patient the diaphragmatic breathing and why is it important to us. Emphasizing the main use of the diaphragmatic breathing is the slow and regular use [14].

Patients with asthma suffer daily and my goal to prevent that with the help of the patient. The patient was diagnosed with mild asthma and his symptoms were coughing, wheezing, sleeping difficulties with chest tightness in the nighttime and these symptoms wakes him up, and anxiety. An allergy test was done to determine the triggers of the patient, which are ragweed, cold air, pet dander specially dogs and cats, tobacco smoke. The patent was asked to avoid all the triggers. And then I did program influenced on the patient hobbies to keep him motivated, which is 12 weeks program scientifically based interventions to improve his control of asthma. The patient was educated on asthma generally and his condition specially and knowing the importance of the intervention. The patient was educated on the different of well-controlled asthma and poor-controlled asthma, so with tests and questionnaires we established that the patient suffer from poor-control asthma. 

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Clinical case studies in physiotherapy

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Case studies in respiratory physiotherapy

CHAPTER FIVE Case studies in respiratory physiotherapy Lead author Janis Harvey, with contributions from Sarah Ridley, Jo Oag, Elaine Dhouieb, Billie Hurst Case study 1: Respiratory Medicine – Bronchiectasis Out-patient 34 Case study 2: Respiratory Medicine – Lung Cancer Patient 36 Case study 3: Respiratory Medicine – Cystic Fibrosis Patient 38 Case study 4: Respiratory Medicine – COPD Patient 41 Case study 5: Surgical Respiratory – Anterior Resection 43 Case study 6: Surgical Respiratory – Division of Adhesions 44 Case study 7: Surgical Respiratory – Hemicolectomy 46 Case study 8: Surgical Respiratory – Bowel Resection 48 Case study 9: Intensive Care – Patient for Extubation 50 Case study 10: Intensive Care – Surgical Patient 51 Case study 11: Intensive Care – Medical Patient 52 Case study 12: Intensive Care – Patient Mobilisation 54 Case study 13: Cardiothoracic Surgery – Self Ventilating Patient 55 Case study 14: Cardiothoracic Surgery – Intensive Care Patient 57 Case study 15: Paediatric Respiratory Care – Medical Patient 59 Case study 16: Paediatric Respiratory Care – Intensive Care Patient 61 Introduction The area of respiratory physiotherapy reaches a number of patient groups, both in the in-patient and out-patient settings. The case studies that follow are based predominantly in the in-patient environment; however, the components of a respiratory assessment and the subsequent identification of physiotherapy problems and treatment plan could be applied to any patient with respiratory compromise in any clinical setting. Like all other areas of physiotherapy practice, respiratory physiotherapy involves accurate patient assessment in order to identify patient problems. Respiratory assessment should include certain key elements: general observations of the patient; consideration of trends in physiological observations (e.g. HR, BP, oxygen saturations); patient position; auscultation, palpation and, where available, analysis of arterial blood gases and chest X-ray (CXR). Patient problems identified from the assessment generally fall into three main categories: loss of lung volume, secretion retention and increased work of breathing. The extent of any resulting respiratory compromise can vary greatly between patients and may not always be reflected by the ward area in which the patient is being treated. On occasion the most acutely unwell patients are in the general ward areas and not within critical care as expected. A problem-orientated treatment plan may include a combination of a number of interventions such as mobilisation, positioning, breathing techniques (e.g. ACBT, AD), manual techniques (percussion, vibrations), mechanical aids (e.g. IPPB, CPAP) or more invasive measures (e.g. airway suctioning). A respiratory assessment is mainly indicated for patients who have undergone surgery, those with medical respiratory conditions, e.g. exacerbation of COPD, and those requiring critical care. Cardiothoracic surgery and paediatrics are other specialist clinical areas that physiotherapists are involved in providing respiratory care. However, it must be remembered that patients requiring such care may not be in these ward areas exclusively. Physiotherapists working in any clinical area may be required to undertake a respiratory assessment and provide respiratory care. For example, assessment of a stroke patient who has aspirated or an oncology patient who develops respiratory failure following chemotherapy. It is important, therefore, that all physiotherapists are familiar with respiratory assessment and intervention. Another key area of work where physiotherapists are required to undertake respiratory care is in the provision of emergency duty/on-call services. Such services are available to patients who have a condition amenable to physiotherapy, which has either deteriorated or is likely to deteriorate without intervention before daytime service resumes ( Scottish Intercollegiate Guideline Network 2004 ). This can be a very challenging area of work for the physiotherapist on-call, who needs to think clearly while being faced with an acutely unwell patient who is in need of their attention, whatever the time of day. Guidance is available to support the clinician involved in providing such care and to aid ongoing assessment of competence ( Chartered Society of Physiotherapy 2002 ). CASE STUDY 1 Respiratory medicine – bronchiectasis out-patient Subjective assessment PC 35-year-old female Attending routine multidisciplinary bronchiectasis clinic appointment HPC Diagnosed 6/12 ago with bronchiectasis following an in-patient admission with community-acquired pneumonia (CAP) in her right lower lobe. This resulted in the development of bronchiectatic changes. Since diagnosis the patient reports daily production of mucopurulent secretions with excessive coughing and feelings of fatigue PMH CAP Gastric oesophageal reflux SH Married with two children Lifelong non-smoker Full-time employment as drug company representative, involving frequent travel around the United Kingdom Normally leads an active lifestyle with two to three visits a week to the gym, although this has decreased over the past 3/12 DH Omeprazole Consultant handover Patient is currently stable but is concerned about the impact of her cough and increased sputum on everyday life, especially in relation to her work, where she frequently does formal presentations Objective assessment Respiratory Ventilation SV room air SpO 2 99% RR 12 CXR Bronchiectatic changes present in right lower lobe ABG Not appropriate to be taken as stable CVS Temp 37°C HR 70 BP 120/70 CNS Nil of note Renal Nil of note MSK Nil of note Microbiology Staphylococcus aureus in sputum sample 6/12 ago Patient position Sitting in chair Observation Looks well, good colour, breathing pattern normal Patient actively trying to suppress cough and noise of secretions Auscultation Breath sounds throughout both lung fields with mid inspiratory crackles right lower lobe Questions 1. You feel this lady seems a little vague regarding her diagnosis, how will you deal with this issue? 2. Following discussion it is now evident that the patient’s knowledge about her condition is sparse. How will you resolve this issue? 3. What is the range of airway clearance techniques commonly taught to this group of patients? 4. Considering this patient’s condition and lifestyle what would be the advantages and disadvantages to each of the treatments mentioned in the previous question? 5. Your patient seems reluctant to undertake airway clearance management, how will you motivate your patient to undertake regular treatment? 6. What frequency and duration may you suggest to this patient for performing airway clearance techniques? 7. What signs and symptoms would you highlight to your patient to recognize at the start of an exacerbation? 8. Your patient asks what she should do if she has an exacerbation, what advice do you give her? 9. Why would you consider asking this patient if she has any urinary stress incontinence problems? CASE STUDY 2 Respiratory medicine – lung cancer patient Subjective assessment PC 70-year-old male Non-small-cell lung cancer (NSCLC) in the right main bronchus Admitted with an acute deterioration in condition and the family are no longer able to cope with the patient at home HPC Diagnosed 9/12 ago following a 3/12 history of increasing shortness of breath and cough. Two episodes of frank haemoptysis also reported. Following diagnosis, patient was deemed appropriate for a course of chemotherapy, but had limited response to intervention. As an out-patient he had a CT scan, which showed brain and spinal metastases, and he has been suffering uncontrollable pain. As a result he has been bed bound for the past month and has required increasing support from Macmillan oncology nurse specialists PMH Nil of note SH Lives with wife in a bungalow Smokes 40 cpd Retired teacher Close family network Until 2/12 ago independent with walking stick, able to walk to local shops approximately 100 m DH Paracetamol Co-codamol Oramorph Lactulose Build up drinks Handover Patient admitted with a decreased GCS, frail, emaciated Family very concerned, emotional and distressed by patient’s breathing pattern and audible secretions Pain management sub-optimal Objective assessment Respiratory Ventilation SV 4L O 2 via non-venturi system mask, unhumidified SpO 2 95% RR 10–22 CXR No CXR taken on admission Previous CXR (1/12 ago): white out of right lung field, secondary to bronchus obstruction ABG None available CVS Temp 39°C HR 120 BP 105/65 CNS GCS fluctuating between 5 and 8 Renal Catheterised on admission MSK Pain at lower back region in keeping with spinal metastases Microbiology None Patient position Supine Observation Flushed, drowsy, intelligible speech with audible secretions. Agitated at times, with arms flailing and pulling at oxygen mask Normal chest shape with altered breathing pattern illustrated by Cheyne–Stoking Auscultation Breath sounds diminished throughout right lung field with widespread coarse inspiratory/expiratory crackles transmitting throughout left lung field Palpation Decreased chest excursion on right with palpable secretions over trachea and left apex Questions 1. How would you describe Cheyne–Stoking? 2. If a patient is performing a Cheyne–Stoke breathing pattern, what does this indicate? 3. Prior to assessing and treating this patient, what further information do you require? 4. What are the main physiotherapy problems? 5. What are the associated problems for this patient that may affect your physiotherapy intervention? 6. How will you treat the problems that you have highlighted? 7. What outcome measures will you use to evaluate the effectiveness of your intervention? 8. In this scenario, which medical and physiotherapy interventions are inappropriate and why? 9. What do you see as the role of the palliative care team in this scenario? CASE STUDY 3 Respiratory medicine – cystic fibrosis patient Subjective assessment PC 19-year-old female Admitted with acute exacerbation of cystic fibrosis (CF) HPC Diagnosed at birth. Multiple hospital admissions over last 3 years due to exacerbation of CF. On admission patient reporting 1/52 history of increased breathlessness, sputum volume and cough. These symptoms have not responded to a 2/52 course of intravenous antibiotics. In respiratory distress. Dehydrated. Recent weight loss and current BMI 17. Under review for lung transplantation assessment. Patient previously agreed to perform twice daily ACBT in alternate side lying/supine for 20 minutes, but generally non-compliant with suggested airway clearance programme and prescribed medications PMH Asthma Osteoporosis SH Lives at home with parents and sister (non-CF) Unemployed and sedentary lifestyle due to health status DH Ventolin via nebuliser Becotide via inhaler Dnase via nebuliser Colomycin via nebuliser Azithromycin Creon Alendronate Vitamins A, D, E, K Long-term oxygen therapy Handover Patient exhausted and only able to clear small amounts of very thick, purulent bronchial secretions with difficulty. Pyrexial and requiring intravenous fluids. C/O nausea following overnight feed via PEG tube Objective assessment Respiratory Ventilation SV 28% O 2 via venturi system mask SpO 2 85% RR 34 CXR ( Figure 5.1 ) Hyperinflated, chronic bronchiectatic/fibrotic changes throughout upper and mid zones bilaterally Intravenous access device in situ Figure 5.1 X-ray for Case Study 3 showing hyperinflated, chronic bronchiectatic/fibrotic changes throughout upper and mid zones bilaterally. Intravenous access device in situ . ABG H + 50 nmol/L pCO 2 13 kPa pO 2 7 kPa HCO 3 − 30 mmol/L BE −9.0 CVS Temp 38.5°C HR 129 BP 100/85 CNS Nil of note Renal Nil of note MSK Kyphotic with history of osteoporosis Microbiology Pseudomonas in sputum Patient position Sitting upright in bed holding onto cot sides Observation Pale with signs of central cyanosis. Unable to speak due to SOB and excessive cough. Looks distressed. Breathing pattern shallow, apical with active expiration Auscultation Coarse inspiratory crackles transmitting throughout chest on background of high-pitched expiratory wheeze Palpation Limited chest excursion on inspiration (right = left) Secretions palpable upper, anterior chest wall Questions 1. Considering the above information, list this patient’s physiotherapy problems. 2. What information from the objective assessment led you to this problem list? 3. What does the ABG result tell you? 4. What are the specific signs of hyperinflation on this patient’s X-ray ( Figure 5.1 )? 5. During this admission, how might you initially modify this patient’s normal daily routine of alternate side lying and ACBT for 20 minutes twice a day? 6. Having decided on an acceptable airway clearance technique, what else would you include in your initial treatment plan? 7. Following two physiotherapy sessions with modified ACBT that morning, you feel that the patient is becoming more exhausted and unable to clear her secretions effectively. How might you change your physiotherapy management and with whom would you want to discuss these potential changes? 8. How might your treatment/management change if your patient was commenced on NIV? 9. Why would it be inappropriate to introduce activity/exercise at this stage? CASE STUDY 4 Respiratory medicine – copd patient Subjective assessment PC 65-year-old male Admitted to respiratory ward with acute exacerbation of COPD HPC Diagnosed 5 years ago with severe emphysema. Recent viral illness that has resulted in a dry cough, wheeze and breathlessness for 1/52. Has been house bound last few days. Normally 1–2 exacerbations per year that are managed by GP. No previous hospital admissions for COPD PMH Hypertension SH Retired engineer. Lives alone in third-floor flat. No lift. Normally manages all ADL independently. Exercise tolerance 50 m on flat – no aid required. Drives a car. No family living locally. No social services required. Smokes 30 cpd DH Salbutamol inhaler Becotide inhaler Atenolol GP letter states that patient has not picked up repeat prescription for inhalers from 1/12 ago Handover Admitted overnight. Patient noted to be drowsy but able to be roused for short periods. When awake, able to talk in short sentences but appears slightly disorientated. Breathing pattern laboured and has a dry, spontaneous cough. Dehydrated but receiving IV fluids Objective assessment Respiratory Ventilation SV 6 L O 2 via a simple face mask SpO 2 97% RR 9 CXR Hyperinflated lung fields with flattened diaphragms Emphysematous bullae upper zones No focal signs of collapse/consolidation ABG H + 58 mmol/L pCO 2 12 kPa pO 2 12 kPa HCO 3 − 30 mmol/L BE +9 CVS Temp 37.5°C HR 115 BP 130/90 CNS Drowsy but able to be roused for short periods Disorientated and confused. Moving all four limbs Renal Nil of note MSK Nil of note Microbiology None available Patient position Slumped lying in bed Observation Obese man with barrel shaped chest and large abdomen. Colour – flushed. Breathing through an open mouth. Predominately a shallow, apical breathing pattern with increased use of accessory muscles. Also demonstrating in-drawing of his lower chest wall on inspiration. Active expiration Auscultation Quiet BS generally with end expiratory polyphonic wheeze throughout Palpation Decreased expansion bi-basally (right = left). No palpable secretions Questions 1. The patient is drowsy with a RR of 9. What may be the contributing factors? 2. What is the difference between fixed and variable oxygen therapy? 3. Which type of oxygen therapy would be more suitable for the patient at this point? 4. What is this patient’s main physiotherapy problem? 5. What led you to this conclusion? 6. What factors may be contributing to this increased WOB? 7. How might your initial treatment plan address this problem of increased WOB? 8. Consider this patient’s CXR report, chest shape and breathing pattern. Would he benefit from lower lateral costal breathing exercises to improve basal chest excursion once he was less drowsy? 9. What goals would you hope to have achieved before this patient was discharged home? CASE STUDY 5 Surgical respiratory – anterior resection Subjective assessment PC 63-year-old male Day 2 post-laparotomy for anterior resection (end to end anastomosis) HPC Emergency admission yesterday with increasing abdominal pain 2/12 altered bowel habit PMH Nil of note- previously fit and well SH Lives with wife, recently retired, independent with ADL, plays golf three times a week, smoker 5 cpd DH Nil of note Handover Acute desaturation this morning. Patient has been coughing – effective and occasionally moist, nil expectorated. Otherwise stable Not been out of bed as yet Objective assessment Respiratory Ventilation SV 4 L O 2 via nasal cannulae SpO 2 90% RR 12 CXR Right basal collapse ABG None available CVS Temp 37.4°C HR 80 BP 130/60 CNS GCS E4 V5 M6 Pain score VAS 2/10 at rest 4/10 on movement/coughing Morphine PCA Renal UO 20–30 mL/hr +1.5 L cumulative balance to date MSK Nil of note Microbiology Nil of note Patient position Slumped in bed Observation Talking freely Auscultation Breath sounds throughout, fine end inspiratory crackles right base Palpation Reduced expansion right base, no secretions palpable Questions 1. Is this patient adequately oxygenated? What suggestions might you make? 2. List this patient’s physiotherapy problem(s). 3. What information from the objective assessment led you to this problem list? 4. Why are patients who have undergone surgery/anaesthetic at risk of developing respiratory compromise? 5. What are the treatment options for this patient? 6. What would your initial treatment plan include? 7. How would you progress this patient? 8. HDU patients can have many attachments including monitoring (ECG, sats probe), oxygen therapy, catheter and wound drains. What considerations would you have to give before mobilising such a patient? CASE STUDY 6 Surgical respiratory – division of adhesions Subjective assessment PC 74-year-old female Day 3 post-laparotomy and division of adhesions HPC Existing ileostomy – no output for 48 hours, vomiting and no significant fluid intake PMH Small bowel resection and formation of ileostomy 2 years previous for incarcerated hernia COPD Right axillary node clearance Previous pulmonary TB SH Lives alone, housebound, home help three times/day, smokes 10 cpd DH Ventolin inhaler Seretide inhaler Handover Initially in intensive care, intubated and ventilated. Extubated yesterday and transferred to HDU. Stable overnight, difficulty clearing secretions Objective assessment Respiratory Ventilation SV FiO 2 0.28 via face mask cold humidification RR16 SpO 2 89% CXR – taken prior to extubation ( Figure 5.2 ) Scoliosis, rotated, hyperinflated, nil focal Figure 5.2 X-ray for Case Study 6 taken prior to extubation showing the patient has a scolosis with hyperinflated lungs and nil focal in lung fields. ABG H + 36.35 nmol/L pCO 2 5.91 kPa pO 2 7.42 kPa HCO 3 − 28.2 mmol/L BE + 4.7 CVS Temp 36.5°C HR 85 BP 110/50 Noradrenaline 8 mL/hr CNS GCS E4 V5 M6 Pain score VAS 3/10 at rest 8/10 on movement/coughing Morphine PCA Renal UO 50 mL/hr +3.2 L cumulative balance to date MSK Nil of note Microbiology Nil of note Patient position Sitting upright in bed, frail Observation Hyperinflated chest, looks well, chatting freely, dry mouth Auscultation Breath sounds throughout, coarse expiratory crackles throughout Palpation Expansion equal, palpable secretions bilateral upper zones Questions 1. Describe the advantages and disadvantages of patient-controlled analgesia (PCA). 2. Considering this patient’s CXR ( Figure 5.2 ), what additional hardware/monitoring is visible? 3. List this patient’s physiotherapy problem(s). 4. What information from the assessment led you to this problem list? 5. From the assessment information, what suggestions should the physiotherapist make before physiotherapy care commences? 6. What would be your initial treatment plan? 7. Given this patient’s present condition and past history, how might you need to modify the treatments delivered? 8. How would you know if your treatment had been effective (outcome measures)? 9. If the initial treatment plan were to be unsuccessful in clearing secretions, how would you modify your treatment? CASE STUDY 7 Surgical respiratory – hemicolectomy Subjective assessment PC 55-year-old male Day 2 post laparotomy for right hemicolectomy (end to end anastomosis) HPC Elective admission for bowel resection – investigated 6/12 ago due to altered bowel habit and weight loss. Tumour identified and biopsy taken during colonoscopy PMH Nil of note SH Lives alone, independent with ADL, non-smoker DH Nil of note Handover Acute desaturation this morning requiring increased FiO 2 , not been out of bed as yet due to reduced blood pressure, otherwise stable Objective assessment Respiratory Ventilation SV FiO 2 0.6 via face mask cold humidification RR 12 SpO 2 96% CXR Left lower lobe collapse ABG None available CVS Temp 37.4°C HR 80 BP 80/45 CNS GCS E4 V5 M6 Pain score VAS 2/10 at rest 3/10 on movement/coughing Epidural analgesia (Bupivacaine and Morphine mix) Renal UO 30 mL/hr +1.5 L cumulative balance to date MSK Nil of note Microbiology Nil of note Patient position Slumped in bed Observation Looks well, talking freely Auscultation Breath sounds throughout, reduced at left base Palpation Reduced expansion left base, no secretions palpable Questions 1. What does the procedure of a right hemicolectomy involve? 2. Why can the presence of an epidural lead to hypotension? 3. List this patient’s physiotherapy problem(s). 4. What information from the objective assessment led you to this problem list? 5. What would be your initial treatment plan? 6. After identifying an appropriate treatment plan, what information/instructions would you handover to the nursing staff caring for the patient? 7. How would you determine if your treatment plan had been effective (outcome measures)? 8. What goals would you hope to have achieved before this patient was discharged home? CASE STUDY 8 Surgical respiratory – bowel resection Subjective assessment PC 80-year-old male Day 3 post-laparotomy for bowel resection HPC Presented to A&E with painful distended abdomen. Bowels not opened for 2/7 previous. Distended loops of bowel and sigmoid volvulus on AXR. Attempted decompression by colonoscopy unsuccessful therefore proceeded to theatre for open procedure PMH Hypertension SH Lives with wife, independently mobile DH Atenolol Handover Patient confused and drowsy since return from theatre. Has a moist, ineffective cough that is not productive Objective assessment Respiratory Ventilation SV 2L O 2 via nasal cannulae RR 17 SpO 2 94% CXR ( Figure 5.3 ) Reduced lung volume bibasally Figure 5.3 X-ray for Case Study 8 showing reduced lung volume bi-basally. ABG H + 49.8 nmol/L pCO 2 4.87 kPa pO 2 10.16 kPa HCO 3 − 18.0 mmol/L BE –8 CVS Temp 37°C HR 100 BP 160/70 CVP +9 CNS GCS E3 V4 M5 Pain score – unable to score reliably Renal UO 35 mL/hr +6 L cumulative fluid balance to date MSK Nil of note Microbiology Nil of note Patient position Slumped in bed Observation Drowsy, audible added sounds at mouth Auscultation Breath sounds throughout reduced bibasally, expiratory crackles upper zones Palpation Expansion equally reduced bilaterally, no secretions palpable Questions 1. Explain the patient’s drug history in relation to the past medical history. 2. Why do post-operative patients tend to have a significant positive fluid balance? 3. Why is metabolic acidosis a common finding when analysing the ABG of a post-operative patient? 4. List this patient’s physiotherapy problem(s). 5. What information from the objective assessment led you to this problem list? 6. Systematically analysing this patient’s CXR ( Figure 5.3 ), what signs do you find that would confirm bibasal loss of lung volume? 7. What would be your initial treatment plan? 8. What could be suggested as a management strategy if the patient required regular suctioning and why? CASE STUDY 9 Intensive care – patient for extubation Subjective assessment PC 55-year-old female Day 7 post-laparotomy for subtotoal colectomy and extensive bowel resection, formation of ileostomy HPC Emergency admission from A&E in shock with reduced BP, abdominal pain Unwell for 3–4 days, intermittent diarrhoea and vomiting Theatre findings – patchy infarction of small and large bowel PMH Hypertension SH Lives with son, 10 cpd smoker DH Bisoprolol Handover Stable overnight Possibly for extubation. Just weaned to ASB from SIMV Objective assessment Respiratory Ventilation ASB (PEEP 5 PS 5) ETT size 7.0 FiO 2 0.35 RR 19 Tv 0.46 L SpO 2 97% M1 secretions CXR Nil focal ABG H + 39.7 nmol/L pCO 2 5.06 kPa pO 2 14.15 kPa HCO 3 − 23.1 mmol/L BE –1.5 CVS Temp 38.6°C HR 135 BP 169/88 CVP +11 CNS GCS E3 VT M4 Propofol 10 mL/hr Alfentanil 2 mL/hr Renal UO 50 mL/hr overall +500 mL MSK Nil of note Microbiology Sputum and urine – no growth Patient position Head-up tilt in bed Observation Intubated and ventilated, settled, relaxed breathing pattern Auscultation Breath sounds throughout, no added sounds Palpation Expansion equal, no secretions palpable Questions 1. Define and explain the difference between SIMV and ASB modes of ventilation. 2. What would you look for in a patient assessment that might indicate to you a patient is ready for extubation? 3. The Glasgow Coma Scale (GCS) is used to assess level of consciousness. What are the components of the scoring system? 4. On assessment this patient GCS is E3 VT M5. What is the patient ‘doing’ and what are the implications of this for the patient with regard to readiness to extubate? 5. List this patient’s physiotherapy problem(s). 6. What information from the objective assessment led you to this problem list? 7. What would be your initial treatment plan? 8. How would you assess as to whether the deep breaths the patient was attempting to take were effective? CASE STUDY 10 Intensive care – surgical patient Subjective assessment PC 51-year-old female Day 1 post laparotomy – drainage of pelvic abscess and over sew of serosal tears HPC Admitted previous day with abdominal pain and distension. CT revealed free gas, fluid and faeces in the abdomen and a pelvic collection PMH Ischaemic colitis Hartmans procedure 1 year ago SH Lives with husband Independent with all ADL DH Nil Handover Problems with cuff leak on repositioning. Aiming to place NG tube then reduce sedation Objective assessment Respiratory Ventilation SIMV ETT size 7.0 FiO 2 0.35 PEEP 5 PS 10 Tv 0.419 L RR 14 SpO 2 92% HMEF brown secretions CXR Nil focal ABG H + 52.19 nmol/L pCO 2 4.6 kPa pO 2 10.96 kPa HCO 3 − 16.6 mmol/L BE –9.8 CVS Temp 36.5°C HR 100 BP 140/90 CVP +10 CNS GCS E3 VT M5 Propofol 7 mL/hr Alfentanil 2 mL/hr Renal UO 35 mL/hr +2.5 L cumulative balance MSK Nil of note Microbiology Nil of note Patient position Head-up tilt in bed Observation Intubated, ventilated, settled Auscultation Breath sounds throughout, coarse expiratory crackles right upper/middle zones Palpation Expansion equal, palpable secretions right upper zone Questions 1. Analyse the ABG presented. 2. On handover the presence of a cuff leak has been highlighted. What is the significance of this information? 3. List this patient’s physiotherapy problem(s). 4. What information from the objective assessment led you to this problem list? 5. Positioning is integral to all respiratory physiotherapeutic input. Which position would you choose for this patient and why? 6. What would be your initial treatment plan? 7. If your initial treatment was unsuccessful in clearing the secretions, how might you modify your treatment? 8. What are the potential hazards associated with endotracheal suctioning? CASE STUDY 11 Intensive care – medical patient Subjective assessment PC 72-year-old male Bilateral pneumonia and sepsis, 4 hours post ICU admission HPC Presented to Acute Receiving Unit today. Poor oral intake for 1/52 – dehydrated and weak PMH Mild learning difficulties, irritable bowel syndrome SH Lives with partner, home help twice a week, otherwise independent DH Nil of note Handover Stable since admission; plan to keep sedated for at least 24 hours Objective assessment Respiratory Ventilation Uncut ETT size 8.0 SIMV FiO 2 0.65 PEEP 10 SpO 2 96% RR 25/0 mandatory/spontaneous Tv 0.55 L nil-M1 secretions CXR Collapse consolidation left lower zone, patchy changes right middle zone ABG H + 53.8 nmol/L pCO 2 6.9 kPa pO 2 10.7 kPa HCO 3 − 24 mmol/L BE –1.2 CVS Temp 38°C HR 90 BP 95/55 CVP +12 Noradrenaline 26 mL/hr CNS Pupils 2+ 2+ GCS E2 VT M4 Sedation – Propofol 10 mL/hr, Alfentanil 2 mL/hr Renal UO 30+ mL/hr +1 L balance MSK Nil of note Microbiology No result as yet, commenced on broad-spectrum antibiotics Patient position Head-up tilt in bed Observation Intubated, ventilated, sedated Auscultation Breath sounds throughout, bronchial breathing left lower zone Palpation Reduced expansion left base, no secretions palpable Questions 1. The patient is septic. What information from the objective assessment indicates this? 2. Analyse the ABG presented. 3. Describe bronchial breathing. 4. List this patient’s physiotherapy problems(s). 5. What information from the objective assessment led you to this problem list? 6. What could be your initial treatment plan for each of these problems? 7. Clinically reason through whether MHI would be appropriate for this patient. 8. What would be your short-term goals for this patient? CASE STUDY 12 Intensive care – patient mobilisation Subjective assessment PC 50-year-old male Community-acquired pneumonia Day 41 in ICU HPC Admitted via A&E drowsy, sweaty and ‘unwell’. Quickly deteriorated with respiratory failure, requiring intubation and ventilation Complicated ICU stay with ARDS and two failed extubations PMH Alcohol excess (½ bottle vodka a day) Previous IV drug abuser Previous ICU admission with pneumonia SH Lives alone, first floor flat DH Nil of note Handover Been on CPAP overnight via tracheostomy, now on speaking valve Patient is keen to mobilise Objective assessment Respiratory Ventilation Trache size 8.0 (with inner tube, non-fenestrated) Speaking valve in situ. 2 L O 2 SpO 2 96% RR 20 MP2 secretions on suction CXR No recent ABG H + 39.42 nmol/L pCO 2 5.34 kPa pO 2 11.5 kPa HCO 3 − 24.1 mmol/L BE –0.2 CVS Temp 36.5°C HR 80 BP 140/80 CNS GCS E4 V5 M6 Renal UO 100 mL/hr overall negative balance MSK Nil of note Microbiology MRSA +ve in sputum Patient position High sitting in bed Observation Looks well, strong clear voice Auscultation Breath sounds throughout, no added sounds Palpation Expansion equal, no secretions palpable Questions 1. This patient developed ARDS due to severe pneumonia. What is ARDS? 2. This patient failed two attempts at extubation and so had a tracheostomy inserted to facilitate weaning. What other indications are there for tracheostomy tube insertion?

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Case Study: Managing Severe Asthma in an Adult

—he follows his treatment plan, but this 40-year-old male athlete has asthma that is not well-controlled. what’s the next step.

By Kirstin Bass, MD, PhD Reviewed by Michael E. Wechsler, MD, MMSc

This case presents a patient with poorly controlled asthma that remains refractory to treatment despite use of standard-of-care therapeutic options. For patients such as this, one needs to embark on an extensive work-up to confirm the diagnosis, assess for comorbidities, and finally, to consider different therapeutic options.

Case presentation and patient history

Mr. T is a 40-year-old recreational athlete with a medical history significant for asthma, for which he has been using an albuterol rescue inhaler approximately 3 times per week for the past year. During this time, he has also been waking up with asthma symptoms approximately twice a month, and has had three unscheduled asthma visits for mild flares. Based on the  National Asthma Education and Prevention Program guidelines , Mr. T has asthma that is not well controlled. 1

As a result of these symptoms, spirometry was performed revealing a forced expiratory volume in the first second (FEV1) of 78% predicted. Mr. T then was prescribed treatment with a low-dose corticosteroid, fluticasone 44 mcg at two puffs twice per day. However, he remained symptomatic and continued to use his rescue inhaler 3 times per week. Therefore, he was switched to a combination inhaled steroid and long-acting beta-agonist (LABA) (fluticasone propionate 250 mcg and salmeterol 50 mcg, one puff twice a day) by his primary care doctor.

Initial pulmonary assessment Even with this step up in his medication, Mr. T continued to be symptomatic and require rescue inhaler use. Therefore, he was referred to a pulmonologist, who performed the initial work-up shown here:

• Spirometry, pre-albuterol: FEV1 79%, post-albuterol: 12% improvement
• Methacholine challenge: PC 20 : 1.0 mg/mL
• Chest X-ray: Within normal limits

Continued pulmonary assessment His dose of inhaled corticosteroid (ICS) and LABA was increased to fluticasone 500 mcg/salmeterol 50 mcg, one puff twice daily. However, he continued to have symptoms and returned to the pulmonologist for further work-up, shown here:

• Chest computed tomography (CT): Normal lung parenchyma with no scarring or bronchiectasis
• Sinus CT: Mild mucosal thickening
• Complete blood count (CBC): Within normal limits, white blood cells (WBC) 10.0 K/mcL, 3% eosinophils
• Immunoglobulin E (IgE): 25 IU/mL
• Allergy-skin test: Positive for dust, trees
• Exhaled NO: Fractional exhaled nitric oxide (FeNO) 53 parts per billion (pbb)

Assessment for comorbidities contributing to asthma symptoms After this work-up, tiotropium was added to his medication regimen. However, he remained symptomatic and had two more flares over the next 3 months. He was assessed for comorbid conditions that might be affecting his symptoms, and results showed:

• Esophagram/barium swallow: Negative
• Esophageal manometry: Negative
• Esophageal impedance: Within normal limits
• ECG: Within normal limits
• Genetic testing: Negative for cystic fibrosis, alpha1 anti-trypsin deficiency

The ear, nose, and throat specialist to whom he was referred recommended only nasal inhaled steroids for his mild sinus disease and noted that he had a normal vocal cord evaluation.

Following this extensive work-up that transpired over the course of a year, Mr. T continued to have symptoms. He returned to the pulmonologist to discuss further treatment options for his refractory asthma.

Diagnosis Mr. T has refractory asthma. Work-up for this condition should include consideration of other causes for the symptoms, including allergies, gastroesophageal reflux disease, cardiac disease, sinus disease, vocal cord dysfunction, or genetic diseases, such as cystic fibrosis or alpha1 antitrypsin deficiency, as was performed for Mr. T by his pulmonary team.

Treatment options When a patient has refractory asthma, treatment options to consider include anticholinergics (tiotropium, aclidinium), leukotriene modifiers (montelukast, zafirlukast), theophylline, anti-immunoglobulin E (IgE) antibody therapy with omalizumab, antibiotics, bronchial thermoplasty, or enrollment in a clinical trial evaluating the use of agents that modulate the cell signaling and immunologic responses seen in asthma.

Treatment outcome Mr. T underwent bronchial thermoplasty for his asthma. One year after the procedure, he reports feeling great. He has not taken systemic steroids for the past year, and his asthma remains controlled on a moderate dose of ICS and a LABA. He has also been able to resume exercising on a regular basis.

Approximately 10% to 15% of asthma patients have severe asthma refractory to the commonly available medications. 2  One key aspect of care for this patient population is a careful workup to exclude other comorbidities that could be contributing to their symptoms. Following this, there are several treatment options to consider, as in recent years there have been several advances in the development of asthma therapeutics. 2

Treatment options for refractory asthma There are a number of currently approved therapies for severe, refractory asthma. In addition to therapy with ICS or combination therapies with ICS and LABAs, leukotriene antagonists have good efficacy in asthma, especially in patients with prominent allergic or exercise symptoms. 2  The anticholinergics, such as tiotropium, which was approved for asthma in 2015, enhance bronchodilation and are useful adjuncts to ICS. 3-5  Omalizumab is a monoclonal antibody against IgE recommended for use in severe treatment-refractory allergic asthma in patients with atopy. 2  A nonmedication therapeutic option to consider is bronchial thermoplasty, a bronchoscopic procedure that uses thermal energy to disrupt bronchial smooth muscle. 6,7

Personalizing treatment for each patient It is important to personalize treatment based on individual characteristics or phenotypes that predict the patient's likely response to treatment, as well as the patient's preferences and practical issues, such as adherence and cost. 8

In this case, tiotropium had already been added to Mr. T's medications and his symptoms continued. Although addition of a leukotriene modifier was an option for him, he did not wish to add another medication to his care regimen. Omalizumab was not added partly for this reason, and also because of his low IgE level. As his bronchoscopy was negative, it was determined that a course of antibiotics would not be an effective treatment option for this patient. While vitamin D insufficiency has been associated with adverse outcomes in asthma, T's vitamin D level was tested and found to be sufficient.

We discussed the possibility of Mr. T's enrollment in a clinical trial. However, because this did not guarantee placement within a treatment arm and thus there was the possibility of receiving placebo, he opted to undergo bronchial thermoplasty.

Bronchial thermoplasty  Bronchial thermoplasty is effective for many patients with severe persistent asthma, such as Mr. T. This procedure may provide additional benefits to, but does not replace, standard asthma medications. During the procedure, thermal energy is delivered to the airways via a bronchoscope to reduce excess airway smooth muscle and limit its ability to constrict the airways. It is an outpatient procedure performed over three sessions by a trained physician. 9

The effects of bronchial thermoplasty have been studied in several trials. The first large-scale multicenter randomized controlled study was  the Asthma Intervention Research (AIR) Trial , which enrolled patients with moderate to severe asthma. 10  In this trial, patients who underwent the procedure had a significant improvement in asthma symptoms as measured by symptom-free days and scores on asthma control and quality of life questionnaires, as well as reductions in mild exacerbations and increases in morning peak expiratory flow. 10  Shortly after the AIR trial, the  Research in Severe Asthma (RISA) trial  was conducted to evaluate bronchial thermoplasty in patients with more severe, symptomatic asthma. 11  In this population, bronchial thermoplasty resulted in a transient worsening of asthma symptoms, with a higher rate of hospitalizations during the treatment period. 11  Hospitalization rate equalized between the treatment and control groups in the posttreatment period, however, and the treatment group showed significant improvements in rescue medication use, prebronchodilator forced expiratory volume in the first second (FEV1) % predicted, and asthma control questionnaire scores. 11

The AIR-2  trial followed, which was a multicenter, randomized, double-blind, sham-controlled study of 288 patients with severe asthma. 6  Similar to the RISA trial, patients in the treatment arm of this trial experienced an increase in adverse respiratory effects during the treatment period, the most common being airway irritation (including wheezing, chest discomfort, cough, and chest pain) and upper respiratory tract infections. 6

The majority of adverse effects occurred within 1 day of the procedure and resolved within 7 days. 6  In this study, bronchial thermoplasty was found to significantly improve quality of life, as well as reduce the rate of severe exacerbations by 32%. 6  Patients who underwent the procedure also reported fewer adverse respiratory effects, fewer days lost from work, school, or other activities due to asthma, and an 84% risk reduction in emergency department visits. 6

Long-term (5-year) follow-up studies have been conducted for patients in both  the AIR  and  the AIR-2  trials. In patients who underwent bronchial thermoplasty in either study, the rate of adverse respiratory effects remained stable in years 2 to 5 following the procedure, with no increase in hospitalizations or emergency department visits. 7,12  Additionally, FEV1 remained stable throughout the 5-year follow-up period. 7,12  This finding was maintained in patients enrolled in the AIR-2 trial despite decreased use of daily ICS. 7

Bronchial thermoplasty is an important addition to the asthma treatment armamentarium. 7  This treatment is currently approved for individuals with severe persistent asthma who remain uncontrolled despite the use of an ICS and LABA. Several clinical trials with long-term follow-up have now demonstrated its safety and ability to improve quality of life in patients with severe asthma, such as Mr. T.

Severe asthma can be a challenge to manage. Patients with this condition require an extensive workup, but there are several treatments currently available to help manage these patients, and new treatments are continuing to emerge. Managing severe asthma thus requires knowledge of the options available as well as consideration of a patient's personal situation-both in terms of disease phenotype and individual preference. In this case, the patient expressed a strong desire to not add any additional medications to his asthma regimen, which explained the rationale for choosing to treat with bronchial thermoplasty. Personalized treatment necessitates exploring which of the available or emerging options is best for each individual patient.

Published: April 16, 2018

• 1. National Asthma Education and Prevention Program: Asthma Care Quick Reference.
• 2. Olin JT, Wechsler ME. Asthma: pathogenesis and novel drugs for treatment. BMJ . 2014;349:g5517.
• 3. Boehringer Ingelheim. Asthma: U.S. FDA approves new indication for SPIRIVA Respimat [press release]. September 16, 2015.
• 4. Peters SP, Kunselman SJ, Icitovic N, et al. Tiotropium bromide step-up therapy for adults with uncontrolled asthma. N Engl J Med . 2010;363:1715-1726.
• 5. Kerstjens HA, Engel M, Dahl R. Tiotropium in asthma poorly controlled with standard combination therapy. N Engl J Med . 2012;367:1198-1207.
• 6. Castro M, Rubin AS, Laviolette M, et al. Effectiveness and safety of bronchial thermoplasty in the treatment of severe asthma: a multicenter, randomized, double-blind, sham-controlled clinical trial. Am J Respir Crit Care Med . 2010;181:116-124.
• 7. Wechsler ME, Laviolette M, Rubin AS, et al. Bronchial thermoplasty: long-term safety and effectiveness in patients with severe persistent asthma. J Allergy Clin Immunol . 2013;132:1295-1302.
• 8. Global Initiative for Asthma: Pocket Guide for Asthma Management and Prevention (for Adults and Children Older than 5 Years).
• 10. Cox G, Thomson NC, Rubin AS, et al. Asthma control during the year after bronchial thermoplasty. N Engl J Med . 2007;356:1327-1337.
• 11. Pavord ID, Cox G, Thomson NC, et al. Safety and efficacy of bronchial thermoplasty in symptomatic, severe asthma. Am J Respir Crit Care Med . 2007;176:1185-1191.
• 12. Thomson NC, Rubin AS, Niven RM, et al. Long-term (5 year) safety of bronchial thermoplasty: Asthma Intervention Research (AIR) trial. BMC Pulm Med . 2011;11:8.

More On This Topic

Treatable traits and future exacerbation risk in severe asthma, baker’s asthma, the long-term trajectory of mild asthma, age, gender, & systemic corticosteroid comorbidities, ask the expert: william busse, md, challenges the current definition of the atopic march, considering the curveballs in asthma treatment, do mucus plugs play a bigger role in chronic severe asthma than previously thought, an emerging subtype of copd is associated with early respiratory disease.

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Article Contents

Case 1 diagnosis: allergy bullying, clinical pearls.

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Case 1: A 12-year-old girl with food allergies and an acute asthma exacerbation

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Lopamudra Das, Michelle GK Ward, Case 1: A 12-year-old girl with food allergies and an acute asthma exacerbation, Paediatrics & Child Health , Volume 19, Issue 2, February 2014, Pages 69–70, https://doi.org/10.1093/pch/19.2.69

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A 12-year-old girl with a history of asthma presented to the emergency department with a three-day history of increased work of breathing, cough and wheezing. She reported no clear trigger for her respiratory symptoms, although she had noted some symptoms of a mild upper respiratory tract infection. With this episode, the patient had been using a short-acting bronchodilator more frequently than she had in the past, without the expected resolution of symptoms.

On the day of presentation, the patient awoke feeling ‘suffocated’ and her mother noted her lips to be blue. In the emergency department, her oxygen saturation was 85% and her respiratory rate was 40 breaths/min. She had significantly increased work of breathing and poor air entry bilaterally to both lung bases, with wheezing in the upper lung zones. She was treated with salbutamol/ipratropium and received intravenous steroids and magnesium sulfate. Her chest x-ray showed hyperinflation and no focal findings.

Her medical history revealed that she was followed by a respirologist for her asthma, had good medication adherence and had not experienced a significant exacerbation for six months. She also had a history of wheezing, dyspnea and pruritis with exposure to peanuts, chickpeas and lentils; she had been prescribed an injectible epinephrine device for this. However, her device had expired at the time of presentation. In the past, her wheezing episodes had been seasonal and related to exposure to grass and pollens; this presentation occurred during the winter. Further history revealed the probable cause of her presentation.

Although reluctant to disclose the information, our patient later revealed that she had been experiencing significant bullying at school, which was primarily related to her food allergies. Three days before her admission, classmates had smeared peanut butter on one of her schoolbooks. She developed pruritis immediately after opening the book and she started wheezing and coughing later that day. This event followed several months of being taunted with peanut products at school. The patient was experiencing low mood and reported new symptoms of anxiety related to school. The review of systems was otherwise negative, with no substance use.

The patient's asthma exacerbation resolved with conventional asthma treatment. Her pulmonary function tests were nonconcerning (forced expiratory volume in 1 s 94% and 99% of predicted) after her recovery. The trigger for her asthma exacerbation was likely multifactorial, related to exposure to the food allergen as well as the upper respiratory infection. A psychologist was consulted to assess the symptoms of anxiety and depression that had occurred as a result of the bullying. During the hospitalization, the medical team contacted the patient's school to provide education on allergy bullying, treatment of severe allergic reactions and its potential for life-threatening reactions with exposure to allergens. The medical team also recommended community resources for further education of students and staff about allergy bullying and its prevention.

Allergy bullying is a form of bullying with potentially severe medical outcomes. In recent years, it has gained increasing notoriety in schools and in the media. Population-based studies have shown that 20% to 35% of children with allergies experience bullying. In many cases (31% in one recent study [ 1 ]), this bullying is related directly to the food allergy. From a medical perspective, there are little published data regarding allergy bullying, and many health care providers may not be aware of the issue.

Allergy bullying can include teasing a child about their allergy, throwing food at a child, or even forcing them to touch or eat allergenic foods. Most episodes of allergy bullying occur at school, and can include episodes perpetrated by teachers and/or staff ( 2 ).

Allergy bullying can lead to allergic reactions, which may be mild or severe (eg, urticaria, wheezing, anaphylaxis), but may also lead to negative emotional consequences (sadness, depression) ( 2 ) and an overall decrease in quality of life measures ( 1 ). Adolescents commonly resist using medical devices, such as injectible epinephrine devices, and bullying may be a contributing factor for this ( 3 ). Attempting to conceal symptoms in a bullying situation may place children at risk for a worse outcome.

Physicians can play a key role in detecting allergy bullying and its health consequences. In many cases, children have not discussed this issue with their parents ( 1 ). Given the prevalence of bullying, its potential to lead to severe harm, including death, and the lack of awareness of this issue, clinicians should specifically ask about bullying in all children and teens with allergies. Physicians can also work with families and schools to support these children, educate their peers and school staff, and help prevent negative health outcomes from allergy bullying.

Online resources

www.anaphylaxis.ca − A national charity that aims to inform, support, educate and advocate for the needs of individuals and families living with anaphylaxis, and to support and participate in research. This website includes education modules for schools and links to local support groups throughout Canada.

www.whyriskit.ca/pages/en/live/bullying.php − A website for teenagers with food allergies; includes a segment that addresses food bullying.

www.foodallergy.org − Contains numerous resources for children and their families, including a significant discussion on bullying and ways to prevent it.

Allergy bullying is common but is often unrecognized as a factor in clinical presentations of allergic reactions.

Physicians should make a point of asking about bullying in patients with allergies and become familiar with resources for dealing with allergy bullying.

Physicians can play roles as advocates, educators and collaborators with the school system to help make the school environment safer for children with allergies who may be at risk for allergy bullying.

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• Case report
• Open access
• Published: 17 August 2024

Trans-spinal magnetic stimulation combined with kinesiotherapy as a new method for enhancing functional recovery in patients with spinal cord injury due to neuromyelitis optica: a case report

• Rodrigo Brito   ORCID: orcid.org/0000-0003-2511-3143 1 , 2 ,
• Bárbara Marroquim   ORCID: orcid.org/0000-0002-0132-757X 1 ,
• Lívia Shirahige   ORCID: orcid.org/0000-0002-3331-0596 1 , 2 ,
• Adriana Baltar 1 , 2 ,
• Sérgio Rocha   ORCID: orcid.org/0000-0003-3220-4537 1 ,
• Alexia Perruci   ORCID: orcid.org/0000-0001-5554-6797 1 &
• Katia Monte-Silva   ORCID: orcid.org/0000-0001-7301-2553 1 , 2  

Journal of Medical Case Reports volume  18 , Article number:  386 ( 2024 ) Cite this article

47 Accesses

Metrics details

Experimental studies have shown that repetitive trans-spinal magnetic stimulation (TsMS) decreases demyelination and enables recovery after spinal cord injury (SCI). However, the usefulness of TsMS in humans with SCI remains unclear. Therefore, the main objective of this study is to evaluate the effects of TsMS combined with kinesiotherapy on SCI symptoms. We describe a protocol treatment with TsMS and kinesiotherapy in a patient with SCI due to neuromyelitis optica (NMO)-associated transverse myelitis.

Case presentation

A 23-year-old white male with NMO spectrum disorders started symptoms in 2014 and included lumbar pain evolving into a mild loss of strength and sensitivity in both lower limbs. Five months later, the symptoms improved spontaneously, and there were no sensorimotor deficits. Two years later, in 2016, the symptoms recurred with a total loss of strength and sensitivity in both lower limbs. Initially, physiotherapy was provided in 15 sessions with goals of motor-sensory recovery and improving balance and functional mobility. Subsequently, TsMS (10 Hz, 600 pulses, 20-seconds inter-trains interval, at 90% of resting motor threshold of the paravertebral muscle) was applied at the 10th thoracic vertebral spinous process before physiotherapy in 12 sessions. Outcomes were assessed at three time points: prior to physiotherapy alone (T-1), before the first session of TsMS combined with kinesiotherapy (T0), and after 12 sessions of TsMS combined with kinesiotherapy (T1). The patient showed a 25% improvement in walking independence, a 125% improvement in balance, and an 18.8% improvement in functional mobility. The Patient Global Impression of Change Scale assessed the patient’s global impression of change as ‘much improved’.

TsMS combined with kinesiotherapy may safely and effectively improve balance, walking independence, and functional mobility of patients with SCI due to NMO-associated transverse myelitis.

Peer Review reports

Introduction

Neuromyelitis optica (NMO) is an autoimmune astrocytopathic disease of the central nervous system with a predilection for the spinal cord and optic nerves and may cause transverse myelitis and optic neuritis, respectively, if these regions are affected [ 47 , 49 ]. The symptoms associated with transverse myelitis are similar to those of spinal cord injury (SCI), including sensorimotor symptoms, pain, cardiovascular symptoms, and symptoms of bladder, bowel, and sexual dysfunction [ 22 ].

Regarding recovery from NMO-associated transverse myelitis, physiotherapy does not seem to result in the deterioration of symptoms in most patients [ 38 ]; however, few cases with poor functional recovery have been reported [ 43 , 45 ]. Despite the proposal of a variety of treatment approaches, such as surgery, physiotherapy, and cell-based therapy, either individually or in combination, their limited efficacy in fully restoring functionality for many patients underscores the need for exploring innovative interventions [ 12 , 15 ]. Non-invasive brain stimulation (NIBS) is a promising tool for altering cortical and spinal excitability safely and painlessly [ 42 ]. Experimental studies in mice with SCI have shown a reduction in demyelination and axonal and walking recovery after trans-spinal magnetic stimulation (TsMS) [ 8 , 31 ].

These studies provide evidence that TsMS induces therapeutic effects in an experimental animal model and suggest a possible translation of the results to clinical application in humans [ 8 ]. The usefulness of TsMS in human patients with SCI has not been documented. In this case report, we describe the usefulness and safety of repetitive TsMS combined with physiotherapy provided to improve mobility of a patient with chronic incomplete SCI due to NMO-associated transverse myelitis.

Case description

Publication of this case report was approved by the local ethics committee (4.755.012), and all study procedures were conducted following the principles stated in the Declaration of Helsinki. The patient underwent physiotherapy at the Applied Neuroscience Laboratory (LANA) at Universidade Federal de Pernambuco (Recife, Pernambuco, Brazil).

The patient was a 23-year-old white male diagnosed with NMO spectrum disorders, presenting no relevant family history. The symptoms started in 2014, when the patient was 18 years old, initially manifesting as lumbar pain evolving into a mild loss of strength and sensitivity in both lower limbs. Five months later, the symptoms improved spontaneously, and there were no sensorimotor deficits. However, 2 years later, in 2016, the symptoms recurred with a total loss of strength and sensitivity in both lower limbs. During this period, the patient did not exhibit any visual symptoms. Over the past 3 years, the patient underwent physiotherapy twice a week, each lasting 35 min, but reported only minimal improvement in their functional sensory-motor symptoms. Consequently, the patient contacted our research group seeking further treatment options.

According to the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) by the American Spinal Injuries Association (ASIA) [ 24 ], the patient had ASIA Impairment Scale (AIS) grade D (motor function is preserved below the neurological level, and at least half of the key muscles below the neurological level have a muscle grade of 3 or more) with sensory level at T5 and motor level at L2 in both right and left sides, and the neurological level was at T5. The patient was independent in activities of daily living such as self-care, dressing, feeding, and movement. Based on the Walking Index for Spinal Cord Injury II (WISCI II) scale [ 14 ], the patient ambulated with two crutches both indoor and outdoor, with no braces and physical assistance.

Initially, we opted for an exclusive kinesiotherapy-based treatment for the patient, conducting 15 sessions. Unfortunately, this strategy failed to produce any noticeable gains in motor function. Given the insights from emerging studies, such as those by Ainhoa Insausti-Delgado et al. [ 21 ], which highlighted TsMS capacity to promote neuroplasticity in the motor cortex, we decided to integrate TsMS into our kinesiotherapy protocol [ 21 ]. After checking the safety criteria for transcranial magnetic stimulation [ 42 ] and obtaining written informed consent for participation in the research, the patient underwent 12 sessions of trans-spinal magnetic stimulation (TsMS) in conjunction with kinesiotherapy, tailored to the patient’s specific functional requirements.

Interventions

The initial plan of rehabilitation.

The patient underwent 15 sessions of physiotherapy; each session lasted for approximately 2 hours, and the therapy was provided two times a week. Each treatment session had the following goals: (i) to regain muscle strength in lower limbs, (ii) to achieve sensory recovery, (iii) to achieve balance, and (iv) to achieve functional mobility. All proposed exercises were performed considering principles of motor learning theory and principles of neuroplasticity [ 25 ]. The physiotherapy protocol is shown in Table  1 .

Trans-spinal magnetic stimulation protocol

The patient was asked to lie prone on a stretcher during the TsMS session. The resting motor threshold (rMT) of the paraspinal muscle at the 10th thoracic vertebral level was assessed (Fig.  1 ). rMT was defined as the lowest intensity of TsMS output that was able to produce visible muscular contraction in the target muscle in more than 5 of 10 trials. TsMS was performed using a figure-of-eight coil attached to a MagStim Super Rapid magnetic stimulator (MagStim Company, Whitland, UK) and placed over the spinous process of the 10th thoracic vertebra. A 10-Hz stimulus was delivered with 600 pulses (60 pulses, 10 trains) and 20-seconds inter-trains intervals at 90% rMT.

Positioning of the figure-of-eight coil for assessing the resting motor threshold of the paraspinal muscle at the level of the 10th thoracic vertebra

Physiotherapy was conducted immediately after TsMS in another 12 sessions (10 sessions were held daily for five times a week [induction phase], and two sessions were performed with a 48-hours interval between them [maintenance phase]). The protocol and main goals of the physiotherapy were the same as those of the initial plan of rehabilitation.

Except for the ISNCSCI grading, all evaluations were performed at the baseline (T-1), before starting TsMS (T0), and immediately after the completion of the 12th TsMS session (T1). The outcome measures were chosen based on the body structure, body function, and activity domains of the International Classification of Functioning, Disability, and Health (ICF) framework.

The activity was assessed using the WISCI II scale for walking independence. The WISCI II scale assesses the extent of physical assistance and devices required for walking following paralysis that results from SCI. There are 20 levels of assessment; higher levels indicate more independent mobility [ 13 ], and a change of one WISCI level can be considered a substantial difference in the clinical context (minimal detectable change [MDC]) [ 6 ]. At baseline, the patient had a WISCI II score of 16 (ambulation with two crutches with no braces and physical assistance), and the score remained the same during the initial rehabilitation period. The WISCI II score changed only after initiating TsMS treatment, reaching the maximum level (20; ambulation with no device, braces, and physical assistance). The patient achieved four times the MDC in the WISCI II scale assessment (Fig.  2 , Table  2 ).

Graphical representation of quantitative assessment before and after 12 sessions of repetitive trans-spinal magnetic stimulation combined with physical therapy. Mini-BEST: short version of the Balance Evaluation Systems test; WISCI II: Walking Index for Spinal Cord Injury scale; TUG: timed get up and go test, before TsMS represent the “T0: before starting TsMS”, after TsMS represent the “T1: after TsMS”; % Change: [(value after TsMS − value before TsMS)/value before TsMS] × 100; TsMS: trans-spinal magnetic stimulation

In addition, the activity was assessed using the timed get up and go (TUG) test [ 41 ] for functional mobility. The TUG test requires the patient to get up from a chair, walk a distance of 3 m, turn around, and return to the chair. During this activity, the time is measured, and a shorter time indicates better functional mobility [ 41 ]. The MDC is 10.8 s or a reduction of 30% [ 29 ]. The time required by the patient to perform the TUG test was reduced by 18% after TsMS. Although the MDC was not attained, a substantial reduction was possible after TsMS (Fig.  2 , Table  2 ).

Body function was assessed using the short version of the Balance Evaluation Systems Test (Mini-BEST) [ 20 ]. The Mini-BEST is a 14-item test scored on a 3-level ordinal scale, where higher scores indicate better balance, and aims to target and identify six different balance control systems [ 17 , 20 ]. Therefore, it assesses the activity as well as ICF domains. There is no MDC suggested for SCI, however, the score for Parkinson’s disease is 5.52 points [ 30 ] and for vestibular disorders is 3.5 points [ 18 ]. Even though the MDC for SCI was not available, we observed that the patient achieved a score comparable with those for the other patient populations (10 points) (Fig.  2 , Table  2 ). This improvement was scored based on anticipatory adjustment (2 to 5 points), reactive postural control (1 to 5 points), sensory orientation (2 to 3 points), and dynamic gait (3 to 5 points).

Finally, the Patient Global Impression of Change Scale (PGICS) that assesses a patient’s belief about the efficacy of treatment was used at the end of the TsMS sessions [ 16 ]. The patient reported “an improvement that has made a real and worthwhile difference” (level 6). The presence of adverse effects was also assessed after the end of each TsMS session. No adverse effects were reported. Thus, TsMS may be considered a safe and non-invasive tool.

The present case demonstrated that improvement in balance, walking independence, and functional mobility occurred after adding TsMS protocol in a physiotherapy program for a patient with SCI. The use of repetitive transcranial magnetic stimulation (rTMS) of the motor cortex to improve functional recovery in patients with chronic incomplete SCI is well-established [ 2 , 7 , 28 , 34 , 39 ]. However, to the best of our knowledge, this is the first case report on the trans-spinal application of magnetic field for improving functional recovery in a patient with SCI.

We hypothesized that TsMS could augment the effects of physiotherapy by causing changes in spinal reflexes, especially a decrease in the amplitude of H-reflex [ 26 , 27 , 36 ]. H-reflex is a control measure of spinal motoneuronal excitability. An increase in the amplitude of H-reflex reflects a clinical sign of spasticity [ 11 , 33 ]. There is high variability in the observed effects of rTMS on H-reflex (a decrease, increase, or no change in the amplitude of H-reflex) [ 40 ], depending on the intensity, frequency, and duration of the stimuli used [ 46 , 48 ] as well as the time since SCI [ 3 ]. Consequently, we preferred to use TsMS in the present case.

Only a few studies have assessed the modulatory effects of TsMS on spinal cord functions. Nielsen et al. [ 35 ] performed the first investigation using TsMS for modifying spasticity in patients with multiple sclerosis. Later, clinical trials were performed to confirm the modulatory effects of TsMS on multiple sclerosis [ 36 , 37 ], SCI, and healthy subjects [ 26 ]. However, these studies only evaluated bodily functions and structures (spasticity) and electrophysiological assessment (stretch reflex), whereas our study evaluated functional and activity recovery and the priming effect of TsMS, since motor recovery improved after the addition of TsMS to the physiotherapy program.

rTMS can augment motor training and enhance the sensitivity of the brain to physiotherapy by increasing cortical excitability [ 5 , 44 ]. Although no study has proved the relationship between spinal and cortical excitability after TsMS, studies on trans-spinal direct current stimulation (tsDCS) have suggested this relationship [ 1 , 4 ]. Consequently, we assumed that TsMS also might be a tool for priming the brain to learn. The patient had a history of non-improvement in motor functions with physiotherapy, which could be noted in T-1 and T0 assessments. TsMS could improve balance, allowing the patient to progress from walking with two crutches to walking with no device, braces, and physical assistance. This improvement was reported as “an improvement that has made a real and worthwhile difference” in the PGICS assessment.

From a clinical perspective, we hypothesize that functional recovery could be achieved through improvement in balance. Maintenance of balance is a complex task that requires coordination among somatosensory/proprioceptive, visual, and vestibular systems [ 19 ]. It is necessary to activate the muscular fuse through stretch reflex that is directly related to the spinal interneurons for activating the somatosensory system [ 32 ]. Previous studies with tsDCS had shown that excitatory stimulation of the spinal cord could modulate polysynaptic and multisegmental spinal reflexes in the case of a nociceptive stimulus [ 1 , 9 , 10 ]. As high-frequency TsMS is also an excitatory stimulation, it may have positively influenced these reflexes and supported the balance recovery in the patient.

Additionally, the patient had improvement in walking independence and functional mobility assessed using the WISCI II scale and TUG test, respectively. In a similar situation such as traumatic SCI, rTMS of the motor cortex area [ 2 ] combined with locomotor training [ 28 ] was not able to improve walking independence. These researchers chose the technique of transcranial application because of its ability to modify corticospinal projections and change cortical and spinal excitability [ 2 ]. However, studies on rTMS for modifying H-reflex have reported uncertain results [ 40 ]. H-reflex depends on the intensity, frequency, and duration of rTMS [ 46 , 48 ] and the time since SCI [ 3 ]. Therefore, we chose trans-spinal instead of transcranial application in the present case.

An experimental study with TsMS had shown a decrease in demyelination, an increase in axonal plasticity, and locomotor recovery after SCI in a rodent model [ 8 ]. Additionally, there may be a relevant center called Central Pattern Generator (CPG) in the thoracolumbar region that regulates locomotor behavior [ 23 ]. During walking, descending commands from neurons of the midbrain and brain stem provide feedback to the CPG, which then generates the walking rhythm and coordinates muscle activation [ 23 ]. Thus, in the present case, TsMS applied in combination with a rhythmic locomotor training program, such as a treadmill training program, might have activated the CPG, which, in turn, might have played a very important role in achieving the results of the treatment.

It’s important to highlight the relapsing–remitting nature of NMO, characterized by phases of acute exacerbations followed by spontaneous remissions. Given this cycling pattern of NMO, we must approach the observed therapeutic benefits of combining TsMS with kinesiotherapy with caution. The improvements seen in patient outcomes could coincide with natural fluctuation of the disease, making it challenging to attribute changes directly to the treatment. Therefore, further studies are necessary to explore the efficacy of these interventions, considering the cyclic dynamics of NMO. However, this case report contributes to the body of knowledge on TsMS and also opens avenues for future investigations into its application in neurorehabilitation.

TsMS in combination with kinesiotherapy could improve the balance and walking independence of a patient with NMO-associated transverse myelitis. The patient showed an improvement of 10 points in balance, assessed using Mini-BEST, and an increase of four levels in the WISCI-II scale for walking independence. This recovery implies an MDC and a patient global impression of “much improved.” Therefore, the present case suggests that TsMS is a safe and promising tool for enabling functional recovery in patients with SCI due to NMO-associated transverse myelitis. However, randomized, sham-controlled clinical trials are required to confirm the results of this study and strengthen the evidence regarding the usefulness of TsMS for motor recovery in patients with SCI.

Availability of data and materials

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Albuquerque PL, Campêlo M, Mendonça T, Fontes LA, Brito RD, Monte-Silva K. Effects of repetitive transcranial magnetic stimulation and trans-spinal direct current stimulation associated with treadmill exercise in spinal cord and cortical excitability of healthy subjects: a triple-blind, randomized and sham-controlled study. PLoS ONE. 2018;13(3): e0195276.

Article   PubMed   PubMed Central   Google Scholar  

Benito J, Kumru H, Murillo N, Costa U, Medina J, Tormos JM, Pascual-Leone A, Vidal J. Motor and gait improvement in patients with incomplete spinal cord injury induced by high-frequency repetitive transcranial magnetic stimulation. Top Spinal Cord Injury Rehabil. 2012;18(2):106–12.

Article   CAS   Google Scholar  

Benito Penalva J, Opisso E, Medina J, Corrons M, Kumru H, Vidal J, Valls-Solé J. H reflex modulation by transcranial magnetic stimulation in spinal cord injury subjects after gait training with electromechanical systems. Spinal Cord. 2010;48(5):400–6.

Article   CAS   PubMed   Google Scholar  

Bocci T, Barloscio D, Vergari M, Di Rollo A, Rossi S, Priori A, Sartucci F. Spinal direct current stimulation modulates short intracortical inhibition. Neuromodul J Int Neuromodul Soc. 2015;18(8):686–93.

Article   Google Scholar  

Bolognini N, Pascual-Leone A, Fregni F. Using non-invasive brain stimulation to augment motor training-induced plasticity. J Neuroeng Rehabil. 2009;6(March):8.

Burns AS, Delparte JJ, Patrick M, Marino RJ, Ditunno JF. The reproducibility and convergent validity of the walking index for spinal cord injury (WISCI) in chronic spinal cord injury. Neurorehabil Neural Repair. 2011;25(2):149–57.

Article   PubMed   Google Scholar  

Calabrò RS, Naro A, Leo A, Bramanti P. Usefulness of robotic gait training plus neuromodulation in chronic spinal cord injury: a case report. J Spinal Cord Med. 2017;40(1):118–21.

Chalfouh C, Guillou C, Hardouin J, Delarue Q, Li X, Duclos C, Schapman D, Marie J-P, Cosette P, Guérout N. The regenerative effect of trans-spinal magnetic stimulation after spinal cord injury: mechanisms and pathways underlying the effect. Neurotherapeutics. 2020;17(4):2069–88.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Cogiamanian F, Vergari M, Pulecchi F, Marceglia S, Priori A. Effect of spinal transcutaneous direct current stimulation on somatosensory evoked potentials in humans. Clin Neurophysiol. 2008;119(11):2636–40.

Cogiamanian F, Vergari M, Schiaffi E, Marceglia S, Ardolino G, Barbieri S, Priori A. Transcutaneous spinal cord direct current stimulation inhibits the lower limb nociceptive flexion reflex in human beings. Pain. 2011;152(2):370–5.

Crone C, Johnsen LL, Biering-Sørensen F, Nielsen JB. Appearance of reciprocal facilitation of ankle extensors from ankle flexors in patients with stroke or spinal cord injury. Brain J Neurol. 2003;126(Pt 2):495–507.

Davletshin E, Sabirov D, Rizvanov A, Mukhamedshina Y. Combined approaches leading to synergistic therapeutic effects in spinal cord injury: state of the art. Front Biosci. 2022;27(12):334.

Dittuno PL, Ditunno JF Jr. Walking index for spinal cord injury (WISCI II): scale revision. Spinal Cord. 2001;39(12):654–6.

Ditunno JF Jr, Ditunno PL, Graziani V, Scivoletto G, Bernardi M, Castellano V, Marchetti M, et al . Walking index for spinal cord injury (WISCI): an international multicenter validity and reliability study. Spinal Cord. 2000;38(4):234–43.

Fawcett JW, Curt A, Steeves JD, Coleman WP, Tuszynski MH, Lammertse D, Bartlett PF, et al . Guidelines for the conduct of clinical trials for spinal cord injury as developed by the ICCP panel: spontaneous recovery after spinal cord injury and statistical power needed for therapeutic clinical trials. Spinal Cord. 2007;45(3):190–205.

Ferguson L, Scheman J. Patient global impression of change scores within the context of a chronic pain rehabilitation program. J Pain. 2009;10(4):S73.

Franchignoni F, Godi M, Guglielmetti S, Nardone A, Giordano A. Enhancing the usefulness of the mini-BESTest for measuring dynamic balance: a Rasch validation study. Eur J Phys Rehabil Med. 2015;51(4):429–37.

CAS   PubMed   Google Scholar  

Godi M, Franchignoni F, Caligari M, Giordano A, Turcato AM, Nardone A. Comparison of reliability, validity, and responsiveness of the mini-BESTest and Berg balance scale in patients with balance disorders. Phys Ther. 2013;93(2):158–67.

Horak FB. Postural orientation and equilibrium: what do we need to know about neural control of balance to prevent falls? Age Ageing. 2006;35(Suppl 2):ii7–11.

Horak FB, Wrisley DM, Frank J. The balance evaluation systems test (BESTest) to differentiate balance deficits. Phys Ther. 2009;89(5):484–98.

Insausti-Delgado A, López-Larraz E, Nishimura Y, Birbaumer N, Ziemann U, Ramos-Murguialday A. Quantifying the effect of trans-spinal magnetic stimulation on spinal excitability. In: 2019 9th international IEEE/EMBS conference on neural engineering (NER). IEEE; 2019. p. 279–82.

Jarius S, Paul F, Weinshenker BG, Levy M, Kim HJ, Wildemann B. Neuromyelitis optica. Nat Rev Dis Prim. 2020;6(1):85.

Kiehn O. Locomotor circuits in the mammalian spinal cord. Annu Rev Neurosci. 2006;29:279–306.

Kirshblum SC, Burns SP, Biering-Sorensen F, Donovan W, Graves DE, Jha A, Johansen M, et al . International standards for neurological classification of spinal cord injury (revised 2011). J Spinal Cord Med. 2011;34(6):535–46.

Kleim JA, Jones TA. Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage. J Speech Lang Hear Res. 2008;51(1):S225–39.

Krause P, Edrich T, Straube A. Lumbar repetitive magnetic stimulation reduces spastic tone increase of the lower limbs. Spinal Cord. 2004;42(2):67–72.

Krause P, Straube A. Reduction of spastic tone increase induced by peripheral repetitive magnetic stimulation is frequency-independent. NeuroRehabilitation. 2005;20(1):63–5.

Kumru H, Benito-Penalva J, Valls-Sole J, Murillo N, Tormos JM, Flores C, Vidal J. Placebo-controlled study of rTMS combined with Lokomat® gait training for treatment in subjects with motor incomplete spinal cord injury. Exp Brain Res Experimentelle Hirnforschung Experimentation Cerebrale. 2016;234(12):3447–55.

Lam T, Noonan VK, Eng JJ, SCIRE Research Team. A systematic review of functional ambulation outcome measures in spinal cord injury. Spinal Cord. 2008;46(4):246–54.

Leddy AL, Crowner BE, Earhart GM. Utility of the mini-BESTest, BESTest, and BESTest sections for balance assessments in individuals with parkinson disease. J Neurol Phys Ther. 2011;35(2):90–7.

Leydeker M, Delva S, Tserlyuk I, Yau J, Wagdy M, Hawash A, Bendaoud S, Mohamed S, Wieraszko A, Ahmed Z. The effects of 15 Hz trans-spinal magnetic stimulation on locomotor control in mice with chronic contusive spinal cord injury. Electromagn Biol Med. 2013;32(2):155–64.

MacKinnon CD. Sensorimotor anatomy of gait, balance, and falls. Handb Clin Neurol. 2018;159:3–26.

Morita H, Crone C, Christenhuis D, Petersen NT, Nielsen JB. Modulation of presynaptic inhibition and disynaptic reciprocal Ia inhibition during voluntary movement in spasticity. Brain J Neurol. 2001;124(Pt 4):826–37.

Nardone R, Höller Y, Thomschewski A, Brigo F, Orioli A, Höller P, Golaszewski S, Trinka E. rTMS modulates reciprocal inhibition in patients with traumatic spinal cord injury. Spinal Cord. 2014;52(11):831–5.

Nielsen JF, Klemar B, Hansen HJ, Sinkjaer T. A new treatment of spasticity with repetitive magnetic stimulation in multiple sclerosis. J Neurol Neurosurg Psychiatry. 1995;58(2):254–5.

Nielsen JF, Sinkjaer T. Long-lasting depression of soleus motoneurons excitability following repetitive magnetic stimuli of the spinal cord in multiple sclerosis patients. Mult Scler. 1997;3(1):18–30.

Nielsen JF, Sinkjaer T, Jakobsen J. Treatment of spasticity with repetitive magnetic stimulation; a double-blind placebo-controlled study. Mult Scler. 1996;2(5):227–32.

Nishikawa Y, Maeda N, Kimura H. Physical therapy for a patient with neuromyelitis optica during the acute phase: a case report. SAGE Open Med Case Rep. 2021. https://doi.org/10.1177/2050313X211013679 .

Nogueira F, Shirahige L, Brito R, Monte-Silva K. Independent community walking after a short protocol of repetitive transcranial magnetic stimulation associated with body weight-support treadmill training in a patient with chronic spinal cord injury: a case report. Physiother Theory Pract. 2020;38(6):839–45.

Perez MA, Lungholt BKS, Nielsen JB. Short-term adaptations in spinal cord circuits evoked by repetitive transcranial magnetic stimulation: possible underlying mechanisms. Exp Brain Res Experimentelle Hirnforschung Experimentation Cerebrale. 2005;162(2):202–12.

Podsiadlo D, Richardson S. The timed ‘up & go’: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39(2):142–8.

Rossi S, Hallett M, Rossini PM, Pascual-Leone A, Safety of TMS Consensus Group. Safety, ethical considerations, and application guidelines for the use of transcranial magnetic stimulation in clinical practice and research. Clin Neurophysiol. 2009;120(12):2008–39.

Sato M, Sugiyama K, Kondo T, Izumi S-I. Rehabilitation for paraplegia caused by neuromyelitis optica: a case report. Spinal Cord. 2014;52(Suppl 3):S14–5.

Schabrun SM, Chipchase LS. Priming the brain to learn: the future of therapy? Man Ther. 2012;17(2):184–6.

Schreiber AL, Fried GW, Formal CS, DeSouza BX. Rehabilitation of neuromyelitis optica (devic syndrome). Am J Phys Med Rehabil. 2008. https://doi.org/10.1097/phm.0b013e31815b5e1a .

Touge T, Gerschlager W, Brown P, Rothwell JC. Are the after-effects of low-frequency rTMS on motor cortex excitability due to changes in the efficacy of cortical synapses? Clin Neurophysiol. 2001;112(11):2138–45.

Uzawa A, Mori M, Kuwabara S. Neuromyelitis optica: concept, immunology and treatment. J Clin Neurosci. 2014;21(1):12–21.

Valero-Cabré A, Oliveri M, Gangitano M, Pascual-Leone A. Modulation of spinal cord excitability by subthreshold repetitive transcranial magnetic stimulation of the primary motor cortex in humans. NeuroReport. 2001;12(17):3845–8.

Wu Y, Zhong L, Geng J. Neuromyelitis optica spectrum disorder: pathogenesis, treatment, and experimental models. Mult Scler Relat Disord. 2019. https://doi.org/10.1016/j.msard.2018.12.002 .

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Acknowledgements

We would like to thank Editage ( www.editage.com ) for English language editing.

Katia Monte-Silva is supported by Conselho Nacional de Desenvolvimento Científico e Tecnológico, CNPq, Brazil (Grant 311224/2019-9). Rodrigo Brito was supported by Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (Finance Code 001). English language editing was funded by PROPG/UFPE n.02/2021.

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Contributions

RB, LS, AB, SR and KMS were responsible for planning the treatment; RB, BM, LS and SR conducted the physiotherapy; BM was responsible for data assessment; RB and AP participated in design and organization of the data in this manuscript; RB and KMS analyzed and interpreted the patient data and were a major contributor in writing and the manuscript. All authors read and approved the final manuscript.

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Correspondence to Katia Monte-Silva .

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Approved by the local ethics committee (Universidade Federal de Pernambuco—Brazil: 4.755.012). Informed written consent to participate was obtained from the patient.

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Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

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Brito, R., Marroquim, B., Shirahige, L. et al. Trans-spinal magnetic stimulation combined with kinesiotherapy as a new method for enhancing functional recovery in patients with spinal cord injury due to neuromyelitis optica: a case report. J Med Case Reports 18 , 386 (2024). https://doi.org/10.1186/s13256-024-04636-7

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Received : 27 July 2022

Accepted : 02 June 2024

Published : 17 August 2024

DOI : https://doi.org/10.1186/s13256-024-04636-7

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• Spinal cord injury
• Transverse myelitis
• Transcranial magnetic stimulation
• Walking independence

Journal of Medical Case Reports

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