Self-taught Breathing Retraining Helps Asthma Patients

Diana Phillips

December 14, 2017

Self-taught breathing retraining exercises resulted in similar symptom control and quality-of-life improvements as those delivered via face-to-face sessions with a physiotherapist in patients with persistently symptomatic mild to moderate asthma, a randomized trial shows.

Further, both methods produced better results than usual medical care, Anne Bruton, PhD, professor of Respiratory Rehabilitation at the University of Southampton in the United Kingdom, and colleagues report in an article published online December 13 in the Lancet Respiratory Medicine.

The findings confirm those of smaller studies demonstrating the benefit of breathing retraining in this patient population and suggest that self-training is a feasible method to gain symptom control and quality-of-life improvements in a more convenient, lest costly manner, the authors write.

Retraining involves teaching breathing techniques to modify patterns and improve breathing efficiency (diaphragmatic breathing, nasal breathing, slow breathing, controlled breath holds, and relaxation techniques). Previous research suggests that, in patients with asthma, these exercises can lead to reduced symptoms and improved quality of life and may reduce use of reliever medication, the authors explain. Even so, they note, "these methods are rarely used because of insufficient access to suitably trained physiotherapists."

Based on evidence supporting the effectiveness of self-management education in patients with asthma, the researchers hypothesized that self-guided breathing retraining would be a cost-effective and acceptable intervention for adult patients with asthma seeking relief from persistent symptoms. To test their hypothesis, the authors conducted a three-group, 12-month randomized trial comparing the use of a DVD and booklet (DVDB) physiotherapy breathing retraining intervention with face-to-face physiotherapy or with a control group receiving usual care in adults with asthma.

Adult participants (aged 16 - 70 years) were recruited from 34 general practices in the United Kingdom between November 5, 2012, and January 28, 2014. Only those with physician-diagnosed asthma who had been prescribed at least 1 asthma medication in the previous year and who had an Asthma Quality of Life Questionnaire (AQLQ) score of less than 5.5 were eligible. Individuals with concomitant chronic obstructive pulmonary disease with forced expiratory volume in 1 second of less than 60% predicted were excluded.

Of 655 adults with asthma included in the analysis, 261 were randomly assigned to the DVDB group, whereas 132 and 262, respectively, were randomly assigned to the face-to-face physiotherapy group (three sessions) and to the standard care group. Both the breathing retraining groups also received a booklet that provided information and behavior change support. Baseline characteristics were similar across all three groups, the authors report.

Participants across the three groups completed the AQLQ at baseline and at 3, 6, and 12 months, and underwent lung function testing throughout the trial.

At baseline, the mean AQLQ scores for the DVDB, face-to-face, and standard care groups were 4.3, 4.2, and 4.3, respectively. At 12 months, the mean AQLQ scores were 5.40 (standard deviation [SD], 1.14) in the DVDB group, 5.33 (SD, 1.06) in the face-to-face group, and 5.12 (SD, 1.17) in the standard care group, the authors report.

After adjusting for predefined covariates, including general practitioner practice, age, sex, smoking status, British Thoracic Society asthma treatment step, and Hospital Anxiety and Depression Score and Nijmegen Questionnaire scores, the mean AQLQ score difference in the DVDB group compared with the usual care group was 0.28 (95% confidence interval [CI], 0.11 - 0.44), and that in face-to-face intervention compared with the usual care group was 0.24 (95% CI, 0.04 - 0.44). In contrast, the adjusted mean difference between the DVDB and face-to-face interventions was 0.04 (95% CI, −0.16 to 0.24), which was not statistically significant.

An analysis of differences in performance on subdomains of the AQLQ survey showed the largest improvements relative to usual care in the emotion subdomain. Specifically, the DVDB group improved by 0.38 (95% CI, 0.16 - 0.60), and the face-to-face group improved by 0.43 (95% CI, 0.16 - 0.71).

Significant improvements in both groups relative to usual care were also observed in the symptom subdomain (0.24 [95% CI, 0.05 - 0.42] in the DVDB group and 0.27 [95% CI, 0.04 - 0.49] in the face-to-face group). The DVDB group also showed significant improvements over usual care in the activities (0.21; 95% CI, 0.04 - 0.41) and environment (0.32; 95% CI, 0.11 - 0.53) AQLQ subdomains. "There were no significant differences in overall or individual domain scores between the DVDB and face-to-face groups," the authors write.

Overall, 62% of patients in the DVDB group showed at least a minimum clinically important difference of 0.5 from baseline, as did 64% in the face-to-face group and 56% in the usual care group.

Conversely, 5% of patients the DVDB group and 4% in the face-to-face group showed symptom deterioration compared with 24 (9%) in the usual care group, "providing [a number needed to treat] of eight for DVDB versus usual care, and seven for face-to-face versus usual care," the authors write.

No significant within-group or between-group changes were observed in secondary outcome measures of airway obstruction, inflammation, Asthma Control Questionnaire or Nijmegen Questionnaire scores, or in the anxiety domain of the Hospital Anxiety and Depression Score, the authors report. Small-magnitude, significant differences were observed in the mean adjusted scores for the depression component of the Hospital Anxiety and Depression Score in the DVDB group relative to usual care (−0.56; 95% CI, −1.07 to −0.05), the authors report.

With respect to clinical outcomes, 78 patients (12%) in the entire study cohort experienced one or more asthma attacks during the study period, including 24, 15, and 39 in the DVDB, face-to-face, and usual care groups, respectively. However, after adjusting for baseline asthma attack frequency and prespecified covariates, there was no significant difference in frequency of asthma attacks between treatment groups.

An economic assessment of the cost-efficacy of the interventions showed that both the DVDB and face-to-face interventions led to superior outcomes in AQLQ and quality-adjusted life-year scores at lower cost than usual care. "The low cost of the DVDB intervention meant that it was highly likely to be the most cost-effective option," they write.

In follow-up surveys and qualitative interviews, patients reported good experiences with both breathing retraining interventions. "Perceived benefits included increased control over breathing, reduced need for medication, feeling more relaxed, and improved quality of life," the authors state.

Given the study findings, "[W]e believe that it is now possible to offer this simple nonpharmacological intervention as a part of a rational overall asthma treatment strategy," the authors write. "There is a need to stress to patients that this intervention is in addition to, not instead of, current medication, and that it does not cure asthma, but rather is a means to improve quality of life."

In an associated comment, John D. Blakey, PhD, and Renu Abraham from the Health Services Research group at the University of Liverpool and Royal Liverpool Hospital, United Kingdom, call the study "a welcome addition" to the asthma literature, particularly given the high prevalence of dysfunctional breathing patterns among individuals treated for asthma and the dearth of specialist physiotherapists to assess and educate them about breathing strategies.

"This situation of insufficient access to specialist health-care professionals risks costly progress up the therapeutic ladder driven by persistent symptoms and additional distress for patients," they write.

The study findings provide "strong evidence that breathing retraining delivered remotely via a DVD and booklet can be an effective intervention," they continue, although they acknowledge the need for future work to determine whether the results are generalizable. "Asthma outcomes have remained poor over recent years, with low expectations around control from patients and health-care providers. Remotely delivered breathing retraining is a key component toward incremental improvement, and a necessary adjunct to improved use of more tailored medical treatments."

Although the materials for the self-guided training were delivered via DVD for this study, the researchers have since made the content freely available online to increase the accessibility of the training and avoid the costs associated with producing booklets and DVDs. However, the editorialists caution that the online tool will not necessarily provide equal benefit. "[I]t is unclear whether engagement with web-based video is equivalent to that with a physical DVD and booklet, and how factors such as age and economic status might influence this," the commenters write. "It could also be the case that individuals are more likely to access content if it is delivered by other routes, such as their usual streaming service."

This study was funded by the UK National Institute of Health Research Several coauthors have disclosed various financial relationships with one or more companies. Full disclosures can be found on the journal website. Dr Blakely reports relationships with GlaxoSmithKline, Novartis, Napp, AstraZeneca, and Boehringer Ingelheim outside the submitted work.

Lancet Respir Med. Published online December 13, 2017. Article full text, Editorial full text

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