Prevalence of dysfunctional breathing in patients treated for asthma in primary care: cross sectional survey

Medically unexplained dyspnea: partly moderated by dysfunctional (thoracic dominant) breathing pattern

BACKGROUND

Dysfunctional breathing (DB) may contribute to disproportionate dyspnea and other medically unexplained symptoms. The extent of dysfunctional breathing is often evaluated using the Nijmegen Questionnaire (NQ) or by the presence of abnormal breathing patterns. The NQ was originally devised to evaluate one form of dysfunctional breathing - hyperventilation syndrome. However, the symptoms identified by the NQ are not primarily due to hypocapnia and may be due to other causes including breathing pattern dysfunction.

OBJECTIVES

The relationships between breathing pattern abnormalities and the various categories of NQ symptoms including respiratory or dyspnea symptoms have not been investigated. This study investigates these relationships.

METHOD

62 patients with medically unexplained complaints, that seemed to be associated with tension and breathing dysfunction, were referred, or self-referred, for breathing and relaxation therapy. Dysfunctional breathing symptoms and breathing patterns were assessed at the beginning and end of treatments using the NQ for assessment of DB symptoms, and the Manual Assessment of Respiratory Motion (MARM) to quantify the extent of thoracic dominant breathing. Subscales for the NQ were created in 4 categories, tension, central neurovascular, peripheral neurovascular and dyspnea. Relationships between the NQ (sum scores and subscales) and the MARM were explored.

RESULTS

Mean NQ scores were elevated and mean MARM values for thoracic breathing were also elevated. There was a small correlation pre-treatment between MARM and NQ (r=0.26, p<0.05), but classification of subjects as normal/abnormal on both measurements agreed in 74% (p < 0.001) of patients. From the sub scores of NQ only the respiratory or 'dyspnea' items correlated with the MARM values. Dyspnea was only elevated for subjects with abnormal MARM. After treatment, both MARM and NQ returned to normal values (p< 0.0001). Changes in NQ were largest for subjects with abnormal MARM pre-treatment. There was a large interaction between the change in the NQ sub score dyspnea and initial MARM values. (p<0.001).

Psychological profile of patients with bronchial asthma and functional dyspnea: a comparison with a non-asthmatic population and impact on the disease

BACKGROUND

Few studies have analysed the relationship between anxiety and alexithymia with functional dyspnea (FD) and its impact on quality of life and asthma control. The aim of this study was to assess the prevalence of DD in asthma, its impact on quality of life and asthma control and its relationship with anxiety and alexithymia.

PATIENTS AND METHODS

We performed a cross-sectional study of 264 asthmatic patients and 111 controls. Both groups completed the following questionnaires: quality of life (AQLQ), alexithymia (TAS-20), anxiety (STAI) and FD (Nijmegen). In asthmatics were evaluated: asthma severity, dyspnoea, exacerbation and control of the disease (ACT test).

RESULTS

38% of asthmatics and 5.5% of non-asthmatics had FD. Asthmatics had more anxiety and were more alexithymic. Asthmatics with FD had significantly more anxiety, more alexithymia, poor control of asthma, more exacerbations and poorer quality of life, that asthma without DD. Asthmatics with an ACT<19, a score >3 in the emotion subscale of the AQLQ, who were being treated for anxiety and scored >19 on the alexithymia subscale that assesses difficulty in identifying emotions, showed ORs for FD of 2.6 (1.1-5.9), 6.8 (2.9-15.8), 4.4 (1.9-9.8) and 3.3 (1.5-7), respectively. A predictive model of FD was constructed.

CONCLUSIONS

We demonstrated the close relationship between anxiety, alexithymia and DD in asthmatics, as well as the significant impact of FD on the control and quality of life of this asthmatics.

The utility of cardiopulmonary exercise testing in difficult asthma

BACKGROUND

Unexplained persistent breathlessness in patients with difficult asthma despite multiple treatments is a common clinical problem. Cardiopulmonary exercise testing (CPX) may help identify the mechanism causing these symptoms, allowing appropriate management.

METHODS

This was a retrospective analysis of patients attending a specialist-provided service for difficult asthma who proceeded to CPX as part of our evaluation protocol. Patient demographics, lung function, and use of health care and rescue medication were compared with those in patients with refractory asthma. Medication use 6 months following CPX was compared with treatment during CPX.

RESULTS

Of 302 sequential referrals, 39 patients underwent CPX. A single explanatory feature was identified in 30 patients and two features in nine patients: hyperventilation (n = 14), exercise-induced bronchoconstriction (n = 8), submaximal test (n = 8), normal test (n = 8), ventilatory limitation (n = 7), deconditioning (n = 2), cardiac ischemia (n = 1). Compared with patients with refractory asthma, patients without "pulmonary limitation" on CPX were prescribed similar doses of inhaled corticosteroid (ICS) (median, 1,300 μg [interquartile range (IQR), 800-2,000 μg] vs 1,800 μg [IQR, 1,000-2,000 μg]) and rescue oral steroid courses in the previous year (median, 5 [1-6] vs 5 [1-6]). In this group 6 months post-CPX, ICS doses were reduced (median, 1,300 μg [IQR, 800-2,000 μg] to 800 μg [IQR, 400-1,000 μg]; P < .001) and additional medication treatment was withdrawn (n = 7). Patients with pulmonary limitation had unchanged ICS doses post CPX and additional therapies were introduced.

CONCLUSIONS

In difficult asthma, CPX can confirm that persistent exertional breathlessness is due to asthma but can also identify other contributing factors. Patients with nonpulmonary limitation are prescribed inappropriately high doses of steroid therapy, and CPX can identify the primary mechanism of breathlessness, facilitating steroid reduction.

Multidimensional assessment of older people with asthma and COPD: clinical management and health status

BACKGROUND

the diagnosis and management of obstructive airway diseases (OADs) such as asthma and chronic obstructive pulmonary disease (COPD) can be challenging in older people.

OBJECTIVE

to assess the clinical, functional, biological and behavioural characteristics relevant to the management of older people with OAD.

METHODS

a cross-sectional study was conducted in a tertiary teaching hospital. Older people (> 55 years) (n = 100) with an OAD underwent a multidimensional assessment (MDA) involving questionnaires, clinical assessments, physiological measurements and biomarkers.

RESULTS

the assessment identified a mean (SD) of 11.3 (2.5) clinical management issues and 3.1 (1.8) comorbid conditions per participant. Common problems were: airways hyper-responsiveness (80%); airway inflammation (74%); activity limitation (74%) and systemic inflammation (60.5%). The number and type of issues were similar irrespective of a diagnosis of asthma or COPD (P = 0.2). The degree of health status impairment correlated significantly with the number of clinical management issues detected (r = 0.59; P < 0.0001).

CONCLUSIONS

older people with OAD experience multiple clinical issues that adversely impact their health status. The number and type are similar irrespective of diagnosis. This MDA identifies significant clinical issues that may not be addressed in a diagnosis centred approach suggesting that a multidisciplinary approach is necessary when assessing and managing older people with OAD.

Asthma in older adults

Asthma in older people is common and is characterised by underdiagnosis and undertreatment. Ageing is associated with unique issues that modify expression, recognition, and treatment of the disease. In particular, asthma and chronic obstructive pulmonary disease (COPD) both overlap and converge in older people. This concurrence, together with absence of precise diagnostic methods, makes diagnosis complex. A multidimensional assessment that addresses airway problems, comorbidities, risk factors, and management skills will draw attention to key needs for intervention. Increased attention to the complications of asthma and obstructive airway disease in older people is needed, specifically to develop effective systems of care, appropriate clinical practice guidelines, and a research agenda that delivers improved health outcomes.

A comparison between patients with dysfunctional breathing and patients with asthma

INTRODUCTION

The term dysfunctional breathing (DB) has been introduced to describe patients who display a divergent breathing pattern and have breathing problems that cannot be attributed to a specific medical diagnosis such as asthma, chronic obstructive pulmonary disease or sensory hyper-reactivity.

OBJECTIVE

The objective of this study was to investigate similarities and differences in patients with DB, and patients with well-controlled asthma regarding health-related quality of life, anxiety, depression, sense of coherence (SOC), hyperventilation and effects on daily life.

METHODS

Twenty-five consecutive patients with DB, and 25 age- and sex-matched patients with asthma (ages 20-73 years) participated in the study. The diagnosis of DB was based on the presence of a dysfunctional breathing pattern and at least five symptoms associated with DB.

RESULTS

The group with DB had lower health-related quality of life (short form 36): vitality (mean) 47 vs 62, social functioning 70 vs 94 and role emotional 64 vs 94 (P < 0.05) than the asthmatic group. The DB group also had a higher prevalence of anxiety (56% vs 24%) and a lower SOC (134 vs 156) (P < 0.05). Hyperventilation, defined according to the Nijmegen symptoms questionnaire, was observed in 56% of patients with DB vs 20% in the asthma group (P = 0.02).

CONCLUSIONS

The results of the study indicate that patients with DB are more disabled than patients with well-controlled asthma. There is a great need for more knowledge about breathing symptoms of a dysfunctional nature, to be able to identify and manage these patients adequately.

Relationships between measures of dysfunctional breathing in a population with concerns about their breathing

BACKGROUND

Dysfunctional breathing (DB) is implicated in physical and psychological health, however evaluation is hampered by lack of rigorous definition and clearly defined measures. Screening tools for DB include biochemical measures such as end-tidal CO(2), biomechanical measures such assessments of breathing pattern, breathing symptom questionnaires and tests of breathing function such as breath holding time.

AIM

This study investigates whether screening tools for dysfunctional breathing measure distinct or associated aspects of breathing functionality.

METHOD

84 self-referred or practitioner-referred individuals with concerns about their breathing were assessed using screening tools proposed to identify DB. Correlations between these measures were determined.

RESULTS

Significant correlations where found within categories of measures however correlations between variables in different categories were generally not significant. No measures were found to correlate with carbon dioxide levels.

CONCLUSION

DB cannot be simply defined. For practical purposes DB is probably best characterised as a multi-dimensional construct with at least 3 dimensions, biochemical, biomechanical and breathing related symptoms. Comprehensive evaluation of breathing dysfunction should include measures of breathing symptoms, breathing pattern, resting CO(2) and also include functional measures such a breath holding time and response of breathing to physical and psychological challenges including stress testing with CO(2) monitoring.

Impact of comorbidities on asthma

Asthma is a common and serious illness with suboptimal outcomes of care. Epidemiological studies show certain comorbidities occurring more frequently than expected with asthma, with some being associated with poor control and a differential response to therapy options. This review summarizes the evidence of clinically important comorbidities, focusing on the best-explored conditions, including rhinitis and rhinosinusitis, anxiety and depression, obesity, gastroesophageal reflux, smoking and dysfunctional breathing. The evidence of epidemiological and pathophysiological associations for these comorbidities is explored, and the practical therapeutic implications are considered. Comorbidities are important for clinicians treating asthma as they may be markers of patients at risk of poor outcomes, they may point to specific effective treatment options and they are important to researchers as possible confounding factors in clinical trials.

Hyperventilation in panic disorder and asthma: empirical evidence and clinical strategies

Sustained or spontaneous hyperventilation has been associated with a variety of physical symptoms and has been linked to a number of organic illnesses and mental disorders. Theories of panic disorder hold that hyperventilation either produces feared symptoms of hypocapnia or protects against feared suffocation symptoms of hypercapnia. Although the evidence for both theories is inconclusive, findings from observational, experimental, and therapeutic studies suggest an important role of low carbon dioxide (CO2) levels in this disorder. Similarly, hypocapnia and associated hyperpnia are linked to bronchoconstriction, symptom exacerbation, and lower quality of life in patients with asthma. Raising CO2 levels by means of therapeutic capnometry has proven beneficial effects in both disorders, and the reversing of hyperventilation has emerged as a potent mediator for reductions in panic symptom severity and treatment success.

Pediatric asthma: an integrative approach to care

Asthma in children and young adults is a complex disease with many different phenotypic expressions. Diagnosis is often made based on history and lung function including measuring airway reversibility. However, in children younger than 6 years of age, the diagnosis is more difficult because many children wheeze in the first 4-6 years of life, especially with viral infections. For those children, asthma treatment is often started empirically. Those who go on to develop chronic asthma most likely have a genetic predisposition and exposure to various environmental factors resulting in chronic inflammation of the lower respiratory tract. There are established national guidelines for diagnosing and treating asthma in children and adults. For persistent asthma, it is recommended that medications be taken on a regular basis after identifying and avoiding environmental triggers. Because many factors play a role in developing asthma in children, many nonmedical approaches to asthma and asthma-like conditions have been promoted even when the diagnosis is at times uncertain. The nonmedical approaches and therapies are often referred to as complementary and alternative medicine (CAM). This review will discuss the conventional therapies recommended for children with asthma in addition to CAM therapies, some of which have supporting scientific evidence. Integrating conventional and CAM therapies can prove to be an effective way to treat pediatric asthma, a common and chronic childhood lung disorder. A case is provided to illustrate how such an integrative approach was used in the successful treatment of a child with moderate persistent asthma.

An observational investigation of dysfunctional breathing and breathing control therapy in a problem asthma clinic

OBJECTIVES

Dysfunctional breathing (DB) is recognized as an associated problem in patients with asthma and may be identified by the Nijmegen questionnaire. We conducted an observational study to determine if breathing control therapy (BCT) improved Nijmegen scores or asthma-related quality of life in patients attending a problem asthma clinic.

METHODS

Nijmegen and Mini Asthma Quality of Life (Mini-AQLQ) questionnaires were completed. Patients with a positive Nijmegen (> or = 23, DB) were referred for BCT and progressive exercise testing (PET) to seek confirmation of dysfunctional breathing. Follow-up questionnaire data were collected at 6 months.

RESULTS

A total of 102 patients were studied. The total mean Nijmegen score was 26.4 (range 1-61). Those with a score > or = 23 (DB group, n = 65, 64%) had significantly lower Mini-AQLQ (mean 2.83) than the non-DB group (n = 37, mean 4.12, 95% CI for difference 0.87, 1.87, p < 0.0001). There was a strong relationship between Nijmegen score and Mini-AQLQ (r = -0.63, p < 0.001) at baseline; 10 of 17 DB patients who completed PET showed inappropriate hyperventilation. Follow-up data, available for Nijmegen and Mini-AQLQ in 44 and 46 patients respectively, showed no significant change in either of these parameters.

CONCLUSIONS

The strong relationship between Mini-AQLQ and Nijmegen scores and poor relationship between Nijmegen scores and PET-identified inappropriate hyperventilation suggest that a positive Nijmegen score overestimates the presence of dysfunctional breathing in patients with moderate to severe asthma. We found no evidence that a moderate intensity breathing control intervention had any impact on Nijmegen scores or asthma-related quality of life in this patient group.

Investigating the claims of Konstantin Buteyko, M.D., Ph.D.: the relationship of breath holding time to end tidal CO2 and other proposed measures of dysfunctional breathing

OBJECTIVES

Konstantin Buteyko, M.D., Ph.D., claimed that breath holding time (BHT) can be used to detect chronic hyperventilation and that BHT predicts alveolar CO(2) (Pa(CO(2))) according to his patented mathematical formula. The Buteyko Breathing Technique (BBT) is believed to correct chronic hyperventilation as evidenced by increased BHT. In this study, we test Buteyko's claims and explore the relationship between BHT and end-tidal carbon dioxide (ETCO(2)) as well as measures of dysfunctional breathing (DB) including the Nijmegen questionnaire, the Self Evaluation of Breathing Questionnaire, and thoracic dominant breathing pattern.

SUBJECTS

Eighty-three (83) adults healthy or suspected of having dysfunctional breathing, 29 with abnormal spirometry readings, 54 with normal spirometry.

OUTCOME MEASURES

BHT, performed according to BBT protocols, was measured along with ETCO(2) and other measures of DB including the Nijmegen questionnaire, and manual assessment of respiratory motion, a palpatory technique for measuring thoraco-abdominal balance during breathing. Correlations between measures of DB were made in the whole sample and also in subgroups with normal or abnormal spirometry. DB measures were compared in normal and abnormal spirometry groups.

RESULTS

The results revealed a negative correlation between BHT and ETCO(2) (r= -0.241, p<0.05), directly opposite to Buteyko's claims. BHT was significantly shorter in people with abnormal spirometry (FEV(1) or FVC<15% below predicted), with no difference in ETCO(2) levels between the abnormal and normal spirometry groups. In the abnormal spirometry group, lower BHT was found to correlate with a thoracic dominant breathing pattern. (r= -0.408, p<0.028).

CONCLUSIONS

Although BHT does not predict resting ETCO(2), it does correlate with breathing pattern in subjects with abnormal spirometry. It is proposed that altered breathing pattern could contribute to breathing symptoms such as dyspnea and that breathing therapies such as BBT might influence symptoms by improving the efficiency of the biomechanics of breathing.

Hyperventilation symptoms are linked to a lower perceived health in asthma patients

BACKGROUND

Hyperventilation symptoms are among the sensations asthma patients tend to report during exacerbations of their disease. However, little is known about their importance for the patients' perceived well-being.

METHOD

We therefore studied the association of reported hyperventilation symptoms (Asthma Symptom Checklist) with perceived physical and mental health (36-item Short-form Health Survey) in a sample of primary care asthma patients (N = 190). We also studied the potential role of perceived control of asthma (Perceived Control of Asthma Questionnaire) in mediating any association between these variables.

RESULTS

In hierarchical multiple regression analyses controlling for demographics, asthma severity, and other asthma symptoms (obstruction, congestion, panic-fear, irritation, and fatigue), hyperventilation symptoms were significantly associated with both physical and mental health status. This association was partially mediated by perceived control of asthma.

CONCLUSION

It is possible that hypocapnia creates symptoms that asthma patients cannot control by using their antiasthmatic medication, thus compromising their perceived control over the management of their asthma, and consequently their perceived health. Behavioral interventions should address the problem of hyperventilation in asthma.

Double blind randomised controlled trial of two different breathing techniques in the management of asthma

BACKGROUND

Previous studies have shown that breathing techniques reduce short acting beta(2) agonist use and improve quality of life (QoL) in asthma. The primary aim of this double blind study was to compare the effects of breathing exercises focusing on shallow nasal breathing with those of non-specific upper body exercises on asthma symptoms, QoL, other measures of disease control, and inhaled corticosteroid (ICS) dose. This study also assessed the effect of peak flow monitoring on outcomes in patients using breathing techniques.

METHODS

After a 2 week run in period, 57 subjects were randomised to one of two breathing techniques learned from instructional videos. During the following 30 weeks subjects practised their exercises twice daily and as needed for relief of symptoms. After week 16, two successive ICS downtitration steps were attempted. The primary outcome variables were QoL score and daily symptom score at week 12.

RESULTS

Overall there were no clinically important differences between the groups in primary or secondary outcomes at weeks 12 or 28. The QoL score remained unchanged (0.7 at baseline v 0.5 at week 28, p = 0.11 both groups combined), as did lung function and airway responsiveness. However, across both groups, reliever use decreased by 86% (p<0.0001) and ICS dose was reduced by 50% (p<0.0001; p>0.10 between groups). Peak flow monitoring did not have a detrimental effect on asthma outcomes.

CONCLUSION

Breathing techniques may be useful in the management of patients with mild asthma symptoms who use a reliever frequently, but there is no evidence to favour shallow nasal breathing over non-specific upper body exercises.

[Hyperventilation syndrome in children]

Hyperventilation syndrome is frequent in adults. There are only very few and very ancient publications in children. Diagnosis is sometimes difficult, because the symptoms often mimic those of organic diseases. Hyperventilation syndrome and organic diseases, especially asthma, often coincide. Intensive efforts should be made to diagnose hyperventilation syndrome at an early stage because this will prevent stigmatization and fixation of symptoms and disease, and also prevent children from undergoing unnecessary medical examinations and therapies. The authors review the literature about hyperventilation syndrome in children.

[Prevalence of hyperventilation syndrome in patients treated for asthma in a pulmonology clinic]

OBJECTIVE

Although the presence of hyperventilation syndrome can affect the symptoms of patients with asthma, there is very little information available regarding its frequency in Spain. The aim of this study was to investigate the prevalence of hyperventilation syndrome in the asthmatic population treated as outpatients and establish its relationship with anxiety disorders.

PATIENTS AND METHOD

We studied 157 consecutive asthmatic patients (61 men and 96 women; mean [SD] age, 45 [17] years; forced expiratory volume in the first second, 84% [21%] of the predicted value) treated in our outpatients clinic. The patients had stable disease with varying degrees of severity. After collecting demographic data and medical histories, we asked the patients to complete the Spanish versions of the Anxiety Sensitivity Index, the Asthma Symptom Checklist, and the Nijmegen questionnaire; in the latter test, a score of 23 or over was considered diagnostic for hyperventilation syndrome. Finally, patients were evaluated to determine whether they had suffered from panic disorder in the last 6 months (according to the criteria of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders).

RESULTS

Hyperventilation syndrome was present in 57 asthmatic patients (36%) and panic disorder in 4 patients (2%). The majority of patients with hyperventilation syndrome were women (78% vs 51%; P=.001) and were older (49 vs 42; P=.01); they displayed more basal dyspnea (1.26 vs 0.89 on the Medical Research Council scale; P=.01), greater sensitivity to anxiety (P=.001), and went to the emergency room more often for exacerbations (P=.002). Patients with hyperventilation syndrome scored significantly higher on all subscales of the Asthma Symptoms Checklist. Finally, the variables introduced in the regression analysis (stepwise) to explain the score on the Nijmegen questionnaire (r(2)=0.57) were basal dyspnea and sensitivity to anxiety.

CONCLUSIONS

Approximately one third of the asthmatic patients treated in a pulmonology clinic also present hyperventilation syndrome. This cannot be explained by comorbidity of asthma with panic disorder, and is only partly linked to the symptoms associated with hyperventilation that appear during an asthma attack.

Hypocapnia and asthma: a mechanism for breathing retraining?

There is some evidence that breathing retraining may be beneficial for patients with asthma, but the mechanism behind this benefit is still unknown. One hypothesis is that individuals can be trained to raise carbon dioxide levels and thereby reverse the bronchoconstrictive effects of hypocapnia and utilize the bronchodilatory effects of hypercapnia. This theory presupposes that individuals with asthma have lower carbon dioxide levels than the healthy population. This article reviews the available evidence supporting the hypothesis and concludes that although attractive, there is currently insufficient evidence to attribute the benefits of breathing retraining to this mechanism.

Can subjective asthma symptoms be learned?

OBJECTIVE

We investigated whether perception of subjective asthma symptoms can be brought under control of biomedically irrelevant cues in the environment, i.e., whether subjective asthma symptoms can be learned in response to harmless stimuli.

METHODS

Twenty patients with asthma and 20 healthy participants were presented with two placebo-inhalers presented as new chemicals for diagnosing asthma. One inhaler was coupled three times with rebreathing 5% CO2 in oxygen, the other inhaler was coupled three times with rebreathing oxygen. In the subsequent test phase, both inhalers were coupled once with oxygen. We assessed airway resistance and subjective symptoms throughout the study.

RESULTS

Both groups expected and reported more symptoms with the inhaler that was previously associated with the CO2 trials compared with trials with the inhaler that was used on trials without CO2 without concomitant effects on respiratory resistance. The learning effects were most pronounced in a subgroup of patients reporting symptoms of hyperventilation during asthma exacerbations in daily life.

CONCLUSIONS

Subjective respiratory symptoms can be learned in response to harmless stimuli and a substantial proportion of patients with asthma might be especially vulnerable to this phenomenon. Because asthma patients rely mainly on perceived symptoms for their medication use, it is likely that they will take reliever medication based on expected symptoms instead of real exacerbations of respiratory dysfunction.

The Buteyko breathing technique for asthma: a review

Breathing exercises and breathing retraining are often used in the management of asthma. One specific form of breathing therapy, known as the Buteyko breathing technique (BBT) has received considerable attention, but there is a paucity of rigorous research evidence to support its recommendation for asthma patients. There are only four published clinical trials and two conference abstracts evaluating BBT. Although all have reported improvements in one or more outcome measures, results have not been consistent. This article provides the background to the BBT, reviews the available evidence for its use and examines the physiological hypothesis claimed to underpin it. In common with other therapies, BBT is not a standardised treatment modality. The BBT 'package' is complex, as it also includes advice and education about medication use, nutrition and exercise, and general relaxation. This makes it difficult, and possibly inappropriate, to attempt to tease out a single mechanism. Buteyko's theory relating to carbon dioxide levels and airway calibre is an attractive one, and has some basis in evidence from experimental studies. However, it is not known whether altering breathing patterns can raise carbon dioxide levels significantly, and there is currently insufficient evidence to confirm that this is the mechanism behind any effect that BBT may exert. Further research is necessary to establish unequivocally whether BBT is effective, and if so, how it may work.

Severe asthma treatment: need for characterising patients

CONTEXT

Asthma is readily diagnosed in most cases and usually responds to inhaled corticosteroids with or without long-acting beta agonists, theophyllines, or leukotriene-receptor antagonists, adjusted stepwise according to symptoms and lung function. However, up to 40% of adult patients with asthma remain symptomatic, and up to 5% have difficult-to-control asthma despite multiple therapies. It is suggested that higher doses of inhaled steroids with long-acting beta2 agonists should be used for total control of symptoms; and anti-IgE therapy is newly licensed in the USA. However, difficult-to-control asthma is complex and multifactorial, and is often not due to severe or therapy-resistant asthma.

STARTING POINT

Last year saw encouraging reports on omalizumab (anti-IgE therapy) in severe allergic asthma, by Stephen Holgate, Jon Ayres, and their respective colleagues (Clin Exp Allergy 2004; 34: 632-38; Allergy 2004; 59: 701-08). Omalizumab reduced exacerbation rates, improved asthma symptoms and quality of life, and allowed lower doses of inhaled steroid compared with placebo. In placebo-controlled studies with anti-IgE, many patients were able to substantially reduce and even withdraw inhaled steroids in the placebo arm.

WHERE NEXT

Severe asthma is often defined as persisting symptoms despite high-dose inhaled steroids. This definition is likely to include patients with various reasons for their persisting symptoms, for whom additional treatment is not always required. Before starting new therapy, it is important to systematically evaluate asthmatic patients to accurately define their disease and to identify those whose symptoms are caused by other factors, and thus avoid unnecessary medication. There might also be subgroups that have differing underlying inflammatory processes and who will respond differently to individual treatments.

Buteyko: A useful tool in the management of asthma?

Medical management of asthma focuses on drugs which, although effective, are costly and produce side-effects. Recent evidence suggests a role for breathing interventions that reduce total ventilation, such as the Buteyko method, which has strong similarities to techniques already used by therapists to manage hyperventilation. Both approaches should be made readily available to patients with asthma. Asthma nurses and therapists should consider these techniques to enable patients to ‘step down’ drug treatments in accordance with medical guidelines. This may involve a re-thinking of their role, from one where the main emphasis is on supporting the established medical model towards one that also offers a non-pharmacological alternative.

This article explains the aims of Buteyko and discusses the increasing evidence base for methods that reduce ventilation and may benefit many patients with asthma, not just those with established chronic hyperventilation.

Hyperventilation in the vestibular clinic: use of the Nijmegen Questionnaire

The objective of the present study was to determine the prevalence of hyperventilation syndrome in patients seen for vestibular assessment and to assess the clinical utility of the Nijmegen Questionnaire in this group. The Nijmegen Questionnaire and Dizziness Handicap Inventory (DHI) were administered prospectively to a consecutive series of 100 patients identified as candidates for vestibular assessment within the University Hospital Neuro-otology practice. Twenty-three per cent of patients seen for vestibular assessment were diagnosed with hyperventilation syndrome using the Nijmegen Questionnaire. Seventeen of these (74%) would have remained undetected had the Nijmegen questionnaire not been used. No relationship was found between vestibular assessment results and either Nijmegen or DHI scores. A significant correlation was found between DHI scores and Nijmegen Questionnaire scores (rho = 0.348, P = 0.0005). In conclusion, the Nijmegen Questionnaire is a quick, easy to administer and low-impact assessment tool for hyperventilation syndrome and is a useful adjunct to the otological consultation. Diagnosed patients can then be offered breathing control exercises as part of a vestibular rehabilitation programme.

Complementary and alternative medicine for bronchial asthma: is there new evidence?

PURPOSE OF REVIEW

Complementary and alternative medicine is widely used in bronchial asthma. Data on efficacy of these treatment modalities are lacking.

RECENT FINDINGS

Studies published since June 2002 on complementary and alternative medicine in bronchial asthma were systematically reviewed.

SUMMARY

Studies do not support the use of homeopathy, air ionizers, manual therapy, or acupuncture for asthma. These methods bear some risks to patients related to undertreatment and side effects. There might be a possible, but so far not clearly established, role for antioxidant dietary supplementation, and some natural antiinflammatory and immunomodulatory remedies. However, their effect size compared with the classical treatment and side-effect profile is not clearly established. Strategies influencing breathing technique or perception, such as breathing or retraining exercises, need to be studied over the next few years to establish their additive role in the treatment of asthma. Breathing exercises could improve lung function and quality of life in different studies. Psychotherapy-related methods such as relaxation, hypnosis, autogenic training, speleotherapy, and biofeedback might have a small effect in selected cases, but have not proven to be superior to placebo. Nevertheless, more randomized controlled trials of good methodological quality are required to allow firm conclusions.

Effect of two breathing exercises (Buteyko and pranayama) in asthma: a randomised controlled trial

BACKGROUND

Patients with asthma are interested in the use of breathing exercises but their role is uncertain. The effects of the Buteyko breathing technique, a device which mimics pranayama (a yoga breathing technique), and a dummy pranayama device on bronchial responsiveness and symptoms were compared over 6 months in a parallel group study.

METHODS

Ninety patients with asthma taking an inhaled corticosteroid were randomised after a 2 week run in period to Eucapnic Buteyko breathing, use of a Pink City Lung Exerciser (PCLE) to mimic pranayama, or a PCLE placebo device. Subjects practised the techniques at home twice daily for 6 months followed by an optional steroid reduction phase. Primary outcome measures were symptom scores and change in the dose of methacholine provoking a 20% fall in FEV(1) (PD(20)) during the first 6 months.

RESULTS

Sixty nine patients (78%) completed the study. There was no significant difference in PD(20) between the three groups at 3 or 6 months. Symptoms remained relatively stable in the PCLE and placebo groups but were reduced in the Buteyko group. Median change in symptom scores at 6 months was 0 (interquartile range -1 to 1) in the placebo group, -1 (-2 to 0.75) in the PCLE group, and -3 (-4 to 0) in the Buteyko group (p=0.003 for difference between groups). Bronchodilator use was reduced in the Buteyko group by two puffs/day at 6 months; there was no change in the other two groups (p=0.005). No difference was seen between the groups in FEV(1), exacerbations, or ability to reduce inhaled corticosteroids.

CONCLUSION

The Buteyko breathing technique can improve symptoms and reduce bronchodilator use but does not appear to change bronchial responsiveness or lung function in patients with asthma. No benefit was shown for the Pink City Lung Exerciser.

Management of asthma in adults: current therapy and future directions

Asthma is increasing in prevalence worldwide and results in significant use of healthcare resources. Although most patients with asthma can be adequately treated with inhaled corticosteroids, an important number of patients require additional therapy and an increasing number of options are available. A further minority of patients develop severe persistent asthma which remains difficult to manage despite current pharmacological therapies. This review discusses the various treatment options currently available for each stage of asthma severity, highlights some of the limitations of current management, and outlines directions which may improve the management of asthma in the future.

Breathing retraining for dysfunctional breathing in asthma: a randomised controlled trial

BACKGROUND

Functional breathing disorders may complicate asthma and impair quality of life. This study aimed to determine the effectiveness of physiotherapy based breathing retraining for patients treated for asthma in the community who have symptoms suggestive of dysfunctional breathing.

METHODS

33 adult patients aged 17-65 with diagnosed and currently treated asthma and Nijmegen questionnaire scores > or =23 were recruited to a randomised controlled trial comparing short physiotherapy breathing retraining and an asthma nurse education control. The main outcome measures were asthma specific health status (Asthma Quality of Life questionnaire) and Nijmegen questionnaire scores

RESULTS

Of the 33 who entered the study, data were available on 31 after 1 month and 28 at 6 months. The median (interquartile range) changes in overall asthma quality of life score at 1 month were 0.6 (0.05-1.12) and 0.09 (-0.25-0.26) for the breathing retraining and education groups, respectively (p=0.018), 0.42 (0.11-1.17) and 0.09 (-0.58-0.5) for the symptoms domain (p=0.042), 0.52 (0.09-1.25) and 0 (-0.45-0.45) for the activities domain (p=0.007), and 0.50 (0-1.50) and -0.25 (-0.75-0.75) for the environment domain (p=0.018). Only the change in the activities domain remained significant at 6 months (0.83 (-0.10-1.71) and -0.05 (-0.74-0.34), p=0.018), although trends to improvement were seen in the overall score (p=0.065), the symptoms domain (p=0.059), and the environment domain (p=0.065). There was a correlation between changes in quality of life scores and Nijmegen questionnaire scores at 1 month and at 6 months. The number needed to treat to produce a clinically important improvement in health status was 1.96 and 3.57 at 1 and 6 months.

CONCLUSION

Over half the patients treated for asthma in the community who have symptoms suggestive of dysfunctional breathing show a clinically relevant improvement in quality of life following a brief physiotherapy intervention. This improvement is maintained in over 25% 6 months after the intervention.

Functional symptoms confused with allergic disorders in children and adolescents

The diagnosis of a functional respiratory disorder is sometimes difficult and time-consuming, because the symptoms often resemble those of organic diseases. The most common entities are hyperventilation syndrome, psychogenic cough, sighing dyspnea, and vocal cord dysfunction. Typical signs are heavy breathing or dyspnea, cough or sneezing, various breathing sounds, tightness of the throat or chest, pain, and fear. Criteria for differentiation include the lack of nocturnal symptoms, the sudden occurrence, no typical trigger factors, the variable duration, a quick regression, and that symptoms do not respond to adequate pharmacotherapy and finally normal results of diagnostic work-up. Therapeutic options comprise psychological intervention (by reassurance, relaxation techniques, and behaviour therapy) and physiotherapy (e.g. breathing therapy, voice training). Intensive efforts should be made to diagnose functional symptoms at an early stage because this will prevent stigmatization and fixation of symptoms and disease, and also prevent children from undergoing unnecessary and potentially harmful therapies.

Psychological aspects of asthma

Asthma can be affected by stress, anxiety, sadness, and suggestion, as well as by environmental irritants or allergens, exercise, and infection. It also is associated with an elevated prevalence of anxiety and depressive disorders. Asthma and these psychological states and traits may mutually potentiate each other through direct psychophysiological mediation, nonadherence to medical regimen, exposure to asthma triggers, and inaccuracy of asthma symptom perception. Defensiveness is associated with inaccurate perception of airway resistance and stress-related bronchoconstriction. Asthma education programs that teach about the nature of the disease, medications, and trigger avoidance tend to reduce asthma morbidity. Other promising psychological interventions as adjuncts to medical treatment include training in symptom perception, stress management, hypnosis, yoga, and several biofeedback procedures.

The structure of symptom report in asthma: a reevaluation

OBJECTIVES

We studied the structure of symptom report in a sample of British asthma patients using the Asthma Symptom Checklist (ASC).

METHODS

The ASC was administered to 193 patients, together with a questionnaire on demographics and asthma-related information and the Perceived Control of Asthma Questionnaire.

RESULTS

Principal Component Analysis yielded evidence for a six-dimensional structure of the ASC, with positively correlated subscales for panic-fear, irritation, obstruction-dyspnea, obstruction-congestion, fatigue, and hyperventilation symptoms. Individual subscales showed good to excellent item characteristics and internal consistencies in individual subscales. Panic-fear and obstruction-congestion were related to self-reported duration of oral corticosteroid intake. Other ASC subscales were positively related to aspects of health care utilization, limitations in daily activity, and lower perceived control of asthma mainly in women. The dyspnea subscale of the ASC showed only little relationship with either of these variables.

CONCLUSION

The ASC can reliably assess the multidimensional structure of asthma symptom report. Its subscales are associated with important aspects of asthma management behavior.