The role of breathing training in asthma management

Basis of preventive and non-pharmacological interventions in asthma

Asthma is one of the most common atopic disorders in all stages of life. Its etiology is likely due to a complex interaction between genetic, environmental, and lifestyle factors. Due to this, different non-pharmacological interventions can be implemented to reduce or alleviate the symptoms caused by this disease. Thus, the present narrative review aimed to analyze the preventive and non-pharmacological interventions such as physical exercise, physiotherapy, nutritional, ergonutritional, and psychological strategies in asthma treatment. To reach these aims, an extensive narrative review was conducted. The databases used were MedLine (PubMed), Cochrane (Wiley), Embase, PsychINFO, and CinAhl. Asthma is an immune-mediated inflammatory condition characterized by increased responsiveness to bronchoconstrictor stimuli. Different factors have been shown to play an important role in the pathogenesis of asthma, however, the treatments used to reduce its incidence are more controversial. Physical activity is focused on the benefits that aerobic training can provide, while physiotherapy interventions recommend breathing exercises to improve the quality of life of patients. Nutritional interventions are targeted on implement diets that prioritize the consumption of fruits and vegetables and supplementation with antioxidants. Psychological interventions have been proposed as an essential non-pharmacological tool to reduce the emotional problems associated with asthma.

The Effect of Threshold Loading Training and an Innovative Respiratory Training Devices with Lower Torso Sports Training in Asthma Patients: A Randomized Trial

This study investigated the influence of two different devices with lower torso sports training in patients with asthma. Patients with asthma (n = 300) aged 55-60 years with FEV1/FVC ratio < 65%, who were repeatedly admitted to a pulmonary rehabilitation centre, participated. Patients were evaluated and randomized into two groups (experimental group 1; EXP-1, n = 150, who applied a conventional threshold loading device, and experimental group 2; EXP-2, n = 150, who used an innovative respiratory training device). Patients were included only if they met the global criteria for asthma. The experimental intervention period lasted 10 weeks with 3 weekly training sessions lasting 30-40 min. The maximal inspiratory pressure (PI, max), pulmonary function test, baseline dyspnoea index (BDI), oxygen saturation, and 6 min walking test (6MWT) performance were all measured at baseline and postintervention. Also, an assessment of the 1 min repeated exercise performance (leg extension and leg press) was performed. Moreover, St. George Respiratory Questionnaire was used to quantify the quality of life (SGRQ). Statistical analysis displayed significant favourable effects on 6MWT, leg press, and FRV1, for patients using both devices (EXP-1 and EXP-2, respectively) with lower torso athletic training. The other variables, weight SPO2 and SGRO, also showed no significant change in neither EXP-1 nor EXP-2. Thus, the new respiratory training device (EXP-2) appeared to be as effective as the conventional threshold loading device (EXP-1). In conclusion, our findings demonstrated beneficial effects of combining respiratory training with athletic training in asthma patients. Additionally, the validity of a unique respiratory training device for asthma patients was confirmed.

Effects of physical therapy on lung function in children with asthma: a systematic review and meta-analysis

BACKGROUND

Asthma is a common chronic respiratory disease in children. In addition to medications, physical therapy is considered as a treatment strategy for asthma. We conducted this study to investigate the effects of physical therapy on lung function in children with asthma.

METHODS

Three databases were searched. We conducted the meta-analysis for the forced expiratory volume in the first second in percent predicted values [FEV1(%pred)], the forced vital capacity in percent predicted values [FVC(%pred)], and the peak expiratory flow in percent predicted values [PEF(%pred)] by using a random effect model.

RESULTS

Of the 6474 identified studies, 18 studies (16 in physical training, 2 in breathing exercise or inspiratory muscle training) were included in the systematic review and 11 studies (all in physical training) were included in the meta-analysis. The meta-analysis showed a significantly improved FVC(%pred) in the experimental group.

CONCLUSIONS

Physical training improved FVC(%pred) significantly in children with asthma. Further study is needed, especially on the effects of breathing exercise and inspiratory muscle training in children with asthma.

IMPACT

Our study reviewed the physical therapies for children with asthma and clarified whether and how these therapies affect them. Our study found that physical training improved the forced vital capacity in percent predicted values [FVC(%pred)] significantly in asthmatic children. Our study provided evidence that physical training could improve lung function in children with asthma, which is not identical to the Global Initiative for Asthma (GINA) guidelines.

12-Week Inspiratory Muscle Training Improves Respiratory Muscle Strength in Adult Patients with Stable Asthma: A Randomized Controlled Trial

This study aims to investigate and compare the effects of conventional breathing exercises and an inspiratory muscle training intervention on clinical symptoms in asthma patients. Sixty asthma patients (40–65 years old) were randomly assigned to either the conventional breathing exercises (BTE) or inspiratory muscle training (IMT) group for a 12-week intervention period. Outcome measurements were performed before and after the intervention, including the spirometry data, maximal inspiratory and expiratory pressures (PImax and PEmax), asthma control test, asthma control questionnaire, six-minute walk test, and three-day physical activity log, were recorded. PImax expressed as % of predicted value controlled for age and gender in healthy subjects (% predicted) increased by 16.92% (82.45% to 99.38%, p < 0.05) in the BTE group and by 29.84% (71.19% to 101.03%, p < 0.05) in the IMT group. Except for forced vital capacity, which was reduced in the BTE group, all other measured variables improved in both groups, and no statistically significant between-group differences were found. IMT appears to be more effective than breathing exercise intervention in promoting improvements in respiratory muscle strength. IMT may act as an alternative to conventional breathing exercises for middle-aged and elderly asthma patients.

Breathing pattern recordings using respiratory inductive plethysmography, before and after a physiotherapy breathing retraining program for asthma: A case report

Breathing retraining (BR) improves symptoms, psychological well-being and quality of life in adults with asthma; but there remains uncertainty as to mechanism of effect. One of the intuitively logical theories is that BR works through altering breathing pattern. There is currently no evidence, however, that BR does result in measurable changes in breathing pattern. In this case report we describe the effects of physiotherapy BR on a 57-year-old female with a 10-year history of asthma. Data were collected before and after a physiotherapy BR program comprising three sessions over 18 weeks: breathing pattern (respiratory inductive plethysmography (RIP); physiology (end tidal carbon dioxide (ETCO₂), heart rate, oxygen saturations, spirometric lung function); questionnaires (Asthma Control Questionnaire (ACQ), Hospital Anxiety and Depression Score, Nijmegen Questionnaire); and medication usage. After BR, the patient's symptoms improved. Her physiology was largely unchanged, although her FEV₁ increased by 0.12L, peak flow by 21L/min. The patient reported using less Salbutamol, yet her asthma control improved (ACQ down 1.5). Her Nijmegen score dropped from positive to negative for hyperventilation (from 39 to 7). Her anxiety-depression levels both reduced into 'normal' ranges. The patient's expiratory time increased, with longer respiratory cycles and slower respiratory rate. No changes were seen in relative contributions of ribcage and abdomen. Controlled trials are now needed to determine the generalizability of these findings.

Patients' experiences of breathing retraining for asthma: a qualitative process analysis of participants in the intervention arms of the BREATHE trial

Poor symptom control and impaired quality of life are common in adults with asthma, and breathing retraining exercises may be an effective method of self-management. This study aimed to explore the experiences of participants in the intervention arms of the BREATHE trial, which investigated the effectiveness of breathing retraining as a mode of asthma management. Sixteen people with asthma (11 women, 8 per group) who had taken part in the intervention arms of the BREATHE trial (breathing retraining delivered by digital versatile disc (DVD) or face-to-face sessions with a respiratory physiotherapist) took part in semi-structured telephone interviews about their experiences. Interviews were analysed using thematic analysis. Breathing retraining was perceived positively as a method of asthma management. Motivations for taking part included being asked, to enhance progress in research, to feel better/reduce symptoms, and to reduce medication. Participants were positive about the physiotherapist, liked having the materials tailored, found meetings motivational, and liked the DVD and booklet. The impact of breathing retraining following regular practice included increased awareness of breathing and development of new habits. Benefits of breathing retraining included increased control over breathing, reduced need for medication, feeling more relaxed, and improved health and quality of life. Problems included finding time to practice the exercises, and difficulty mastering techniques. Breathing retraining was acceptable and valued by almost all participants, and many reported improved wellbeing. Face to face physiotherapy was well received. However, some participants in the DVD group mentioned being unable to master techniques.

Patients with asthma taught how to change their unconscious breathing patterns generally like non-pharmacological interventions. Researchers in the UK, led by Mike Thomas from the University of Southampton, interviewed 16 people about their experiences in a trial that tested breathing retraining exercises delivered by DVD or face-to-face sessions with a respiratory physiotherapist. Overwhelmingly, trial participants reported that breathing retraining sessions gave them greater control over their symptoms, helped them relax, improved their quality of life and reduced the need for medications. Some participants who received DVD instruction said they had trouble mastering the techniques, and many in both groups found it hard to find time to practice the exercises. Overall, however, patients were positive about the experience. The authors conclude that breathing exercises are likely to be a well-received method of asthma management.

Singing Lessons for Respiratory Health: A Literature Review

OBJECTIVE

Several studies have explored the role of music and singing as a treatment for respiratory symptoms. The objective of this paper was to review the current body of literature in regard to the use of singing as both a physiological and a psychological therapy for respiratory disease and assess the role the singing teacher might play in this treatment.

STUDY DESIGN

This is a literature review, discussion of results and directions for further research.

METHOD

Multiple databases were searched using keywords such as "respiratory," "physiotherapy," and "pulmonary" in conjunction with "singing." Studies that met selection criteria were summarized and analyzed.

RESULTS

Seventeen studies pertaining to multiple conditions including chronic obstructive pulmonary disease, asthma, cystic fibrosis, cancer, Parkinson disease, quadriplegia, and multiple sclerosis were analyzed. All studies reported trends of positive physical and/or quality of life outcomes after a series of singing lessons, regardless of statistical significance. Several noted improvements in maximum expiratory pressure and overall breathing technique. Many studies included open-ended interviews revealing participants' perception of singing as an effective therapy that was fun, improved mood, taught breathing and breath control, was a good exercise for the lungs, and had improved physical functioning.

CONCLUSIONS

Singing can be used as an adjunctive treatment for respiratory disease, with the best results occurring after long-term study. Group lessons and a strong teacher relationship feed the need for social interaction and support, which can facilitate treatment compliance. Further research is warranted.

The impact of dysfunctional breathing on the assessment of asthma control

BACKGROUND AND OBJECTIVE

Dysfunctional breathing (DB) is a respiratory disorder, which involves a pattern of breathing too deeply, too superficially and/or too rapidly. In asthma patients, DB may lead to an overestimation of the severity of asthma symptoms, and hence potentially to overtreatment. However, it is not known to which degree DB may affect estimates of asthma control, in a specialist clinical setting.

METHODS

The MAPOut-study examined all patients referred consecutively over a 12-months period for specialist assessment of asthma at the Respiratory Outpatient Clinic at Bispebjerg Hospital in Copenhagen. All patients were examined with the Nijmegen questionnaire with a DB defined as a score ≥23 and the ACQ questionnaire. Linear regression analysis of predictors of ACQ score was performed. Asthma was defined as asthma symptoms and a positive asthma test.

RESULTS

Of the 256 patients referred to the lung clinic, data on both the Nijmegen questionnaire and ACQ score was obtained in 127 patients, who were included in the present analysis. Median (range) age: 30 (15-63) years, and 76 (59.8%) were females. DB was found in 31 (24.4%). Asthmatic patients with co-existing DB had a poorer asthma control compared to asthmatics without DB (Median (range) ACQ score: 2.40 (0.20-4.60) vs 1.20 (0.00-4.40); p < 0.001.). A regression analysis showed that the effect of DB on asthma control was independent of airway hyperresponsiveness or airway inflammation in patients with DB.

CONCLUSION

Dysfunctional breathing is common among asthma patients in a specialist setting, and results in a clinically significant underestimation of asthma control, which may potentially lead to overtreatment.

Breathing exercises for adults with asthma

Asthma is a common long-term condition that remains poorly controlled in many people despite the availability of pharmacological interventions, evidence-based treatment guidelines and care pathways.(1) There is considerable public interest in the use of non-pharmacological approaches for the treatment of asthma.(2) A survey of people with asthma reported that many have used complementary and alternative medicine, often without the knowledge of their clinical team.(3) Such interventions include breathing techniques, herbal products, homeopathy and acupuncture. The role of breathing exercises within the management of asthma has been controversial, partly because early claims of effectiveness were exaggerated.(4) UK national guidance and international guidelines on the management of asthma have included the option of breathing exercise programmes as an adjuvant to pharmacological treatment.(5,6) Here we discuss the types of breathing exercises used and review the evidence for their effectiveness.

A modified breathing exercise program for asthma is easy to perform and effective

OBJECTIVES

Breathing exercises are used by some asthmatic patients, yet are often difficult to perform and time-consuming. This study evaluated a simple, modified breathing exercise program regarding ease to perform and effectiveness as an adjunctive therapy.

METHODS

Subjects age 18 to 65 with a current diagnosis of persistent asthma were enrolled. A program that incorporated three different breathing exercises (yoga pranayama techniques, diaphragmatic breathing and pursed lip breathing) was taught to subjects. The program was designed to be completed in less than 10 minutes per day. Subjects completed the Asthma Control Test (ACT) and mini-Asthma Quality of Life Questionnaire (AQLQ) at baseline and at 1-month follow-up. They also completed a survey that asked them to rate the effectiveness and difficulty of the exercises, and whether they would recommend them in the future.

RESULTS

A total of 74 subjects were enrolled in this study. The intervention improved breathing for 52.9% of the subjects, while 67.6% felt that their daily activity was improved and 66.1% noted that the exercises allowed decreased use of a rescue inhaler. Most subjects (80.9%) recommended breathing exercises as a complementary therapy for asthma and 79.4% of the subjects stated the exercises took less than 10 minutes per day total. Overall, ACT scores improved significantly (p = 0.002) with a statistically non-significant improvement in AQLQ scores.

CONCLUSION

A simple program of breathing exercises was found to be effective and could be completed in less than 10 minutes per day. Furthermore, there was a statistically significant improvement in ACT scores post-exercise.

Breathing retraining for African-American adolescents with asthma: a pilot study of a school-based randomized controlled trial

OBJECTIVE

Asthma affects approximately seven million children/adolescents in the USA, with African-American children disproportionately affected. Breathing retraining techniques have been shown to improve asthma outcomes in adults, though research in youth is limited. The purpose of this pilot study was to test the feasibility and preliminary efficacy of a school-based randomized controlled trial of breathing retraining for asthma outcomes and anxiety symptoms in a sample of urban, African-American adolescents.

METHODS

Adolescents were randomized into either the intervention group (20-min breathing retraining plus education) or control group (20-min standard education). Participants completed two study visits, one month apart. Asthma control, asthma quality of life and lung functioning (FEV1 and peak flow) were the primary outcomes, and state anxiety (pre-post the intervention) and trait anxiety (over the one-month period) were the secondary outcomes.

RESULTS

Thirty-three African-American adolescents participated in the study, with a 90% retention rate between visit 1 and visit 2. Asthma control and asthma quality of life, significantly improved over time (p ≤ 0.01) with no differences between intervention and control groups. State anxiety significantly decreased (p ≤ 0.01) immediately post intervention at both time points with no differences between groups. There were no significant differences found in lung functioning or trait anxiety over the one-month time period.

CONCLUSIONS

These preliminary results suggest that breathing retraining is a feasible, acceptable and potentially efficacious intervention (although no significant differences between groups were found) for improving asthma symptoms in urban adolescents with asthma in a school-based setting.

Singing for respiratory health: theory, evidence and challenges

The premise that singing is a health promoting activity for people with respiratory conditions of chronic obstructive pulmonary disease (COPD) and asthma is a growing area of interest being investigated by researchers from various disciplines. The preliminary evidence, a theoretical framework and identification of methodological challenges are discussed in this perspective article with an eye to recommendations for further research to advance knowledge. After a brief summary of main research findings on singing in healthy people to provide background context, research is reviewed on singing in people with COPD and asthma. Studies include published research and as yet unpublished work by the authors. Methodological challenges arising from the reviewed studies are identified such as attrition from singing or control groups based on weak and strong, respectively, beliefs about singing's effectiveness. Potential solutions for these problems are considered with further recommendations made for other singing research.

Patients' perceptions of the potential of breathing training for asthma: a qualitative study

Background:

Poor symptom control is common in asthma. Breathing training exercises may be an effective adjunct to medication; it is therefore important to understand facilitators and barriers to uptake of breathing training exercises.

Aims:

To gain insight into patients' perceptions of breathing training exercises designed to help control asthma symptoms.

Methods:

Semi-structured think-aloud interviews were conducted with 29 people with asthma about their views of a booklet on breathing training exercises.

Results:

Thematic analysis showed breathing training exercises were seen as acceptable in principle because they were viewed as non-pharmacological, holistic, unobtrusive, and likely to increase patient confidence in managing symptoms. Anticipated disadvantages included the time required and perceived irrelevance for those with well-controlled asthma. These views were influenced by prior experience of changing breathing, wanting to self-manage asthma, negative views of medication, and perceived asthma control/severity. Anticipated barriers to carrying out the exercises included difficulties with nose breathing, remembering to do them, and persevering with them. Anticipated facilitators included monitoring tools and social support.

Conclusions:

The idea of breathing training was viewed positively as an acceptable non-pharmacological treatment that patients can do discreetly to help them breathe more easily and reduce their reliance on medication. Uptake of breathing training may be greater among those who perceive their asthma as severe and/or have negative views of medication. To enhance uptake, it might be helpful to present breathing training exercises as holistic skills that can also benefit those with mild symptoms.

Physiotherapy in asthma using the new Lotorp method

BACKGROUND

Physiotherapy in bronchial asthma has given various results.

AIM

To test a new method focusing on breathing exercise and massage of the thoracic muscles.

PATIENTS AND METHODS

Twenty-eight adult patients with a physician-diagnosed asthma were studied during 6 weeks. All patients were prescribed asthma medication. The new method [active group, n = 17) was compared with physical training (control group, n = 12).

RESULTS

PEF was significantly improved (p = 0.001) in the active group, however, FEV1 showed no significant change. The symptoms "tightness of the chest", "difficult breathing in", "air hunger", and the individually dominating symptom (p = 0.001) were significantly reduced in the active group. Exercise-induced breathing troubles and chest expansion were also significantly reduced.

CONCLUSION

Physiotherapy including breathing exercise and massage of the thoracic muscles (the Lotorp method) in patients with physician-diagnosed asthma resulted in significantly reduced respiratory symptoms during rest and exercise and increased chest expansion. The improvements may be due to an increased mobility of the chest and diaphragm.

Hyperventilation and exhaustion syndrome

Chronic stress is among the most common diagnoses in Sweden, most commonly in the form of exhaustion syndrome (ICD-10 classification - F43.8). The majority of patients with this syndrome also have disturbed breathing (hyperventilation). The aim of this study was to investigate the association between hyperventilation and exhaustion syndrome. Thirty patients with exhaustion syndrome and 14 healthy subjects were evaluated with the Nijmegen Symptom Questionnaire (NQ). The participants completed questionnaires about exhaustion, mental state, sleep disturbance, pain and quality of life. The evaluation was repeated 4 weeks later, after half of the patients and healthy subjects had engaged in a therapy method called 'Grounding', a physical exercise inspired by African dance. The patients reported significantly higher levels of hyperventilation as compared to the healthy subjects. All patients' average score on NQ was 26.57 ± 10.98, while that of the healthy subjects was 15.14 ± 7.89 (t = -3.48, df = 42, p < 0.001). The NQ scores correlated strongly with two measures of exhaustion (Karolinska Exhaustion Scale KES r = 0.772, p < 0.01; Shirom Melamed Burnout Measure SMBM r = 0.565, p < 0.01), mental status [Hospital Anxiety and Depression Score (HADS) depression r = 0.414, p < 0.01; HADS anxiety r = 0.627, p < 0.01], sleep disturbances (r = -0.514, p < 0.01), pain (r = -.370, p < 0.05) and poor well-being (Medical Outcomes Survey Short Form 36 questionnaire- SR Health r = -0.529, p < 0.05). In the logistic regression analysis, the variance in the scores from NQ were explained to a high degree (R(2) = 0.752) by scores in KES and HADS. The brief Grounding training contributed to a near significant reduction in hyperventilation (F = 2.521, p < 0.124) and to significant reductions in exhaustion scores and scores of depression and anxiety. The conclusion is that hyperventilation is common in exhaustion syndrome patients and that it can be reduced by systematic physical therapy such as Grounding.

Psychosocial factors and behavioral medicine interventions in asthma

OBJECTIVE

This review examines the evidence for psychosocial influences in asthma and behavioral medicine approaches to its treatment.

METHOD

We conducted a systematic review of the literature on psychosocial influences and the evidence for behavioral interventions in asthma with a focus on research in the past 10 years and clinical trials. Additional attention was directed at promising new developments in the field.

RESULTS

Psychosocial factors can influence the pathogenesis and pathophysiology of asthma, either directly through autonomic, endocrine, immunological, and central nervous system mechanisms or indirectly through lifestyle factors, health behaviors, illness cognitions, and disease management, including medication adherence and trigger avoidance. The recent decade has witnessed surging interest in behavioral interventions that target the various pathways of influence. Among these, self-management training, breathing training, and exercise or physical activation programs have proved particularly useful, whereas other essential or promising interventions, such as smoking cessation, dietary programs, perception and biofeedback training, and suggestive or expressive psychotherapy, require further, more rigorous evaluation. Given the high comorbidity with anxiety and mood disorders, further evaluation of illness-specific cognitive behavior therapy is of particular importance. Progress has also been made in devising community-based and culturally tailored intervention programs.

CONCLUSION

In concert with an essential medication treatment, behavioral medicine treatment of asthma is moving closer toward an integrated biopsychosocial approach to disease management.

The effectiveness of physiotherapy in patients with asthma: a systematic review of the literature

Since the introduction of medical therapy for asthma the interest in non-medical treatments deteriorated. Physiotherapy could have beneficial effects in asthmatics. This review investigates the effectiveness of physiotherapy in the treatment of patients with asthma. A review was performed on the terms breathing exercises (BE), inspiratory muscle training (IMT), physical training (PhT) and airway clearance (AC) in patients with asthma. The search resulted in 237 potentially relevant articles, after exclusion 23 articles remained. BE (n = 9) may improve disease specific quality of life (QoL), reduce symptoms, hyperventilation, anxiety and depression, lower respiratory rate and medication use. IMT (n = 3) can improve inspiratory pressure and may reduce medication use and symptoms. PhT (n = 12) can reduce symptoms, improve QoL and improve cardiopulmonary endurance and fitness. In conclusion, physiotherapy may improve QoL, cardiopulmonary fitness and inspiratory pressure and reduce symptoms and medication use. Further studies, investigating combinations of techniques, are needed to confirm these findings.

Imposing respiratory variability patterns

To ensure respiratory stability and flexibility, healthy breathing shows balanced variability consisting of considerable correlated variability (parameters of each breath are correlated to parameters of adjoining breaths) and some random variability. Sighing resets this balance when respiration lacks variability or becomes excessively irregular. The present study aimed to investigate the effect of imposed patterns of breathing variability on sighing and self-reported (dis)comfort. Spontaneous breathing was compared to imposed non-variable, correlated and random breathing. Results show that executing imposed breathing is difficult, demanding, and induces tension. Sigh occurrence following spontaneous and imposed breathing patterns could be predicted by self-reported discomfort and increased random variability. However, including non-variable, correlated and random breathing patterns only, the effects of self-reported discomfort on sigh occurrence override the effects of altered breathing variability.

Dysfunctional breathing phenotype in adults with asthma - incidence and risk factors

Background

Abnormal breathing patterns may cause characteristic symptoms and impair quality of life. In a cross-sectional survey 29% of adults treated for asthma in primary care had symptoms suggestive of dysfunctional breathing (DB), more likely to be female and younger, with no differences for severity of asthma. No clear risk factors were demonstrated for DB in asthma, nor the impact of asthma medication was evaluated. The objective of this study was to describe the DB phenotype in adults with asthma treated in a specialised asthma centre.

Methods

Adult patients aged 17–65 with diagnosed asthma were screened for DB using the Nijmegen questionnaire (positive predictive score >23) and confirmed by progressive exercise testing. The following were evaluated as independent risk factors for DB in the multiple regression analysis: female sex; atopy, obesity, active smoker, moderate/severe rhinitis, psychopathology, GERD, arterial hypertension; severe asthma, asthma duration > 5 years, lack of asthma control, fixed airway obstruction, fast lung function decline, frequent exacerbator and brittle asthma phenotypes; lack of ICS, use of LABA or LTRA.

Results

91 adults with asthma, mean age 35.04 ±1.19 years, 47(51.65%) females were evaluated. 27 (29.67%) subjects had a positive screening score on Nijmegen questionnaire and 16(17.58%) were confirmed by progressive exercise testing as having DB. Independent risk factors for DB were psychopathology (p = 0.000002), frequent exacerbator asthma phenotype (p = 0.01) and uncontrolled asthma (p < 0.000001).

Conclusion

Dysfunctional breathing is not infrequent in asthma patients and should be evaluated in asthma patients presenting with psychopathology, frequent severe asthma exacerbations or uncontrolled asthma. Asthma medication (ICS, LABA or LTRA) had no significant relation with dysfunctional breathing.

Respiratory physiotherapy: towards a clearer definition of terminology

Interventions used in clinical practice and research need to be described in sufficient detail to permit accurate replication. Since words and phrases can change their meaning over time, it is important that authors choose their words carefully and define anything which might be ambiguous. 'Breathing exercises' is a phrase which covers a multitude of therapeutic approaches. Recent randomised controlled trials have established the value of teaching patients with asthma to retrain their breathing. However, the descriptions of the breathing interventions are generally inadequate. This problem stems partly from a degree of confusion surrounding terms such as 'diaphragmatic breathing' which has been variously interpreted. A more structured approach to reporting such interventions is proposed. This approach will help to avoid confusion, and will permit the transfer of those interventions found to be effective in research trials into routine clinical practice.