The effects of controlled breathing during pulmonary rehabilitation in patients with COPD

JD. RespiCo: A novel, flexible, and stand-alone electronic respiratory coaching device

Conscious respiratory pattern and rate control is desired by patients with some forms of pulmonary disease that are undergoing respiratory muscle conditioning and rehabilitation, by practitioners of meditation hoping to improve mindfulness and wellbeing, by athletes striving to obtain breathing control in order to increase competitiveness, and by engineers and scientists that wish to use the data from breathing subjects to test hypotheses and develop physiological monitoring systems. Although prerecorded audio sources and computer applications are available that guide breathing exercises, they often suffer from being inflexible and allow only limited customization of the breathing cues. Here we describe a small, lightweight, battery-powered, microprocessor-based respiratory coaching device (RespiCo), which through wireless or wired connections, can be easily customized to precisely guide subjects to breathe at desired respiratory rates using specific breathing patterns through visual, auditory, or haptic cues. Digital signals can also be captured from the device to document the breathing cues provided by the device for research purposes. It is anticipated that this device will have important utility for those who wish to be guided to breathe in a precise manner or in research and development of physiologic monitoring systems.

Effects of Diaphragmatic Breathing on Health: A Narrative Review

Background: Breathing is an essential part of life. Diaphragmatic breathing (DB) is slow and deep breathing that affects the brain and the cardiovascular, respiratory, and gastrointestinal systems through the modulation of autonomic nervous functions. However, the effects of DB on human health need to be further investigated. Methods: The author conducted a PubMed search regarding the current evidence of the effect of DB on health. Results: This review consists of a total of 10 systematic reviews and 15 randomized controlled trials (RCTs). DB appears to be effective for improving the exercise capacity and respiratory function in patients with chronic obstructive pulmonary disease (COPD). Although the effect of DB on the quality of life (QoL) of patients with asthma needs to be investigated, it may also help in reducing stress; treating eating disorders, chronic functional constipation, hypertension, migraine, and anxiety; and improving the QoL of patients with cancer and gastroesophageal reflux disease (GERD) and the cardiorespiratory fitness of patients with heart failure. Conclusions: Based on this narrative review, the exact usefulness of DB in clinical practice is unclear due to the poor quality of studies. However, it may be a feasible and practical treatment method for various disorders.

Effects of Breathing Exercises in Patients With Chronic Obstructive Pulmonary Disease: Systematic Review and Meta-Analysis

Objective

To update evidence on the effects of breathing exercises (BEs) on ventilation, exercise capacity, dyspnea, and quality of life (QoL) in chronic obstructive pulmonary disease (COPD) patients.

Methods

Randomized controlled trials investigating the effects of BEs in COPD patients published through May 2018, were retrieved from five electronic databases (MEDLINE, CINAHL, Cochrane, Scopus, and ScienceDirect). Risk of bias and quality of evidence were assessed, using Cochrane Collaboration’s tool, and the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach, respectively.

Results

Nineteen studies (n=745), were included. Quality of evidence, was low to moderate. When compared to the control groups, respiratory rate significantly (p≤0.001) improved in the pursed-lip breathing (PLB), ventilatory feedback (VF) plus exercise, diaphragmatic breathing exercise (DBE), and combined BEs. Additionally, PLB significantly improved tidal volume (p<0.001), inspiratory time (p=0.007), and total respiratory time (p<0.001). VF plus exercise significantly improved inspiratory capacity (p<0.001), and singing significantly improved the physical component of QoL, than did the control groups (p<0.001). All BEs did not significantly improve dyspnea, compared to the controls (p>0.05).

Conclusion

PLB, VF plus exercise, DBE, combined BEs, and singing could be used to improve ventilation and QoL. Based on low to moderate quality of evidence, use of these BEs to improve ventilation and QoL in COPD patients is conditional (Registration No. CRD42018102995).

Autonomic symptoms in patients with moderate and severe chronic obstructive pulmonary disease

OBJECTIVES

A synoptic description of the autonomic symptoms profile (ASP) of patients with COPD is not available. Therefore, we aimed to provide an overview of autonomic symptoms and its associates in COPD.

METHODS

We evaluated 89 subjects with COPD (65 ± 7.3 years; 66 males; GOLD II-IV) with an equal number of age- and sex-matched control subjects by means of the composite autonomic symptom score (COMPASS 31) questionnaire, which assesses autonomic symptoms across six domains (orthostatic intolerance, vasomotor, secretomotor, gastrointestinal, urinary and pupillomotor). Lung function, medication use and health status variables (quality of life: physical/mental component summary [PCS/MCS], fatigue, anxiety, depression and dyspnea levels) were also assessed.

RESULTS

Compared to controls, all subjects with COPD reported significantly higher orthostatic intolerance, secretomotor and total autonomic symptom scores (p < .05). Additionally, subjects with moderate COPD also reported significantly higher scores for vasomotor, gastrointestinal, urinary and pupillomotor symptoms compared to controls (p < .05). Nevertheless, these symptoms were comparable between the moderate and severe COPD subgroups (p > .05). The COPD subjects had poorer health status compared to controls as exhibited by significantly higher scores for depression, anxiety, fatigue and dyspnea, and lower scores values for PCS and MCS scores (p < .05). These health status variables were mildly associated with autonomic symptoms (0.214 ≤ r ≥ 0.421; p < .05), but not with demographic and lung function (p > .05). The MCS was the only significant predictor of total autonomic symptoms score in COPD (p = 0.001; β = -0.430).

CONCLUSION

Autonomic symptoms are present in all domains of the COMPASS-31 in COPD, irrespective of disease severity and demographic variables. Autonomic symptoms in COPD were mainly influenced by poor mental health.

Effect of respiratory rehabilitation techniques on the autonomic function in patients with chronic obstructive pulmonary disease: A systematic review

Patients with chronic obstructive pulmonary disease (COPD) show several extrapulmonary abnormalities such as impairment in the autonomic function (AF). Similarly, the use of respiratory training techniques such as controlled breathing techniques, noninvasive mechanical ventilation (NIMV), and oxygen supplementation for AF modulation in patients with COPD is popular in existing literature. However, the evidence to support their use is nonexistent. A systematic search of studies reporting on the effect of controlled breathing techniques, NIMV, and/or oxygen supplementation techniques on AF outcome parameters was conducted in three online databases: PubMed, Embase, and Web of Science. Following the Preferred Reporting Items for Systematic reviews and Meta-Analyses statement, relevant studies were retained and qualitatively analyzed for evidence synthesis. The methodological quality in these studies was evaluated using the evidence based guideline development (EBRO) checklists per designs provided by the Dutch Cochrane Centre. Eighteen studies met the inclusion criteria of the review and were included and discussed. The evidence synthesis revealed that a strong and moderate level evidence supported oxygen supplementation and slow breathing techniques, respectively, in significantly enhancing the baroreceptor sensitivity (BRS) values in patients with COPD. The effect of the examined techniques on the heart rate variability and muscle sympathetic nerve activity was of a limited or inconsistent evidence. The findings from this review suggest that oxygen supplementation and controlled breathing techniques have profound positive influence on the BRS in patients with COPD. However, it is not fully clear whether these influence translates to any therapeutic benefit on the general AF of patients with COPD in the long term.

Effect of "add-on" interventions on exercise training in individuals with COPD: a systematic review

The aim of this review was to identify the effectiveness of therapies added on to conventional exercise training to maximise exercise capacity in patients with chronic obstructive pulmonary disease (COPD). Electronic databases were searched, identifying trials comparing exercise training with exercise training plus "add-on" therapy. Outcomes included peak oxygen uptake (V'_O2peak), work rate and incremental/endurance cycle and field walking tests. Individual trial effects on exercise capacity were extracted and collated into eight subgroups and pooled for meta-analysis. Sensitivity analyses were conducted to explore the stability of effect estimates across studies employing patient-centred designs and those deemed to be of "high" quality (PEDro score >5 out of 10). 74 studies (2506 subjects) met review inclusion criteria. Interventions spanned a broad scope of clinical practice and were most commonly evaluated via the 6-min walking distance and V'_O2peak. Meta-analysis revealed few clinically relevant and statistically significant benefits of "add-on" therapies on exercise performance compared with exercise training. Benefits favouring "add-on" therapies were observed across six different interventions (additional exercise training, noninvasive ventilation, bronchodilator therapy, growth hormone, vitamin D and nutritional supplementation). The sensitivity analyses included considerably fewer studies, but revealed minimal differences to the primary analysis. The lack of systematic benefits of "add-on" interventions is a probable reflection of methodological limitations, such as "one size fits all" eligibility criteria, that are inherent in many of the included studies of "add-on" therapies. Future clarification regarding the exact value of such therapies may only arise from adequately powered, multicentre clinical trials of tailored interventions for carefully selected COPD patient subgroups defined according to distinct clinical phenotypes.

Self-management of health care behaviors for COPD: a systematic review and meta-analysis

Purpose

This systematic review aimed to identify the most effective components of interventions to facilitate self-management of health care behaviors for patients with COPD. PROSPERO registration number CRD42011001588.

Methods

We used standard review methods with a systematic search to May 2012 for randomized controlled trials of self-management interventions reporting hospital admissions or health-related quality of life (HRQoL). Mean differences (MD), hazard ratios, and 95% confidence intervals (CIs) were calculated and pooled using random-effects meta-analyses. Effects among different subgroups of interventions were explored including single/multiple components and multicomponent interventions with/without exercise.

Results

One hundred and seventy-three randomized controlled trials were identified. Self-management interventions had a minimal effect on hospital admission rates. Multicomponent interventions improved HRQoL (studies with follow-up >6 months St George’s Respiratory Questionnaire (MD 2.40, 95% CI 0.75–4.04, I² 57.9). Exercise was an effective individual component (St George’s Respiratory Questionnaire at 3 months MD 4.87, 95% CI 3.96–5.79, I² 0%).

Conclusion

While many self-management interventions increased HRQoL, little effect was seen on hospital admissions. More trials should report admissions and follow-up participants beyond the end of the intervention.

Supported self-management for patients with moderate to severe chronic obstructive pulmonary disease (COPD): an evidence synthesis and economic analysis

BACKGROUND

Self-management (SM) support for patients with chronic obstructive pulmonary disease (COPD) is variable in its coverage, content, method and timing of delivery. There is insufficient evidence for which SM interventions are the most effective and cost-effective.

OBJECTIVES

To undertake (1) a systematic review of the evidence for the effectiveness of SM interventions commencing within 6 weeks of hospital discharge for an exacerbation for COPD (review 1); (2) a systematic review of the qualitative evidence about patient satisfaction, acceptance and barriers to SM interventions (review 2); (3) a systematic review of the cost-effectiveness of SM support interventions within 6 weeks of hospital discharge for an exacerbation of COPD (review 3); (4) a cost-effectiveness analysis and economic model of post-exacerbation SM support compared with usual care (UC) (economic model); and (5) a wider systematic review of the evidence of the effectiveness of SM support, including interventions (such as pulmonary rehabilitation) in which there are significant components of SM, to identify which components are the most important in reducing exacerbations, hospital admissions/readmissions and improving quality of life (review 4).

METHODS

The following electronic databases were searched from inception to May 2012: MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and Science Citation Index [Institute of Scientific Information (ISI)]. Subject-specific databases were also searched: PEDro physiotherapy evidence database, PsycINFO and the Cochrane Airways Group Register of Trials. Ongoing studies were sourced through the metaRegister of Current Controlled Trials, International Standard Randomised Controlled Trial Number database, World Health Organization International Clinical Trials Registry Platform Portal and ClinicalTrials.gov. Specialist abstract and conference proceedings were sourced through ISI's Conference Proceedings Citation Index and British Library's Electronic Table of Contents (Zetoc). Hand-searching through European Respiratory Society, the American Thoracic Society and British Thoracic Society conference proceedings from 2010 to 2012 was also undertaken, and selected websites were also examined. Title, abstracts and full texts of potentially relevant studies were scanned by two independent reviewers. Primary studies were included if ≈90% of the population had COPD, the majority were of at least moderate severity and reported on any intervention that included a SM component or package. Accepted study designs and outcomes differed between the reviews. Risk of bias for randomised controlled trials (RCTs) was assessed using the Cochrane tool. Random-effects meta-analysis was used to combine studies where appropriate. A Markov model, taking a 30-year time horizon, compared a SM intervention immediately following a hospital admission for an acute exacerbation with UC. Incremental costs and quality-adjusted life-years were calculated, with sensitivity analyses.

RESULTS

From 13,355 abstracts, 10 RCTs were included for review 1, one study each for reviews 2 and 3, and 174 RCTs for review 4. Available studies were heterogeneous and many were of poor quality. Meta-analysis identified no evidence of benefit of post-discharge SM support on admissions [hazard ratio (HR) 0.78, 95% confidence interval (CI) 0.52 to 1.17], mortality (HR 1.07, 95% CI 0.74 to 1.54) and most other health outcomes. A modest improvement in health-related quality of life (HRQoL) was identified but this was possibly biased due to high loss to follow-up. The economic model was speculative due to uncertainty in impact on readmissions. Compared with UC, post-discharge SM support (delivered within 6 weeks of discharge) was more costly and resulted in better outcomes (£683 cost difference and 0.0831 QALY gain). Studies assessing the effect of individual components were few but only exercise significantly improved HRQoL (3-month St George's Respiratory Questionnaire 4.87, 95% CI 3.96 to 5.79). Multicomponent interventions produced an improved HRQoL compared with UC (mean difference 6.50, 95% CI 3.62 to 9.39, at 3 months). Results were consistent with a potential reduction in admissions. Interventions with more enhanced care from health-care professionals improved HRQoL and reduced admissions at 1-year follow-up. Interventions that included supervised or unsupervised structured exercise resulted in significant and clinically important improvements in HRQoL up to 6 months.

LIMITATIONS

This review was based on a comprehensive search strategy that should have identified most of the relevant studies. The main limitations result from the heterogeneity of studies available and widespread problems with their design and reporting.

CONCLUSIONS

There was little evidence of benefit of providing SM support to patients shortly after discharge from hospital, although effects observed were consistent with possible improvement in HRQoL and reduction in hospital admissions. It was not easy to tease out the most effective components of SM support packages, although interventions containing exercise seemed the most effective. Future work should include qualitative studies to explore barriers and facilitators to SM post exacerbation and novel approaches to affect behaviour change, tailored to the individual and their circumstances. Any new trials should be properly designed and conducted, with special attention to reducing loss to follow-up. Individual participant data meta-analysis may help to identify the most effective components of SM interventions.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42011001588.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Relaxation Techniques for People with Chronic Obstructive Pulmonary Disease: A Systematic Review and a Meta-Analysis

Introduction. Chronic Obstructive Pulmonary Disease (COPD) people suffer from severe physical impairments, which often elicit significant psychological distress and impact their quality of life. This meta-analysis aimed to assess evidence from the scientific literature on the effects of relaxation techniques. Methods. We investigated 9 databases to select 25 RCTs. Studies included both inpatients and outpatients with COPD. Both respiratory and psychological outcomes were considered. Results. Relaxation techniques showed a little positive effect on the value of the percentage of predicted FEV1 (d = 0.20; 95% Cl: 0.40--0.01) as well as a slight effect on levels of both the anxiety (d = 0.26; 95% Cl: 0.42-0.10) and depression (d = 0.33; 95% Cl: 0.53-0.13). The higher effect size was found in the quality of life value (d = 0.38; 95% Cl: 0.51-0.24). The assessed quality of the studies, based on the PEDro Scale, was generally medium/high. Conclusion. Relaxation training can have a moderate impact on both psychological well-being and respiratory function, resulting in noticeable improvements in both. Although higher quality research is required, our results sustain the importance of relaxation techniques as a tool to manage COPD.

Evidence for cognitive-behavioral strategies improving dyspnea and related distress in COPD

BACKGROUND

Dyspnea is a complex, prevalent, and distressing symptom of chronic obstructive pulmonary disease (COPD) associated with decreased quality of life, significant disability, and increased mortality. It is a major reason for referral to pulmonary rehabilitation.

METHODS

We reviewed 23 COPD studies to examine the evidence for the effectiveness of cognitive-behavioral strategies for relieving dyspnea in COPD.

RESULTS

Preliminary evidence from randomized controlled trials exists to support cognitive- behavioral strategies, used with or without exercise, for relieving sensory and affective components of dyspnea in COPD. Small to moderate treatment effects for relieving dyspnea were noted for psychotherapy (effect size [ES] = 0.08-0.25 for intensity; 0.26-0.65 for mastery) and distractive auditory stimuli (ES = 0.08-0.33 for intensity; 0.09 to -0.61 for functional burden). Small to large dyspnea improvements resulted from yoga (ES = 0.2-1.21 for intensity; 0.67 for distress; 0.07 for mastery; and -8.37 for functional burden); dyspnea self-management education with exercise (ES = -0.14 to -1.15 for intensity; -0.62 to -0.69 for distress; 1.04 for mastery; 0.14-0.35 for self-efficacy); and slow-breathing exercises (ES = -0.34 to -0.83 for intensity; -0.61 to -0.80 for distress; and 0.62 for self-efficacy). Cognitive-behavioral interventions may relieve dyspnea in COPD by (1) decreasing sympathetic nerve activity, dynamic hyperinflation, and comorbid anxiety, and (2) promoting arterial oxygen saturation, myelinated vagus nerve activity, a greater exercise training effect, and neuroplasticity.

CONCLUSION

While evidence is increasing, additional randomized controlled trials are needed to evaluate the effectiveness of psychosocial and self-management interventions in relieving dyspnea, in order to make them more available to patients and to endorse them in official COPD, dyspnea, and pulmonary rehabilitation practice guidelines. By relieving dyspnea and related anxiety, such interventions may promote adherence to exercise programs and adaptive lifestyle change.

Quantifying the speed of fluctuations in systolic blood pressure

Increased blood pressure variability (BPV), even in the absence of hypertension, has been identified as an important independent cardiovascular risk factor (CVRF). However, the role of the speed of changes in systolic blood pressure (SBP; vSBP) on cardiovascular risk needs to be investigated. The objective of this study was to investigate whether subjects with a high cardiovascular risk profile have an increased degree and speed of changes in SBP compared with subjects with low or no risk. Resting beat-to-beat blood pressure (BP) was recorded for 5 min. Standard BPV measures in both time and frequency domains were conducted. The s.d. of SBP (s.d.-SBP) values was used to quantify the degree of BPV. vSBP was assessed by calculating the slopes of oscillatory fluctuations in SBP for different interbeat intervals (IBI). Subjects were allocated to one of four groups according to the number of CVRFs (0, 1, 2, ≥ 3 CVRF). Of 122 subjects, 19.7% had 0 CVRF, 27.0% had 1, 32.0% had 2 and 21.3% had ≥ 3 CVRFs. There was an increase in vSBP across the four risk groups. The vSBP in patients without CVRF was 3.12 (1.09), 1 CVRF 3.23 (1.07), 2 CVRF 4.16 (2.26) and ≥ 3 CVRF 4.22 (1.66; P = 0.015). The s.d.-SBP was not significantly different between the cardiovascular risk groups. The speed of fluctuations in SBP rather than the degree of BPV is pronounced in patients with elevated cardiovascular risk. Increased speed of BP fluctuations may thus be a contributing mechanism to cardiovascular morbidity.

Breathing exercises for chronic obstructive pulmonary disease

BACKGROUND

Breathing exercises for people with chronic obstructive pulmonary disease (COPD) aim to alter respiratory muscle recruitment, improve respiratory muscle performance and reduce dyspnoea. Although some studies have reported positive short-term physiological effects of breathing exercises in people with COPD, their effects on dyspnoea, exercise capacity and well being are unclear.

OBJECTIVES

To determine whether breathing exercises in people with COPD have beneficial effects on dyspnoea, exercise capacity and health-related quality of life compared to no breathing exercises in people with COPD; and to determine whether there are any adverse effects of breathing exercises in people with COPD.

SEARCH METHODS

The Cochrane Airways Group Specialised Register of trials and the PEDro database were searched from inception to October 2011.

SELECTION CRITERIA

We included randomised parallel trials that compared breathing exercises to no breathing exercises or another intervention in people with COPD.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias. Primary outcomes were dyspnoea, exercise capacity and health-related quality of life; secondary outcomes were gas exchange, breathing pattern and adverse events. To determine whether effects varied according to the treatment used, we assessed each breathing technique separately.

MAIN RESULTS

Sixteen studies involving 1233 participants with mean forced expiratory volume in one second (FEV(1)) 30% to 51% predicted were included. There was a significant improvement in six-minute walk distance after three months of yoga involving pranayama timed breathing techniques (mean difference to control 45 metres, 95% confidence interval 29 to 61 metres; two studies; 74 participants), with similar improvements in single studies of pursed lip breathing (mean 50 metres; 60 participants) and diaphragmatic breathing (mean 35 metres; 30 participants). Effects on dyspnoea and health-related quality of life were inconsistent across trials. Addition of computerised ventilation feedback to exercise training did not provide additional improvement in dyspnoea-related quality of life (standardised mean difference -0.03; 95% CI -0.43 to 0.49; two studies; 73 participants) and ventilation feedback alone was less effective than exercise training alone for improving exercise endurance (mean difference -15.4 minutes; 95% CI -28.1 to -2.7 minutes; one study; 32 participants). No significant adverse effects were reported. Few studies reported details of allocation concealment, assessor blinding or intention-to-treat analysis.

AUTHORS' CONCLUSIONS

Breathing exercises over four to 15 weeks improve functional exercise capacity in people with COPD compared to no intervention; however, there are no consistent effects on dyspnoea or health-related quality of life. Outcomes were similar across all the breathing exercises examined. Treatment effects for patient-reported outcomes may have been overestimated owing to lack of blinding. Breathing exercises may be useful to improve exercise tolerance in selected individuals with COPD who are unable to undertake exercise training; however, these data do not suggest a widespread role for breathing exercises in the comprehensive management of people with COPD.