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The Lancet Respiratory Medicine: Self-taught breathing retraining improves quality of life for people with asthma

The Lancet

Self-taught breathing retraining improves quality of life just as much as training by a physiotherapist, according to the largest randomised controlled trial to test such training published in The Lancet Respiratory Medicine journal.

The self-taught training includes a video and booklet, and shows similar results to face-to-face training with a physiotherapist in helping improve people's quality of life by improving symptoms, mood, and ability to conduct day-to-day activities. The self-taught training was cheaper and less resource-intensive than physiotherapist training.

Many people with asthma still have difficulties breathing despite drug treatment, and access to breathing retraining physiotherapy is limited due to low numbers of appropriately trained specialist physiotherapists worldwide. The technique helps people to cope better with having asthma, but it does not reduce inflammation of the airways or improve lung function. As a result, it is not a replacement for medication and people would need to continue their usual treatment alongside the breathing exercises.

"Our findings suggest that a self-help breathing intervention can be offered conveniently and cost-effectively alongside usual drug treatments to people with asthma whose quality of life is impaired by their disease, despite treatment," says lead author Professor Mike Thomas, University of Southampton, UK. "In the UK, over five million people have asthma and although drug treatments can improve symptoms, many people live with persistent symptoms that impair their quality of life. With these patients often expressing interest in other medication-free ways to manage their symptoms, we hope that our results will offer an effective addition to usual treatment." [1]

The randomised clinical trial included 655 people with asthma aged 16-70 years from 34 centres across the UK who had used a drug treatment and had impaired quality of life. Participants were randomly allocated to receive self-taught training (261), physiotherapist training (132), or usual care (262).

The self-taught training involved breathing exercises (diaphragmatic breathing, nasal breathing, slow breathing, controlled breath holds, and relaxation techniques), information on how the techniques worked to improve symptoms and a daily planner and progress chart.

By comparison, participants assigned to the physiotherapy group were seen by a respiratory physiotherapist for three one-to-one sessions that lasted 30-40 minutes. During these sessions they were taught the same breathing techniques as the self-taught group. The usual care group received no additional treatment.

Participants completed quality of life questionnaires at the start of the trial and after three, six and 12 months, with 556 participants completing the questionnaire at 12 months and all patients responding to at least one of the questionnaires. Their lung function was also measured throughout the trial, and 16 participants were interviewed to give feedback on the training.

One year after the beginning of the trial, participants in the self-taught and physiotherapist training groups showed improved quality of life, compared to those given usual care. Quality of life was similar in both training groups.

These groups also showed slightly reduced levels of depression compared to the usual care group, but the breathing retraining had no effect on anxiety. In addition, none of the participants in any groups showed improvements in their lung function, or reduced inflammation of their airways.

Participants rated the self-taught and physiotherapist training positively, and felt that they had better control over their breathing, less need for rescue medication during breathing difficulties, felt more relaxed and had a better quality of life.

There were similar rates of adverse events in the three groups (39% in self-taught group; 42% in physiotherapist group; 50% in usual care), suggesting that the breathing retraining caused no additional adverse events or side effects.

A cost-effectiveness study published elsewhere [2] suggests that both types of breathing retraining are more effective than usual care. The cost of both interventions per patient were £2.85 for self-taught training, and £83.45 for physiotherapist breathing retraining.

The authors note some limitations, including that the participants who signed up were generally older and so more research is needed to see if breathing retraining is effective in younger groups.

Writing in a linked Comment, Dr John Blakey, Royal Liverpool Hospital, UK, says: "The study by Bruton and colleagues provides strong evidence that breathing retraining delivered remotely via a DVD and booklet can be an effective intervention, but further work will be required to fully explore the generalisability of the findings... Asthma outcomes have remained poor over recent years, with low expectations around control from patients and health-care providers. Remotely delivered breathing retraining is a key component toward incremental improvement, and a necessary adjunct to improved use of more tailored medical treatments."



This study was funded by the UK National Institute of Health Research. It was conducted by researchers from the University of Southampton, NIHR Southampton Biomedical Research Centre, University of Aberdeen, Bournemouth University, Southampton General Hospital, Asthma UK, Respiratory Medicine Unit and Oxford NIHR Biomedical Research Centre, University of Oxford, University of Edinburgh.

The video and booklet materials will be freely available on the Asthma UK website in 2018.

[1] Quote direct from author and cannot be found in the text of the Article.



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