A STUDY TO EVALUATE THE EFFECT OF BUTEYKO
BREATHING TECHNIQUE IN MANAGEMENT OF COPD
By
RITU CHAUHAN
Dissertation Submitted to
Rajiv Gandhi University of Health Sciences
Bangalore, Karnataka
In partial fulfillment of the requirements for the degree of
MASTER OF PHYSIOTHERAPY
IN
CARDIO-RESPIRATORY DISORDERS AND INTENSIVE
CARE
Under the guidance of
Dr ELDO PETER
Asst. Professor
Dr. M.V. SHETTY COLLEGE OF PHYSIOTHERAPY
Mangalore, 2013
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA
ACKNOWLEDGEMENT
First and foremost, I offer this study to the Almighty God without whose blessings,
this study would have not been possible, my parents, Mr.R.C.Chauhan, Mrs.Yashoda
Chauhan, my loving sister-in-law Laxmi Chauhan and Ashish Roy whose constant love
and valuable support gave me courage and confidence throughout this study.
I wish to express my gratitude to my guide Dr. Eldo Peter, Lecturer, Dr. M. V. Shetty
College of Physiotherapy, for his guidance and interest shown in my dissertation, without
whom, this study would have not been possible.
I take this opportunity to acknowledge my deep sense of gratitude and thanks to Dr.
M. Ramgopal Shetty, secretary Dr. M.V.Shetty Trust Colleges for permitting me to conduct
this study.
My sincere thanks to Prof. L Gladson Jose, Principal Dr. M.V. Shetty College of
Physiotherapy for his constant support and guidance throughout my study.
It is my pleasure and privilege to record my deep sense of gratitude to Prof.
U.T.Ifthikar Ali, Professor, Dr. M. V. Shetty College of Physiotherapy for giving
meticulous guidance for being extremely helpful throughout the study which helped me in
framing and completing the dissertation work.
I wish to express my sincere thanks to Dr. Meryl Joe Colaco, and all the respectable
staff members of Dr. M. V. Shetty College of Physiotherapy without whose co-operation
this study wouldn’t have been successful.
I am deeply thankful to my brother Jitendra, my friends AnuNitin, Shivam, Ritika,
Nimisha, Abhilash and my loving juniors Poonam, Astha, Ripun and Neelam for their
constant, support and co-operation throughout the study.
Last but not the least I would like to thank my subjects without whom, this task would
not have been possible. I thank all who have helped me all the while.
Greatfully Acknowledged,
Ritu Chauhan
LIST OF ABBREVIATIONS USED
NIV Non invasive ventilation
MCP Manual chest physiotherapy techniques ( involving chest percussion, vibration
and assisted coughing)
ITT intention to treat
CI confidence interval
RR respiratory rate
SB spontaneous breathing at rest
DB diaphragmatic breathing
FVC Forced Vital Capacity
FEV1 Forced expiratory volume
CB combination of DB and PLB
AECOPD acute exacerbations of chronic obstructive pulmonary disease
ETS Environmental tobacco smoke
AAT Alpha Anti Trypsin
ARDS Acute respiratory distress syndrome
ADL Activity of daily living
CO2 Carbon di Oxide
CP Control Pause
EIA exercise-induced asthma
BBT Buteyko breathing training
ICSAS idiopathic central sleep apnea syndrome
AQLQ Asthma Quality of Life Questionnaire
HAD Hospital Anxiety and Depression
TABLE OF CONTENTS
SERIAL NO PARTICULARS PAGE NO.
1 INTRODUCTION 1-10
2 AIMS AND OBJECTIVE 11
3 REVIEW OF LITERATURE 12-46
4 METHODOLOGY 47-53
5 RESULTS 54-59
6 DISCUSSION 60-63
7 CONCLUSION 64
8 SUMMARY 65
9 BIBLIOGRAPHY 66-80
10 ANNEXURES 81-86
LIST OF TABLES
TABLE NO. PARTICULARS PAGE NO.
5.1 Age wise distribution of subjects in three
age group
54
5.2 Pre and Post comparison between Mean
and Standard Deviation values of Heart
rate, Respiratory rate, FVC and FEV1
56
3.3 Average improvement in Heart rate,
Respiratory rate, FVC and FEV1
58
LIST OF GRAPHS
TABLE NO. PARTICULARS PAGE NO.
5.1 Age wise distribution of subjects in three
age group
55
5.2 Pre and Post comparison between Mean
and Standard Deviation values of Heart
rate, Respiratory rate, FVC and FEV1
57
3.3 Average improvement in Heart rate,
Respiratory rate, FVC and FEV1
59
ABSTRACT
Background and purpose:
COPD is characterized by symptoms of breathlessness, wheeze, cough, sputum production
and exercise intolerance. Breathlessness is principally an outcome of poor oxygen exchange.
The Buteyko Institute Method program improves symptoms of breathlessness by normalising
the volume of air breathed, maximising oxygen exchange. The aim of the study is to study the
effects of Buteyko breathing technique in management of chronic obstructive pulmonary
disease (COPD) patients in chronic obstructive pulmonary disease patients.
Method:
According to American Thoracic Society (ATS) Guideline for COPD diagnosis, COPD
patients in the age group 40-60 yrs were recruited for the study. Diagnosed COPD patients
referred by the physician or pulmonologist were initially assessed in the Physiotherapy
Department for inclusion and exclusion criteria. The COPD patients were diagnosed as per
the GOLD criteria. Prior to participation patients are oriented to the study and informed
consent was taken in a written consent form. Instructions on how to perform the spirometer
test was demonstrated to the patient. FVC, FEV1 , respiratory rate and heart rate were
evaluated. Buteyko breathing exercise was demonstrated and explained. After 3 weeks of
regular daily exercise session final readings were taken.
Result:
The data obtained were analyzed by using paired t-test to find out the difference in pre and
post spirometric evaluation for FVC and FEV1 along with heart rate and respiratory rate. Pre
and post comparison shows p<0.05 means there is significant improvement in respiratory rate
and heart rate whereas p the treatment.
Conclusion:
Buteyko breathing exercise was found to be effective in management of COPD patient.
Keywords:
COPD, Heart rate, Respiratory rate, FVC, FEV1, Buteyko breathing exercise, Spirometer
My angelic
Baby
Niece
RUI
INTRODUCTION
Chronic obstructive pulmonary disease (COPD) is characterized by airflow obstruction with
breathing-related symptoms such as chronic cough, exertion dyspnea, expectoration, and
wheeze. These symptoms may occur in conjunction with airway hyper responsiveness and
may be partially reversible. Although COPD is a nonspecific term referring to a set of
conditions that develop progressively as a result of a number of different disease processes, it
most commonly refers to chronic bronchitis and emphysema and a subset of patients with
asthma. These conditions can be present with or without significant physical impairment.
Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease state
characterized by airflow limitation that is not fully reversible. The airflow limitation is
usually progressive and is associated with an abnormal inflammatory response of the lungs to
noxious particles or gases, primarily caused by cigarette smoking. Although COPD affects
the lungs, it also produces significant systemic consequences.
GOLD Criteria for COPD
Several different definitions have existed for COPD. The recently published and widely
accepted definition from GOLD defines COPD as “a disease state characterized by airflow
limitation that is not fully reversible. The airflow limitation is usually both progressive and
associated with an abnormal inflammatory response of the lungs to noxious particles or gases.
Airflow limitations is the slowing of expiratory airflow as measured by spirometry, with a
persistently low forced expiratory volume in 1 second (FEV1) and a low FEV1/forced vital
capacity (FVC) ratio despite treatment.4 The GOLD definition for airflow limitation is an
FEV1/FVC ratio of less than 70%.
The Global Scenario of COPD
COPD is presently ranked fourth among the leading causes of mortality worldwide. By the
year 2020, it is expected to rank among the first three diseases to claim the maximum number
of lives. According to recent estimates, 600 million people suffer from COPD all over the
world. The disease claims 2.75 million lives every year.
The Indian Scenario of COPD
The Journal of the Association of Physicians of India 2004, reports that 65 Million. Indians
suffer from various chronic respiratory diseases excluding tuberculosis. While current
prevalence figures for COPD are not available; in 2001, the Indian Journal of Chest Diseases
and Allied Sciences reported that close to 13 million Indians suffered from COPD. About 62
percent of these were men and the remaining women.
Etiology of COPD
The most important cause of COPD is active exposure to cigarette smoke. Although only 15
to 25% of smokers actually develop COPD, susceptibility to certain host factors makes some
individuals more vulnerable to the effects of cigarette smoke than others. These host factors
include a variety of genetic and nongenetic factors such as socioeconomic status and gender;
however, the precise role and importance of each factor are not yet fully understood. In only a
minority of patients with COPD is smoking not the primary cause of their disease. This group
includes patients with AAT deficiency and those exposed to certain occupational agents.
Cigarette smoking is overwhelmingly the most important etiologic agent in the development
of COPD. In every population for which prevalence data are available, respiratory symptoms
and airflow obstruction are more prevalent among smokers than nonsmokers.
In most multivariate analyses, cigarette smoking has been shown to be an independent
predictor of airflow obstruction after adjustment for age and initial FEV1. Altogether,
cigarette smoking accounts for 80 to 90% of cases of COPD. Smokers have a greater rate of
decline in FEV1 compared to age-matched nonsmokers, and this increases further with a
higher smoking intensity. Smoking also retards the normal increase in expiratory flow that
occurs during adolescent growth. Passive exposure during childhood can affect lung growth
and may also be associated with an increased risk of COPD later in life. Environmental
tobacco smoke (ETS) has been associated with functional impairment and lower than
expected increases in lung function during growth.
Hyperventilation in COPD
The idea of a hyperventilation syndrome characterized by a larger number of psychological
and somatic symptoms that could be related to either acute or chronic hyperventilation began
to develop after Kerr reported his findings on the effects of hyperventilation challenge on 35
patients with unexplained symptom. His patients were able to reproduce their symptoms by
voluntary and prolonged hyperventilation. The name “Hyperventilation Syndrome” began to
be used at around this time and was considered to exist mostly in neurotic patients and to be a
relatively rare condition.
The range of symptoms attributed to Hyperventilation Syndrome gradually increased until a
large number of symptoms of central and peripheral neurovascular, muscular, respiratory,
cardiac, gastrointestinal origin were attributed to this syndrome.
There are studies studies which demonstrated that administration of carbon dioxide either
through rebreathing or by administration of CO2 enriched gas mixtures was able to eliminate
the symptoms of hyperventilation that either came on spontaneously or were brought on by
hyperventilation provocation tests.
When respiratory control centres in the brain receive messages from the cortex, limbic
system, chemoreceptor or mechanoreceptors that ventilation is inadequate, the respiratory
muscles adjust their functions to increase ventilation. If respiration is stimulated for
prolonged periods, the diaphragm and accessory muscles of breathing may become
chronically hypertonic.
Typical changes in breathing pattern that reject increased respiratory drive include, upper
chest breathing with decreased lateral expansion of the lower rib cage and tendency to
asynchronous and paradoxical breathing. Disease processes can increase ventilator needs,
stimulate respiratory drive and alter respiratory control often creating characteristic changes
in breathing pattern. This is seen in respiratory conditions such as asthma and COPD and in
heart disease.
Psychological and emotional states also alter respiratory control and respiratory rhythm
generation. Subsequently changes in breathing pattern which can be dysfunctional are very
common in people with respiratory and cardiovascular disease and under psychological
stress.
Hypocapnia in COPD patients
Carbon dioxide is a waste product of aerobic cellular respiration in all aerobic life forms.
PaCO2 represents the balance between the carbon dioxide produced and that eliminated.
Hypocapnia remains a common and generally underappreciated -component of many disease
states, including early asthma, high-altitude pulmonary edema, and acute lung injury.
Induction of hypocapnia remains a common, if controversial, practice in both adults and
children with acute brain injury. In contrast, hypercapnia has traditionally been avoided in
order to keep parameters normal. More recently, advances in understanding of the role of
excessive tidal volume has prompted clinicians to use ventilation strategies that result in
hypercapnia. Consequently, hypercapnia has become increasingly prevalent in the critically
ill patient. Hypercapnia may play a beneficial role in the pathogenesis of inflammation and
tissue injury, but may hinder the host response to sepsis and reduce repair. In contrast,
hypomania may be a pathogenic entity in the setting of critical illness.
Attacks of acute bronchoconstriction often occur in patients with COPD when exposed to air
pollutants, irritant fumes, and during respiratory infections. Breathing exercises for COPD are
vital since acute COPD exacerbations are always accompanied by increased lungs ventilation,
because of which breathing becomes faster and usually deeper. Studies also show that COPD
patients have heavy breathing at rest before acute exacerbations, when they are in stable
conditions .As a result of heavy breathing, all these people suffer from alveolar hypomania. It
is a known physiological law that all smooth muscles are highly sensitive to CO2 levels.
Thus, spasm in the smooth muscles of bronchi and bronchioles is a normal physiological
reaction to alveolar hyperventilation The outcomes of randomized controlled studies support
the evidence for physiotherapy in COPD, more specifically exercise training and peripheral
and respiratory muscle training.
Physiotherapy consists of various treatment modalities specifically exercise training,
peripheral and respiratory muscle training, breathing exercises. The most prominent and
distressing symptom of chronic obstructive pulmonary disease is air hunger, the feeling that
one cannot get enough air to breathe. Significant concerns exist regarding potential adverse
effects of lowered CO2 tension on several aspects of both pulmonary and systemic organ
dysfunction.
Hypomania has been associated with worsened lung injury in the context of
bronchopulmonary dysphasia and ARDS. Although the pathogenic links between hypomania
and adverse pulmonary outcome are incomplete, several potential contributory factors have
been determined. Hypomania causes and exacerbates bronchospasm and attenuates hypoxic
pulmonary vasoconstriction, worsening intrapulmonary shunt and systemic oxygenation.
Hypomania may exert adverse pulmonary effects via several distinct mechanisms. Airway
hypomania increases tracheal micro vascular permeability. Furthermore, hypomania
decreases lung compliance in healthy volunteers and in patients with chronic obstructive lung
disease probably as a result of increased production of dysfunctional surfactant. Furthermore,
we have demonstrated in this study that hypomania is both directly deleterious to the lung
and potentates acute lung injury following ischemia-reperfusion. The cellular basis for injury
may relate to specific adverse processes associated with hypomania. The physiological basis
for injury involves increases in micro vascular permeability, which is consistent with the
previously described effects of hypomania on tracheal micro vascular permeability39 possibly
involving products of cyclooxygenase activation. Additional specific cellular effects
associated with hypomania include increased inositol phosphate turnover and activation of
ATP sensitive K channels and voltage sensitive Ca channels, all of which may play
pathogenic roles in reperfusion injury.
Low CO2 levels can develop quickly because of the very high solubility of CO2 (twenty
times more soluble than oxygen). Its ease of excretion means that increased ventilation
resulting from non-metabolic stimuli, for example stress, anxiety or increase sensations of
dyspnea, can result in depletion of CO2. The effects of hyperventilation and carbon dioxide
depletion are far reaching and include inhibiting the dissociation of oxygen from hemoglobin
in the blood, resulting in low oxygen concentration in tissues. The effects on the brain and the
nervous system of hypomania are particularly. Hypomania produces bronchoconstriction in
the lungs and vasoconstriction in the blood vessels.
Similarities And Differences In Coped And Asthma
The presence or absence of reversibility was once thought to be the major distinction between
asthma and COPD, with reversibility of airflow obstruction being the hallmark of asthma,
and mainly irreversible obstruction the hallmark of COPD. Newer definitions of both asthma
and COPD acknowledge the overlap between these conditions and highlight their similarities
and differences. Chronic inflammation underlies both conditions, but the nature of the
inflammation differs, as does the response to different classes of medications.
While reversible airflow obstruction is the hallmark of asthma and mainly irreversible airflow
obstruction the hallmark of COPD, many patients with asthma have persistent obstruction,
while many with COPD have a reversible component. Chronic inflammation underlies both
diseases. Both conditions involve small airways, perhaps slightly more in COPD, causing a
slightly larger decrease in FVC. Both cause obstruction with mucus and constriction of
smooth muscle, and both are affected by genetic environmental interactions. There is
considerable overlap in older asthmatics and COPD patients in the nature of their response to
bronchodilators. Treatment of asthma is characterized by suppression of inflammation, while
treatment of COPD is characterized by relief of symptoms.
Buteyko breathing technique
There are several breathing therapies that aim to correct hyperventilation and restore normal
carbon dioxide tension. Breathing biofeedback using a manometer to monitor end-tidal
carbon dioxide levels during breathing training is one approach to treating hypomania.
Biofeedback training that employs the use of a capnometer aims at normalizing end-tidal
CO2 at approximately 5%. There are various systems for capnometry biofeedback available
to the practitioner and in recent years these have become increasingly available.
Other breathing therapists use no instrumentation and rely on a combination of slow
controlled breathing, breathing pattern correction and relaxation strategies.
The Buteyko Breathing Technique (BBT) is yet another technique whose primary aim is the
correction of acute and chronic hypocapnia. It uses a unique set of breathing techniques in
which breath holding is combined with reduced volume breathing. BBT exercises aim to
increase carbon dioxde and reset chemoreceptor thresholds however they may also be useful
in reducing hyperinflation.
The Buteyko concept is a system of breathing exercises originally devised in the 1950s by
Professor Konstantin Buteyko, a Russian physician and academic personality. Following its
popularity in Russia, the concept has gradually spread to western countries over the last 20
years, notably Australia and New Zealand and other parts of Europe. The technique offers a
complementary method of reliving respiratory symptoms based on the voluntary control of
breathing, as well as considering the effects of environmental and dietary triggers.
The primary goal in Buteyko is for patients to be able to manage any intermittent symptom of
breathlessness by teaching them to use short period of voluntary hypoventilation, breaths –
holding exercises and relaxation techniques during the period of onset.
Underlying theories :
One of the theories behind the Buteyko method is based on the assumption that
hyperventilation may b responsible for incusing bronchospasm as the body attempts to retain
carbon do oxide. Therefore, correcting the hyperventilation should reduce bronchospasm and
result in more stable symptom control.
Another explanation proposed is that slow nasal breathing can reduced the effects of
turbulence to create a laminar flow, which may improve any ventilation perfusion mismatch.
The importance of nasal breathing is widely known in relation to its effect of warming,
moisturizing and filtering the air before contact with the small structures of the bronchioles.
Other theories being explored are the effect of intermittent hypoxia training and the role of
nitric oxide, which has been found to be present in the nasal passages, but there is no
definitive evidence to date.
Over 90% of 100 000 patients who completed the Buteyko course in Russia are said to need
no further asthma medication and a similar success rate has been claimed for 8000 patients in
Australia. In 1968, in his research article “The mechanism of bronchoconstriction due to
hypocapnia in man” Sterling explained that carbon dioxide deficiency leads to an excited
state of the cholinergic nerve (Sterling, 1968). Since this nerve is responsible for the tone or
relaxation of the smooth muscles in bronchi, its excited state prevents bronchodilator. Dr.
Herxheimer was probably the first scientist who proposed that CO2 causes bronchodilator
Soviet Doctor K Buteyko independently proposed this link in the 1950’s (his first publication
was in 1964) when he discovered the central roles of CO2 in bronchodilator and over
breathing in the development and degree of COPD and asthma (Buteyko, 1964). Buteyko
breathing induces hypercapnia and hence overcomes bronchoconstriction.
NEED AND OBJECTIVES
Need of the study
Buteyko Breathing has been identified as a potent mechanism for reducing
bronchoconstriction. It is suggestive of that Buteyko may be a more effective pattern of
breathing than natural breathing. However there are lack of studies and hence the need arises
to measure the effects of Buteyko breathing on pulmonary functions in COPD patients.
Objectives of the study
To evaluate the effectiveness of Buteyko breathing technique in the management of patients
with chronic obstructive bronchial disease.
REVIEW OF LITERATURE
COPD
SK Jindal studied on “Emergence of chronic obstructive pulmonary disease as an epidemic
in India” and he found that the population prevalence of COPD was 4.1 per cent of 35,295
subjects with a male to female ratio of 1.56 : 1. Almost all forms of smoking products such as
cigarettes and ‘beedis’ used in different States were found to be significantly associated with
COPD. In non-smokers, especially women, exposures to indoor air pollution from domestic
combustion of solid fuels were an important factor. More significantly the exposure to
environmental tobacco smoke (ETS) was an established cause for COPD. The odds ratio for
risk from ETS exposure in non-smokers (1.535) was significant during both the childhood
and the adulthood. Tobacco smoking was also the most frequent cause of chronic cor-
pulmonale which occurred as a long term complication of COPD both amongst men and
women.
Stephen H. Loring, Mauricio Garcia-Jacques et al. conducted a study to analyze
mechanical characteristics and gas exchange inefficiencies of the lungs contribute to
increased work of ventilation in chronic obstructive pulmonary disease (COPD) at rest and
exercise, and the energy cost of ventilation is increased in COPD at any external work level.
In COPD, dynamic hyperinflation not only increases the work done during inspiration, it
profoundly reduces the capacity of the aspiratory muscles to generate force and shorten,
decreasing the ventilator reserve capacity and increasing the sense of effort and dyspnea the
diminished gas exchange efficiency of the lung in COPD, which results in increased
ventilator requirements at rest and exercise that increase respiratory muscle work.
Roberto Rodríguez-Roisin MD, Mitra Drakulovic mdet al in a study assessed the
relationship between pulmonary gas exchange and airflow limitation in patients with COPD
across the severity spectrum. Ventilation-perfusion mismatch (VA/Q) was measured using
the multiple inert gas elimination technique in 150 patients from previous studies. The
distribution of patients according to the GOLD stage of COPD was: 15 with stage 1; 40 with
stage 2; 32 with stage 3; and 63 with stage 4. In GOLD stage 1, AaPO2 and VA/Q mismatch
were clearly abnormal; thereafter, hypoxemia, AaPO2 and VA/Q imbalance increased, but
the changes from GOLD stages 1 to 4 were modest. Post-bronchodilator FEV1 was related to
PaO2 (r = 0.62) and PaCO2 (r = – 0.59) and to overall VA/Q heterogeneity (r = – 0.48) (p <
0.001 each). Pulmonary gas exchange abnormalities in COPD are related to FEV1 across the
spectrum of severity. VA/Q imbalance, predominantly perfusion heterogeneity, is
disproportionately greater than airflow limitation in GOLD stage 1.
Koskela HO, Koskela AK et al. did a study to clarify how cold weather may induce
bronchoconstriction in patients with COPD, a series of challenges were performed in 20
patients with COPD in stable condition as well as in 13 healthy subjects. A whole-body
exposure to -17°C during resting nasal breathing was performed to study the reflex effects of
facial cooling on lung function. In addition, a near-maximal hyperventilation of cold air was
performed in a warm room to study the direct airway effects of cold air. The whole-body
exposure to cold air induced statistically significant bronchoconstriction in both groups, the
maximal decrements in FEV1 being 9.4±1.4% in the patients with COPD and 10.3±0.8% in
the healthy subjects (p=NS). The whole-body exposure to cold air also increased the resting
ventilation. The hyperventilation challenge induced bronchoconstriction only in the patients
with COPD, the maximal decrements in FEV1 being 8.0±1.3% and 1.5±1.0%, respectively
(p<0.01). These results suggest that cooling of the facial skin is predominantly responsible
for the bronchoconstriction due to cold weather both in patients with COPD and in healthy
subjects. At high ventilation level, as during heavy exercise, the direct airway effects of cold
air may also contribute to the bronchoconstriction in patients with COPD.
Hogg JC, Chu F, Utokaparch S, et al. studied evolution of the pathological effects of
airway obstruction in patients with COPD.The small airways were assessed in surgically
resected lung tissue from 159 patients — 39 with stage 0 (at risk), 39 with stage 1, 22 with
stage 2, 16 with stage 3, and 43 with stage 4 (very severe) COPD, according to the
classification of the Global Initiative for Chronic Obstructive Lung Disease (GOLD).The
progression of COPD was strongly associated with an increase in the volume of tissue in the
wall (P<0.001) and the accumulation of inflammatory mucous exudates in the lumen
(P<0.001) of the small airways. The percentage of the airways that contained polymorph
nuclear Europhiles (P<0.001), macrophages (P<0.001), CD4 cells (P=0.02), CD8 cells
(P=0.038), B cells (P<0.001), and lymphoid aggregates containing follicles (P=0.003) and the
absolute volume of B cells (P=0.03) and CD8 cells (P=0.02) also increased as COPD
progressed. Progression of COPD is associated with the accumulation of inflammatory
mucous exudates in the lumen and infiltration of the wall by innate and adaptive
inflammatory immune cells that form lymphoid follicles. These changes are coupled to a
repair or remodeling process that thickens the walls of these airways.
F J J van den Elshout studied the effects of hypercapnia and hypocapnia on respiratory
resistance were studied in 15 healthy subjects and 30 asthmatic subjects. Respiratory
resistance (impedance) was measured with the pseudo-random noise forced oscillation
technique while the subjects recreated from a wet spirometry in a closed respiratory circuit in
which end tidal carbon dioxide tension (Pco2) could be controlled. Hypercapnia was induced
by partially short circuiting the carbon dioxide absorber, and hypomania by voluntary
hyperventilation. The circulating air was saturated with water vapor and kept at body
temperature and ambient pressure. A rise of end tidal Pco2 of 1 kPa caused a significant fall
in respiratory resistance in both normal and asthmatic subjects (15% and 9% respectively). A
fall of Pco2 of 1 kPa did not cause any significant change in impedance in the control group.
In the asthmatic patients resistance increased by 13%, reactance fell by 45%, and the
frequency dependence of resistance rose 240%. These findings confirm that hypomania may
contribute to airway obstruction in asthmatic patients, even when water and heat loss are
prevented.
CM Parker, N. Voduc, SD Aaron, KA Webb et al. did a study on "Physiological changes
during symptom recovery from moderate exacerbations of COPD" and concluded that
moderate acute exacerbation of chronic obstructive pulmonary disease is characterized by
worsening airflow obstruction and lung hyperinflation. Improvement of dyspnea was
associated with reduction in lung hyperinflation and consequent increase in expiratory flow
rates.
Bonilha, a. G., onofre, conducted a study aimed to investigate the effects of weekly singings
classes on pulmonary function parameters and quality of life (QoL) of COPD patients. Forty-
three patients were randomized to weekly classes of singing practice, or handcraft work.
They performed spirometry and completed maximal respiratory pressure measurements,
evaluations of dyspnea, and the Saint George’s Respiratory Questionnaire, before and after
24 training classes. A functional evaluation, immediately after 10 minutes of singing practice,
was also performed at the end of the study. Fifteen subjects completed the study in each
group. In comparison to controls the singing group exhibited transitory elevations on the
dyspnea Borg scale (p = 0.02), and inspiratory capacity (p = 0.01), and decreases of
expiratory reserve volume (p = 0.03), just after a short session of singing. There was a
significant difference on changes of maximal expiratory pressures in the comparison between
groups at the end of training. While the control group showed deterioration of maximal
expiratory pressure, the singing group exhibited a small improvement (p = 0.05). Both groups
showed significant improvements of QoL in within group comparisons. We have concluded
that singing classes are a well tolerated activity for selected subjects with COPD. Regular
practice of singing may improve QoL, and preserve the maximal expiratory pressure of these
patients.
Casciari RJ, Fairshter RD conducted a study to evaluate the effects of breathing retraining
(BRT) on exercise tolerance in subjects with severe chronic obstructive pulmonary disease
(COPD). Twenty-two subjects exercised on a treadmill three times weekly for six weeks.
Twelve of the subjects (controls) then exercised for three more weeks; the other ten subjects
received three more weeks of exercise reconditioning plus BRT. Results of routine
pulmonary function and exercise tests were similar in both groups at the beginning of the
study and after six weeks of exercise. However, in the last three weeks of the study,
increments in exercise performance were significantly greater in the BRT subjects than in
controls (P less than .002). Following BRT, respiratory rate during exercise decreased (P less
than .005) and tidal volume and PaO2 during exercise increased (P less than .05). Thus, these
data suggest that BRT increases exercise performance in subjects with severe COPD.
Jennifer A Alison, Rosemary Samios conducted a study to evaluate the effect of a 12-week
bicycle training program on the exercise tolerance of 10 patients with chronic airway
obstruction was assessed. Six men and four women whose ages ranged from 45 to 75 years
(mean 60 yr) and who all had spirometry evidence of airway obstruction were studied. Two
methods of evaluation were used before and after training: the maximum working capacity
obtained during a progressive bicycle exercise test and the distance walked on a flat surface
in 12 minutes. There was a statistically significant improvement in maximum working
capacity and in the distance walked in 12 minutes following training (p <.02 and p <.001,
respectively). The improvement in work performance was not accompanied by any
significant change in forced expiratory volume in one second. At equivalent workloads the
ventilation and frequency of breathing were lower following training (p <.02 and p <.05,
respectively) This study demonstrates improved effort tolerance in patients with chronic
obstructive lung disease after bicycle training when assessed by either an increase in Wmax
or an ability to walk a greater distance in 12 minutes.
Delgado HR, Braun SR et. al. conducted a study to evaluate the role of coordination
between the chest wall and abdomen during exercise in patients with chronic obstructive
pulmonary disease (COPD). There were 40 patients with COPD and 6 control subjects with
normal lung function who underwent a progressive exercise stress test on a treadmill
ergometer. The normal subjects exhibited symmetrical motion between the chest wall and
abdomen. Three separate patient groups were differentiated by differences in abdominal
response to increasing exercise. Group I was similar to normal or showed an early abdominal
peak. Group II had a prolonged outward motion of the abdomen, and Group III had an inward
motion of the abdomen during inspiration. Resting pulmonary function (FEV1, VC, DL,
RV/TLC) and exercise response (duration, O2 saturation, and maximal VO2) were
progressively more abnormal from Group I through Group III. The addition of oxygen to
Group III had no effect on the pattern observed. However, when 2 patients with a Group III
response were reexercised flexed 45 degrees at the waist they no longer were completely
paradoxical, they were less dyspneic, and they could walk farther. It is concluded that the
chest-abdominal coordination is related to the underlying pulmonary abnormality, and the
paradoxical pattern seen in some patients (Group III) is associated with very severe exercise
limitation.
Montes DO, Rassulo J et. al. assessed respiratory muscle (RM) and cardiopulmonary
function during exercise in very severe COPD (FEV1 0.79 +/- 0.17 L). We determined
minute ventilation (VE), oxygen consumption (VO2), carbon dioxide production (VCO2),
heart rate (HR), respiratory rate (RR), and O2 pulse with a metabolic cart. RM function was
assessed from esophageal and gastric pressures. Dyspnea was assessed with a visual analog
scale (VAS). Exercise capacity (peak VO2 = 36 +/- 31%), ventilator reserve (VE/maximum
voluntary ventilation [MW] = 89 +/- 31%), HR = 76 +/- 15%, and O2 pulse (O2Pmax = 45
+/- 15%) were abnormal. Peak VO2 correlated with O2Pmax(r = 0.82), the change in end-
aspiratory pleural pressure (delta Ppli) (r = -0.74), maximal Tran diaphragmatic pressure
(Pdimax) (r = 0.68), and VEmax (r = 0.58). There were similar correlations with exercise
endurance time. Multiple regression analysis revealed O2 Pmax to be the best predictor of
peak VO2. Thereafter, only VEmax and deltaPpli remained significant (r2 = 0.87). O2Pmax
correlated with inspiratory muscle function (Pplimax, r = -0.58; Pdimax, r = 0.53; deltaPpli, r
= -0.47; and PImax, r = -0.47). By multiple regression analysis, the predictors of O2Pmax
were P climax and delta Ppli (r2 = 0.47). In very severe COPD, the impressive swings in
intrathoracic pressure resulting from deranged ventilator mechanics are the most likely cause
of exercise limitation and reduced O2 pulse. The contributions of factors such as
reconditioning, hypoxemia, and concurrent heart disease remain unknown.
Nield MA, Soo Hoo GW et al. compared 2 programs of prolonging expiratory time (pursed-
lips breathing and expiratory muscle training) on dyspnea and functional performance in copd
patients. A randomized, controlled design was used for the pilot study. Subjects recruited
from the outpatient pulmonary clinic of a university-affiliated Veteran Affairs healthcare
center were randomized to: 1) pursed-lips breathing, 2) expiratory muscle training, or 3)
control. Changes over time in dyspnea [modified Borg after 6-minute walk distance (6MWD)
and Shortness of Breath Questionnaire] and functional performance (Human Activity Profile
and physical function scale of Short Form 36-item Health Survey) were assessed with a
multilevel modeling procedure. Weekly laboratory visits for training were accompanied by
structured verbal, written, and audiovisual instruction. Forty subjects with chronic obstructive
pulmonary disease [age = 65 +/- 9 (mean +/- standard deviation) years, forced expiratory
volume 1 second/forced vital capacity % = 46 +/- 10, forced expiratory volume 1 second %
predicted = 39 +/- 13, body mass index = 26 +/- 6 kg/m, aspiratory muscle strength = 69 +/-
22 cm H2O, and expiratory muscle strength (PEmax) = 102 +/- 29 cm H2O] were enrolled.
No significant Group x Time difference was present for PEmax (P = .93). Significant
reductions for the modified Borg scale after 6MWD (P = .05) and physical function (P = .02)
from baseline to 12 weeks were only present for pursed-lips breathing. It was concluded that
Pursed-lips breathing provided sustained improvement in exert ional dyspnea and physical
function.
Napolis, Lara Maris et al conducted a prospective and cross-over study to investigate the
effects of high-frequency neuromuscular electrical stimulation in COPD patients with better-
preserved peripheral muscle function. Thirty COPD patients were randomly assigned to
either home-based, high-frequency neuromuscular electrical stimulation or sham stimulation
for six weeks. The training intensity was adjusted according to each subject's tolerance. Fat-
free mass, isometric strength, six-minute walking distance and time to exercise intolerance
(Tlim) were assessed. Thirteen (46.4%) patients responded to high-frequency neuromuscular
electrical stimulation; that is, they had a post/pre Δ Tlim >10% after stimulation (unimproved
after sham stimulation). Responders had a higher baseline fat-free mass and six-minute
walking distance than their seventeen (53.6%) non-responding counterparts. Responders
trained at higher stimulation intensities; their mean amplitude of stimulation during training
was significantly related to their fat-free mass (r = 0.65; p<0.01). Logistic regression revealed
that fat-free mass was the single independent predictor of Tlim improvement (odds ratio
[95% CI] = 1.15 [1.04-1.26]; p<0.05).It was concluded that high-frequency neuromuscular
electrical stimulation improved the exercise capacity of COPD patients with better-preserved
fat-free mass because they tolerated higher training stimulus levels. These data suggest that
early training with high-frequency neuromuscular electrical stimulation before tissue wasting
begins might enhance exercise tolerance in patients with less advanced COPD.
Delgado Hr, Braun Sr, Skatrud Jb et al. undertook a study to evaluate the role of
coordination between the chest wall and abdomen during exercise in patients with chronic
obstructive pulmonary disease (COPD). There were 40 patients with COPD and 6 control
subjects with normal lung function who underwent a progressive exercise stress test on a
treadmill ergo meter. The normal subjects exhibited symmetrical motion between the chest
wall and abdomen. Three separate patient groups were differentiated by differences in
abdominal response to increasing exercise. Group I was similar to normal or showed an early
abdominal peak. Group II had a prolonged outward motion of the abdomen, and Group III
had an inward motion of the abdomen during inspiration. Resting pulmonary function (FEV1,
VC, DL, RV/TLC) and exercise response (duration, O2 saturation, and maximal VO2) were
progressively more abnormal from Group I through Group III. The addition of oxygen to
Group III had no effect on the pattern observed. However, when 2 patients with a Group III
response were exercised flexed 45 degrees at the waist they no longer were completely
paradoxical, they were less dyspnea, and they could walk farther. It is concluded that the
chest-abdominal coordination is related to the underlying pulmonary abnormality, and the
paradoxical pattern seen in some patients (Group III) is associated with very severe exercise
limitation.
Casciari RJ, Fairshter RD, Harrison A conducted a study to evaluate the effects of
breathing retraining (BRT) on exercise tolerance in subjects with severe chronic obstructive
pulmonary disease (COPD) . Twenty-two subjects exercised on a treadmill three times
weekly for six weeks. Twelve of the subjects (controls) then exercised for three more weeks;
the other ten subjects received three more weeks of exercise reconditioning plus BRT.
Results of routine pulmonary function and exercise tests were similar in both groups at the
beginning of the study and after six weeks of exercise. However, in the last three weeks of
the study, increments in exercise performance were significantly greater in the BRT subjects
than in controls (P less than .002). Following BRT, respiratory rate during exercise decreased
(P less than .005) and tidal volume and PaO2 during exercise increased (P less than .05).
Thus, these data suggest that BRT increases exercise performance in subjects with severe
COPD.
Parola D, Romani S et al. conducted a study to evaluate the effect of NIV treatment in
patients with acute exacerbation of COPD with or without respiratory acidosis and its effect
in patients with pulmonary hypertension. We enrolled 61 consecutive subjects (M 41; F 20)
with COPD admitted to our respiratory ward for acute respiratory exacerbation. Patients were
divided into two groups on the basis of arterial pH (group A: 26 individuals with pH <7.35;
group B: 35 with pH > or =7.35) and treated with optimal medical therapy (oxygen-therapy,
systemic corticosteroids, bronchodilators, antibiotics) and NIV. Moreover, we evaluated
functional autonomy thought Six Minute Walking Test (6 MWT), and pulmonary arterial
pressure (by transthoracic echocardiography). In group A NIV treatment was associated to a
total regression of uncompensated respiratory acidosis (pH 7.36 vs. 7.29). In both groups we
observed a significant reduction of PaCO2 (group A: 77.14 +/- 10.4 vs. 45.1 +/- 2.8 mmHg;
group B: 70.1 vs. 44 +/- 3.9 mmHg) and and improvement in PaO2 (group A: 51.2 +/- 10.3
vs 84.2 mmHg; group B: 59 +/- vs. 87 +/- 3.3 mmHg). Total average duration of NIV
administration was longer in Group A than in Group B (81.14 hours vs 55.83 hours). At the
end of NIV treatment, we observed improvement in the autonomy of walking (175.1 meters
vs 118.4 meters) in both groups. Patients with severe pulmonary hypertension (PASP > or
=55 mmHg) showed a lower reduction of PaCO2 (47.8 vs. 43.7 mmHg) and a minor
improvement of arterial pH (7.37 vs. 7.41) compared to patients with a lower value of
pulmonary hypertension. It was concluded that NIV is useful in patients with or without
uncompensated respiratory acidosis, through the improvement of symptoms, blood gases
parameters, and walking autonomy. Patients with severe pulmonary hypertension are
associated with poorer response to NIV treatment.
J Cross, F Elender, G Barton et al. conducted study to estimate the effect, if any, of Manual
Chest Physiotherapy (MCP) administered to patients hospitalized with COPD exacerbation
on both disease-specific and generic health-related quality of life. To compare the health
service costs for those who either receive or do not receive MCP while in hospital. The
primary study outcome was COPD-specific quality of life, measured using the St George’s
Respiratory Questionnaire (SGRQ). An effect size of 0.3 standard deviations in the SGRQ
was specified in advance as the threshold for superiority. Equivalence was demonstrated with
respect to the primary outcome at the primary end point. The ITT analyses indicated no
significant difference at 6 months in total SGRQ score [adjusted effect size (no MCP–MCP)
0.03 (95% confidence interval, CI –0.14 to 0.19)], SGRQ symptom score [adjusted effect size
0.04 (95% CI –0.15 to 0.23)], SGRQ activity score [adjusted effect size –0.02 (95% CI –0.20
to 0.16)] or SGRQ impact score [adjusted effect size 0.02 (95% CI –0.15 to 0.18)]. The
imputed ITT and PP results were similar. No significant differences were observed in any of
the outcome measures or subgroup analyses.
Elisabeth Ståhl, Anne Lindberg et al. conducted a study to evaluate the association
between health-related quality of life (HRQL) and disease severity using lung function
measures. A survey was performed in subjects with COPD in Sweden. 168 subjects (70
women, mean age 64.3 years) completed the generic HRQL questionnaire, the Short Form 36
(SF-36), the disease-specific HRQL questionnaire; the St George's Respiratory Questionnaire
(SGRQ), and the utility measure, the EQ-5D. The subjects were divided into four severity
groups according to FEV1 per cent of predicted normal using two clinical guidelines: GOLD
and BTS. Age, gender, smoking status and socio-economic group were regarded as
confounders. The COPD severity grades affected the SGRQ Total scores, varying from 25 to
53 (GOLD p = 0.0005) and from 25 to 45 (BTS p = 0.0023). The scores for SF-36 Physical
were significantly associated with COPD severity (GOLD p = 0.0059, BTS p = 0.032). No
significant association was noticed for the SF-36, Mental Component Summary scores and
COPD severity. Scores for EQ-5D VAS varied from 73 to 37 (GOLD I-IV p = 0.0001) and
from 73 to 50 (BTS 0-III p = 0.0007). The SGRQ Total score was significant between age
groups (p = 0.0047). No significant differences in HRQL with regard to gender, smoking
status or socio-economic group were noticed. The results showed that HRQL in COPD
deteriorates with disease severity and with age. These data show a relationship between
HRQL and disease severity obtained by lung function.
Alice YM Jones, Elizabeth Dean et al. conducted a study to evaluate the oxygen demand of
breathing exercises and the clinical implications. In the study, the oxygen cost of 3 common
breathing exercises believed to reduce oxygen cost (ie, work of breathing) was compared
with that of spontaneous breathing in patients with chronic obstructive pulmonary disease
(COPD). Thirty subjects with stable, moderately severe COPD participated. Oxygen
consumption (V̇O2) and respiratory rate (RR) during spontaneous breathing at rest (SB) were
recorded for 10 minutes. Subjects then performed 3 breathing exercises in random order, with
a rest between exercises: diaphragmatic breathing (DB), pursed-lip breathing (PLB), and a
combination of DB and PLB (CB). Oxygen consumption and RR were measured. Mean
V̇O2 (±SD) was lower during the breathing exercises (165.8±22.3 mL O2/min for DB,
164.8±20.9 mL O2/min for PLB, and 167.7±20.7 ML O2/min for CB) compared with SB
(174.5±25.2 mL O2/min). Correspondingly, mean RR (±SD) was higher during SB
(17.3±4.23 breaths/min), followed by DB (15.0±4.32 breaths/min), PLB (12.8±3.53
breaths/min), and CB (11.2±2.7 breaths/min). It was concluded that Given that patients do
not spontaneously adopt the breathing pattern with the least V̇O2 and the lowest RR, the
results suggest that determinants of the breathing pattern other than metabolic demand
warrant being a primary focus in patients with COPD.
Gunen H, Hacievliyagil S S, Kosar F. et al conducted a study to assess the parameters
related to in-hospital mortality and long-term survival after hospitalisation of patients with
AECOPD. Clinical and epidemiological parameters on admission in 205 consecutive patients
hospitalised with AECOPD were prospectively assessed. Patients were followed-up for 3 yrs.
Factors determining short- and long-term mortality were analysed. In total, 17 patients (8.3%)
died in hospital. In-hospital mortality was significantly associated with lower arterial oxygen
tension (P(a,O2)), higher carbon dioxide arterial tension, lower arterial oxygen saturation and
longer hospital stay. The overall 6-month mortality rate was 24%, with 1-, 2- and 3-yr
mortality rates of 33%, 39% and 49%, respectively. These findings show that patients
hospitalised with acute exacerbations of chronic obstructive pulmonary disease have poor
short- and long-term survival. Prediction of survival status may be enhanced by considering
arterial oxygen tension, albumin, body mass index, disease duration and time elapsed since
the first hospitalisation.71
NON INVASIVE INTERVENTIONS IN COPD
Thomas M, Simpson Jet al. conducted a study to determine the impact of home-based
physiotherapy interventions on breathlessness during activities of daily living (ADL) in
severe chronic obstructive disease (COPD). Inclusion criteria consisted of individuals over 18
years of age with severe COPD (defined as forced expiratory volume in 1 second < or = 50%
predicted) without cardiovascular co-morbidities, home-based interventions and valid,
reliable breathlessness ADL outcome measures. The PEDro scale was used to assess
methodological quality. Data extraction included baseline characteristics, treatment
intervention, frequency of training, level of supervision, breathlessness ADL outcome
measure and results. The random-effects indicated that, on average, inspiratory muscle
training improved the breathlessness score significantly by 2.36 (95% confidence interval
0.76 to 3.96) compared with controls. Inspiratory muscle training and exercise are home-
based physiotherapy interventions that may improve breathlessness during ADL in severe
COPD. 72
Tang C, Taylor N et al. conducted a study to examine the effectiveness of chest
physiotherapy for patients admitted to hospital with an acute exacerbation of chronic
obstructive pulmonary disease (COPD). There was moderate evidence that intermittent
positive pressure ventilation and positive expiratory pressure were effective in improving
sputum expectoration. In addition, there was moderate evidence that walking programmes led
to benefits in arterial blood gases, lung function, dyspnoea and quality of life. No evidence
was found supporting the use of any other chest physiotherapy techniques to change lung
function, arterial blood gases, perceived level of dyspnoea or quality of life. Chest
physiotherapy techniques such as intermittent positive pressure ventilation and positive
expiratory pressure may benefit patients with COPD requiring assistance with sputum
clearance, while walking programmes may have wider benefits for patients admitted with an
exacerbation of COPD. Chest physiotherapy techniques other than percussion are safe for
administration to this patient population.73
Sassi-Dambron DE, Eakin EG, Ries AL, et al conducted a randomized clinical trial to
evaluate a limited pulmonary rehabilitation program focused on coping strategies for
shortness of breath but without exercise training. Eighty-nine patients with COPD were
randomly assigned to either 6-week treatment or general health education control groups.
Treatment consisted of instruction and practice in techniques of progressive muscle
relaxation, breathing retraining, pacing, self-talk, and panic control. Tests of 6-min walk
distance, quality of well-being, and psychological function as well as six dyspnea measures
were administered at baseline, post treatment, and 6 months after the intervention. Baseline
pulmonary function tests also were obtained. At the end of the 6-week treatment, there were
no significant differences between the treatment and control groups on any outcome measure.
At the 6-month follow-up, a significant group difference was seen on only one variable,
Mahler's transition dyspnea index. The results of this evaluation suggest that a treatment
program of dyspnea management strategies, without structured exercise training or other
components of a comprehensive pulmonary rehabilitation program, is not sufficient to
produce significant improvement in dyspnea, exercise tolerance, health-related quality of
well-being, anxiety, or depression.74
Slinde F, Gronberg AM et al. conducted a study to evaluate the effect of an 1 year
individual multifaceted dietary intervention during multidisciplinary rehabilitation. Eighty-
seven patients with severe COPD, not demanding oxygen therapy were included, 24 of them
served as controls. A dietary history interview was performed at baseline and at study end.
Dietary advice given were based on results from the dietary history and socio-economic
status. The intervention group was divided into three parts; NW: normal weight (dietary
advice given aiming to weight maintenance), OW: overweight (weight-reducing advice) and
UW: underweight (dietary advise based on an energy- and protein-rich diet). Results: UW-
group: Eighty-one per cent of the patients gained weight or kept a stable weight. OW-group:
Fifty-seven per cent lost more than 2 kg. NW-group: Seventy-six per cent kept a stable
weight or gained weight. Increased dietary intake from baseline was seen for energy, protein,
carbohydrates and certain micronutrients (P<0.05) in the UW group. Six minutes walking
distance increased by approximately 20 m in both NW (P<0.05) and UW patients. To
conclude, slight, but uniform, indications of positive effects of dietary intervention during
multidisciplinary rehabilitation was seen. Dietary intervention in underweight COPD patients
might be a prerequisite for physical training.75
Spruit MA, Gosselink R, Troosters T, et al. studied the effects of endurance training on
exercise capacity and health-related quality of life (HRQL) in chronic obstructive pulmonary
disease (COPD) patients have been studied thoroughly, while resistance training has been
rarely evaluated. This study investigated the effects of resistance training in comparison with
endurance training in patients with moderate to severe COPD and peripheral muscle
weakness (isometric knee extension peak torque <75% predicted). Forty-eight patients (age
64±8 yrs, forced expiratory volume in one second 38±17% pred) were randomly assigned to
resistance training (RT, n=24) or endurance training (ET, n=24). The former consisted of
dynamic strengthening exercises. The latter consisted of walking, cycling and arm cranking.
Respiratory and peripheral muscle force, exercise capacity, and HRQL were re-evaluated in
all patients who completed the 12-week rehabilitation (RT n=14, ET n=16). Statistically
significant increases in knee extension peak torque (RT 20±21%, ET 42±21%), maximal
knee flexion force (RT 31±39%, ET 28±37%), elbow flexion force (RT 24±19%, ET
33±25%), 6-min walking distance (6MWD) (RT 79±74 m, ET 95±57 m), maximum
workload (RT 15±16 Watt, ET 14±13 Watt) and HRQL (RT 16±25 points, ET 16±15 points)
were observed. No significant differences in changes in HRQL and 6MWD were seen
between the two treatments. Resistance training and endurance training have similar effects
on peripheral muscle force, exercise capacity and health-related quality of life in chronic
obstructive pulmonary disease patients with peripheral muscle weakness.76
Simpson K, Killian K et al. conducted a study designed to determine whether specific
muscle training techniques are helpful. Thirty four patients with chronic airflow
limitation (forced expiratory volume in one second (FEV1) 38% of predicted values) were
stratified for FEV1 to vital capacity (VC) ratio less than 40% and arterial oxygen
desaturation during exercise and randomised to a control or weightlifting training group.
In the experimental group training was prescribed for upper and lower limb muscles as a
percentage of the maximum weight that could be lifted once only. It was carried out
three times a week for eight weeks. Three subjects dropped out of each group; results in
the remaining 14 patients in each group were analysed. Adherence in the training group
was 90%. In the trained subjects muscle strength and endurance time during cycling at
80% of maximum power output increased by 73% from 518 (SE69) to 898 (95) s, with
control subjects showing no change (506 (86) s before training and 479 (89) s after
training). No significant changes in maximum cycle ergometer exercise capacity or
distance walked in six minutes were found in either group. Responses to a chronic
respiratory questionnaire showed significant improvements in dyspnoea and mastery of
daily living activities in the trained group. Weightlifting training may be successfully
used in patients with chronic airflow limitation, with benefits in muscle strength,
exercise endurance, and subjective responses to some of the demands of daily living. 77
Levine S, Weiser P et al. To evaluate the role of ventilatory muscle endurance training
(VMET) in the rehabilitation of outpatients with chronic obstructive pulmonary disease, we
carried out a prospective random allocation trial of VMET versus IPPB. Data were obtained
from 15 men allocated to VMET and from 17 men assigned to IPPB. The mean age of our
experimental cohort was 61 +/- SEM 1 yr, and the FEV1 was 1.2 +/- 0.1 L. Prior to and after
6 wk of daily therapy, the following data were obtained on each subject: (1) vital statistics,
(2) standard pulmonary function tests, (3) activities of daily living (ADL), (4) maximal
sustainable ventilatory capacity (MSVC), (5) psychologic status (PS), and (6) exercise
tolerance (ET). Prior to therapy, the VMET and IPPB groups showed no significant
differences with respect to these parameters. After therapy, VMET subjects exhibited a
greater increase (p less than 0.05) in MSVC than did IPPB subjects. However, VMET and
IPPB groups did not differ with respect to improvements noted in ADL, PS, and ET. These
results from our controlled study raise the possibility that some aspect of the experimental
protocol, other than VMET, accounted for the improvements noted in ADL, PS, and ET.78
Wijkstra PJ, van der Mark TW et al. investigated whether 12 weeks of rehabilitation at
home in patients with chronic obstructive pulmonary disease (COPD) had a beneficial effect
on lactate production, metabolic gas exchange data, workload of the inspiratory muscles, and
dyspnoea during a maximal bicycle ergometer test. Exercise tolerance was measured by
means of a 6 min walking distance test (6MWD) and maximal workload (Wmax) during an
incremental symptom-limited cycle ergometer test. Inspiratory muscle workload at Wmax
was assessed with the Tension Time Index (TTI), and dyspnoea at Wmax with the Borg
scale. After 12 weeks, the rehabilitation group showed a significantly larger increase in
6MWD (from 438 to 447 m) and in Wmax (from 70 to 78 W) compared with the control
group. A significant improvement in oxygen consumption (V1O2) (from 1.0 to 1.1 L), lactate
level (from 3.7 to 3.1 mEq.L(-1)), dyspnoea (from 6.0 to 4.5) and TTI (from 0.10 to 0.08) at
Wmax occurred in the rehabilitation group during the programme. The reduction in TTI was
not significantly correlated with the fall in dyspnoea, as assessed by the Borg scale. We
conclude that 12 weeks of rehabilitation at home in COPD patients increases symptom-
limited V1O2 in combination with an increased Wmax. At this significantly higher Wmax,
there was a reduction in dyspnoea, lactate level and inspiratory muscle workload. The
reduction in dyspnoea was not related to a decreased inspiratory muscle workload. This study
shows that rehabilitation at home can produce beneficial physiological improvements during
exercise in patients with chronic obstructive pulmonary disease.79
SPIROMETRY
Enright PL, Lebowitz MD et al in a study stated that baseline spirometry gives a highly
accurate "snapshot" of asthma severity and the degree of airways obstruction. The FEV1,
derived from spirometry, is the most reproducible pulmonary function parameter and is
linearly related to the severity of airways obstruction. There are no contraindications for the
test, spirometers are widely available at reasonable cost, and methods and result interpretation
are comprehensively standardized. The post-bronchodilator FEV1 measures the best lung
function that can be achieved by bronchodilator therapy on the day of the visit and therefore
is a more stable measure in asthmatics than comparing visit-to-visit baseline FEV1. Although
a positive acute response to bronchodilator helps to confirm the diagnosis of asthma, the
degree of bronchodilator reversibility from visit-to-visit (change in reversibility) is not a
useful index of asthma outcome. 80
Rebuck DA, Hanania NA et al in a study “ The accuracy of a handheld portable
spirometer” concluded that measurements obtained using the pneumotachograph device are
closely related to those obtained by volume displacement spirometry and that the handheld
device may be useful in clinical practice. However, because the limits of agreement are wide
and the difference between the two instruments measurements are significant for FEV1,
FEF25-75%, and PEFR, the bias between them is not consistent nor is it insignificant.
Therefore, the measurements made with the two types of machine cannot be used
interchangeably.81
Jenkins Sc, Barnes Nc, Moxham J in a study “Evaluation of a hand-held spirometer, the
Respiradyne, for the measurement of forced expiratory volume in the first second (FEV1),
forced vital capacity (FVC) and peak expiratory flow rate (PEFR)” suggested that close
agreement for FEV1; r = 0.99, R = 0.961V + 0.03 X 10(-5) and FVC; r = 0.99, R = 1.003V-
0.044. Results for PEFR using the Respiradyne were generally higher than with the peak flow
meter; r = 0.98, R = 1.151W-17.576. The Respiradyne is portable and simple to operate and
may be suited to use in a variety of non-laboratory situations82.
Johns DP, Abramson M, Bowes G in a study “Evaluation of a new ambulatory spirometer
for measuring forced expiratory volume in one second and peak expiratory flow rate”
suggested that Reliability in the ambulatory setting was assessed in six meters on several
occasions over a 10-week period using five versions of waveform PW#24. Results show that
the 10 meters conform to the ATS accuracy specifications for PEFR with one or less errors
and marginally outside these limits for FEV1 with four errors. For the nine versions of
PW#24, the 95% confidence intervals indicate that the meter is accurate to within +/- 5.5% or
+/- 15 L/min for PEFR and +/- 3.5% or +/- 0.12 L for FEV1. The mean within-meter
coefficient of variation was 1.24% for FEV1 and 0.35% for PEFR. There was no significant
change in meter accuracy or performance over the 10-wk reliability study. We conclude that
the meter is suitable for use as an ambulatory spirometer for measuring FEV1 and PEFR83.
Aaron SD, Dales RE, Cardinal P in a study “How accurate is spirometry at predicting
restrictive pulmonary impairment?” stated that Spirometry is very useful at excluding a
restrictive defect. When the VC is within the normal range, the probability of a restrictive
defect is < 3%, and unless restrictive lung disease is suspected a priori, measurement of lung
volumes can be avoided. However, spirometry is not able to accurately predict lung
restriction; < 60% of patients with a classical spirometric restrictive pattern had pulmonary
restriction confirmed on lung volume measurements. For these patients, measurement of the
TLC is needed to confirm a true restrictive defect.84
Dirksen A, Madsen F, Pedersen OF et al in a study “Long-term performance of a hand
held spirometer” concluded that the small hand held turbine spirometers are suitable for long
term patient-administered serial spirometric testing. The two year durability is acceptable and
the long term reproducibility excellent85.
Burki NK in a study “Spirometry and other pulmonary function tests” suggested
thatPulmonary function tests provide important clinical information in patients with
pulmonary disease. Spirometry gives accurate, rapid information regarding the presence or
absence of obstructive or restrictive lung disease and the response to bronchodilators.
Particular attention to technique is necessary for valid results86.
Swanney MP, Beckert LE, Frampton CM et al in a study “Validity of the American
Thoracic Society and other spirometric algorithms using FVC and forced expiratory volume
at 6 s for predicting a reduced total lung capacity” rovides evidence that spirometry-based
algorithms can accurately predict when TLC is either normal or increased, and can also
increase the a priori probability that TLC is reduced to approximately 50%. FEV(6) is
equivalent to FVC in these predictions87.
BR Celli conducted a study on "The importance of spirometry in COPD and asthma" and
stressed that spirometry remains essential for the diagnosis and monitoring of both asthma
and COPD.88
H Pineda, F Haas, K Axen and A Haas performed a study on “Accuracy of pulmonary
function tests in predicting exercise tolerance in chronic obstructive pulmonary disease” and
investigated the exercise capacity by using linear regression analysis to quantify the
relationships between (1) maximum oxygen consumption during treadmill exercise and PFT
parameters and (2) total external work performed during treadmill exercise and PFT
parameters. They concluded that FEV1 can predict exercise tolerance from PFT
measurements with some accuracy.89
F Esteve, N Blanc-Gras, J Gallego and G Benchetrit performed a study on “The effects of
breathing pattern training on ventilatory function with COPD” and stated that there were
short term increases in FEV1 and FVC in COPD patients practicing breathing pattern training
in addition to respiratory rehabilitation, in comparison with controls. Also he advocated the
need for further studies to incorporate outcome data to clarify the mechanisms and the
duration of this effect.90
BUTEYKO BREATHING TECHNIQUE
McHugh P, Aitcheson F et al. conducted a study to assess the impact of the Buteyko
Breathing Technique (BBT) on medication use in asthma. A blinded randomised controlled
trial comparing BBT with control was conducted in 38 people with asthma aged between 18
and 70. Participants were followed for six months following the intervention. Medication use
and indices of ventilatory function were recorded. Result showed that no significant change
in FEV1 (forced expiratory volume in one second) was recorded in either group. The BBT
group exhibited a reduction in inhaled steroid use of 50% and β2-agonist use of 85% at six
months from baseline. In the control group inhaled steroid use was unchanged and β2-agonist
use was reduced by 37% from baseline. Investigator contact between the two groups was
equal. There were no adverse events recorded in either group. It was concluded that BBT is a
safe and efficacious asthma management technique. BBT has clinical and potential
pharmaco-economic benefits that merit further study.91
Tattersfield A. conducted a study to see the effect of two breathing exercises (Buteyko and
pranayama) in asthma Ninety patients with asthma taking an inhaled corticosteroid were
randomised to mimic pranayama, or a 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.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. It was concluded that 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.92
Thomas M, McKinley RK et al. conducted a study to estimate the prevalence of
dysfunctional breathing in adults with asthma treated in the community. Nijmegen
questionnaire was used. All adult patients aged 17-65 with diagnosed asthma who were
receiving treatment. 227/307 patients returned completed questionnaires; 219 (71.3%)
questionnaires were suitable for analysis. 63 participants scored 23. Those scoring were more
likely to be female than male (46/132 (35%) v 17/87 (20%), P=0.016) and were younger
(mean (SD) age 44.8 (14.7) v 49.0 (13.8, (P=0.05). Patients at different treatment steps of the
British Thoracic Society asthma guidelines were affected equally. About a third of women
and a fifth of men had scores suggestive of dysfunctional breathing.93
Al-Delaimy WK, Hay SM et al. conducted a study to examine the effect of breathing 3%
CO2 on exercise-induced asthma (EIA), as a raised airway CO2 level is suggested to mediate
the effects of Buteyko breathing training (BBT). Double-blind crossover study was done ,
using a standard laboratory-based exercise challenge, with EIA defined as a fall of 15% or
greater in the forced expiratory volume in one second (FEV1) within 30 minutes of
completing a standard exercise protocol. 10 adults with confirmed EIA participated in the
study. Air enriched with 3% CO2 during and for 10 minutes after exercise was intervened.
Mean maximum fall in FEV1 was similar: 19.9% with air, and 26.9% with 3% CO2 (P =
0.12). The mean AUC for the total 30-minute post-exercise period was 355 for air and 520
for 3% CO2 (P = 0.07). After discontinuing the 3% CO2 at 10 minutes after exercise, there
was a further and sustained fall in FEV1. Mean AUC for the period 10-30 minutes post-
exercise was significantly greater for CO2 than air (275 and 137, respectively [P = 0.02]).
Mean minute ventilation was increased when subjects exercised breathing 3% CO2: 77.5
L/min for 3% CO2, compared with 68.7 L/min for air (P = 0.02). It was concluded that
Breathing 3% CO2 during exercise does not prevent EIA. The shape of the FEV1 response
curve after 3% CO2 suggests that a greater degree of EIA (because of increased minute
ventilation during exercise) was opposed by a direct relaxant effect of CO2 on the airway.94
A.J. Opat, M.M. Cohen et al conducted a study to examine whether the Buteyko Breathing
Technique, as taught by a video, is an efficacious asthma therapy. Thirty-six adult subjects
with mild to moderate asthma were randomized to receive either a BBT or placebo video to
watch at home twice per day for 4 weeks. Asthma-related quality of life, peak expiratory flow
(PEF), symptoms, and asthma medication intake were assessed both before and after
intervention. Our results demonstrated a significant improvement in quality of life among
those assigned to the BBT compared with placebo (p = 0.043), as well as a significant
reduction in inhaled bronchodilator intake (p = 0.008). We conclude that the BBT may be
effective in improving the quality of life and reducing the intake of inhaled reliever
medication in patients with asthma.95
Bowler SD, Green A et al. conducted a study to evaluate the effect of Buteyko breathing
techniques (BBT) in the management of asthma. Subjects recruited from the community,
aged 12 to 70 years, with asthma and substantial medication use. Result showed no change in
daily PEF or FEV1 was noted in either group. At three months, the BBT group had a median
reduction in daily beta 2-agonist dose of 904 micrograms (range, 29 micrograms to 3129
micrograms), whereas the control group had a median reduction of 57 micrograms (range, -
2343 micrograms to 1143 micrograms) (P = 0.002). Daily inhaled steroid dose fell 49%
(range, -100% to 150%) for the BBT group and 0 (range, -82% to +100%) for the control
group (P = 0.06). A trend towards greater improvement in QOL score was noted for BBT
subjects (P = 0.09). Initial MV was high and similar in both groups; by three months, MV
was lower in the BBT group than in the control group (P = 0.004). ET CO2 was low in both
groups and did not change with treatment. Those practicing BBT reduced hyperventilation
and their use of beta 2-agonists. A trend toward reduced inhaled steroid use and better quality
of life was observed in these patients without objective changes in measures of airway
caliber.96
Holloway E, Ram F. conducted a study to assess the evidence for the efficacy of breathing
retraining in the treatment of patients with asthma. Abstracts were identified and 42 full text
papers were obtained for assessment and possible inclusion. Thirty five studies were
excluded. A total of five studies were included in the original review. Two further studies
have been added to this update. Most studies were of small size. Two studies demonstrated
significant reductions in rescue bronchodilator use and three studies showed reductions in
acute exacerbations, although these were measured in different ways. Two single studies
showed significant improvements in quality of life measures. Overall, benefits of breathing
exercises were found in isolated outcome measures in single studies. Five studies compared
breathing retraining with no active control and two with asthma education control groups.97
Xje A. Rankin F et al. studied the Effects of inhaled CO2 and added dead space on
idiopathic central sleep apnea patients with ICSAS were studied overnight on four occasions
during which the fraction of end-tidal CO2 and transcutaneous PCO2 were measured: during
room air breathing (N1), alternativing room air and OC2 breathing (N2), CO2 breathing all
night (N3), and addition of dead space via a face mask all night (N4). Central apenas were
invariably preceded by reductions in fraction of end-tidal CO2. Both administration of a
CO2-enriched gas mixture and addition of dead space induced 1- to 3-Ton increases in
transcutaneous PCO2, which virtually eliminated apneas and hypopneas during room air
breathing to 5.9 +/- 2.5 apneas and hypopneas/h of sleep during CO2 inhalation during N2 (P
< 0.01), and to 11.6% of the room air level while the patients were breathing through addded
dead space during N4 (P < 1.005). Because raising PaCO2 through two different means
virtually eliminated central sleep apneas, it was conclude that central apneas during sleep in
ICSA are due to reductions in PaCO2 below the apnea threshold.98
C A Osborne; B J O’ Connoret et al conduced a study on “Hyperventilation and
asymptomatic chronic asthma” Twenty three currently asymptomatic chronically asthmatic
patients (occasional use of bronchodilators, normal lung function, hyperresponsive to
methacholine) were studied and 17 matched normal subjects acted as controls. Ventilation,
pattern of breathing, arterial carbon dioxide and oxygen tensions (PaCO 2, PaO 2), end tidal
PCO 2(PETCO 2), standard lung function, airway responsiveness to methacholine, airway
inflammation assessed by eosinophils in induced sputum, and psychiatric morbidity
(Spielberger STAI-Y and Beck Depression Inventory) were measured. Despite the absence of
current asthmatic symptoms, no clinical evidence of hyperventilation, and normal lung
function in the patients with asthma, PaCO 2 and PETCO 2were significantly (p<0.01) lower
in the patients than in the control group (mean (SD) PaCO 24.96 (0.43) kPa for patients versus
5.27 (0.38) kPa for controls (mean difference 0.31 kPa, 95% confidence interval (CI) 0.06 to
0.56, p<0.02)). PETCO 2 was very similar to PaCO 2 in both groups (mean (SD)
PETCO 2 4.89 (0.47) kPa for the patients and 5.28 (0.40) for the controls (mean difference
0.39 kPa, 95% CI 0.12 to 0.66, p<0.01)). There was no significant difference in ventilation or
respiratory pattern between the two groups. The reduced PaCO 2 in the asthmatic patients
correlated significantly with the concentration of methacholine provoking a fall in FEV1 of
more than 20% (PC20) (r = 0.56, p<0.01) but not with any aspect of lung function, eosinophil
count, or anxiety/depression. It was concluded that mild asymptomatic asthma is not
associated with clinically significant hyperventilation but is associated with a significant
reduction in both arterial and end tidal PCO 2 which relates to airway hyperresponsiveness
rather than to the degree of airway obstruction or mucosal inflammation. Anxiety and
depression appear not to be implicated.99
M. Thomas, R.K. McKinley et al. conducted a 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. 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. 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. It was concluded that 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.100
Robert L. Cowie et al conducted a study to assess the effectiveness of a non-
pharmacological intervention in patients with asthma on conventional therapy including
inhaled corticosteroid. A randomised controlled trial of the Buteyko technique in a group of
adults with asthma. The control group was trained by a physiotherapist in breathing and
relaxation techniques. Both groups showed substantial and similar improvement and a high
proportion with asthma control 6 months after completion of the intervention. In the Buteyko
group the proportion with asthma control increased from 40% to 79% and in the control
group from 44% to 72%. In addition the Buteyko group had significantly reduced their
inhaled corticosteroid therapy compared with the control group (p=0.02) Six months after
completion of the interventions, a large majority of subjects in each group displayed control
of their asthma with the additional benefit of reduction in inhaled corticosteroid use in the
Buteyko group. The Buteyko technique, an established and widely recognised intervention, or
an intensive programme delivered by a chest physiotherapist appear to provide additional
benefit for adult patients with asthma who are being treated with inhaled corticosteroid.101
McGowan J conducted a study determine the effectiveness of Buteyko breathing technique
for individuals being treated for asthma. 600 adult patients aged 18-69 years diagnosed and
treated asthma with a symptom score > 1 per day was recruited to a randomized blinded
controlled trial. This tested active Buteyko (Group 1) with asthma nurse education (Group 2)
and continued medication control (Group 3). The main outcome measures were quality of life
(SF36), activity, asthma symptoms, and medication reduction. Asthma symptoms and activity
were measured by diary card scoring from 0-3. Of all who commenced study, data were
available on 500 after 6 months, 384 after 12 months, and 384 after 24 months.Asthma
Symptoms: Buteyko Group - decreased by 98%, 6 months and remained same at 12 months -
Placebo and Control Groups - no significant change.102
McHugh P, Bruce Duncan Pet al. conduted a study on Buteyko breathing technique and
asthma in children. Twenty-six children were identified of whom 8 (aged 7–16 years) were
eligible for inclusion; being previously diagnosed with asthma by their GP and using
medication for asthma for at least 6 months with significant use of medication for asthma in
the 2 weeks prior; no prior instruction in BBT; and no significant unstable medical condition.
Participants underwent training in BBT (by a representative of the Buteyko Institute of
Breathing and Health) over five sessions of 60–90 minutes held over 5 consecutive days.
BBT consists of a series of exercises promoting nasal breathing and periods of
hypoventilation.8 Average β2-agonist use reduced from 743 mEq of salbutamol per day to
254 mEq/day, a drop of 66%. Inhaled steroid use reduced from 138 mEq of fluticasone per
day to 81 mEq/day, a drop of 41% These trials have all shown positive results with marked
reductions in inhaled β2-agonist along with reductions in inhaled corticosteroids without
negative impact on measures of lung function and with no apparent adverse effect. There is,
however, no data for BBT in a paediatric setting.103
McHugh P, Aitcheson F et al. conducted a study to assess the impact of the Buteyko
Breathing Technique (BBT) on medication use in asthma. A blinded randomized controlled
trial comparing BBT with control was conducted in 38 people with asthma aged between 18
and 70. Participants were followed for six months following the intervention. Medication use
and indices of ventilatory function were recorded. No significant change in FEV1 (forced
expiratory volume in one second) was recorded in either group. The BBT group exhibited a
reduction in inhaled steroid use of 50% and beta2-agonist use of 85% at six months from
baseline. In the control group inhaled steroid use was unchanged and beta2-agonist use was
reduced by 37% from baseline. Investigator contact between the two groups was equal. There
were no adverse events recorded in either group. BBT is a safe and efficacious asthma
management technique.104
Marks, G., Kotsirilos et al conducted a study to evaluate that the Buteyko breathing
technique is a system of breathing exercises that focuses on breathing through the nose,
hypoventilating and avoiding deep breaths. It is based on the theory that slowing the rate of
breathing will raise levels of carbon dioxide, a natural bronchodilator, and will therefore
result in bronchodilatation and symptomatic improvement. Controlled studies of the Buteyko
breathing technique have demonstrated symptomatic improvement and reduction in the use of
reliever medication in some patients,17-19 but have not demonstrated changes in carbon
dioxide levels, lung function measures or measures of airway inflammation.105
Kolbe, J., Kleeherger et al. studied the response of the peripheral lung to hypocapnia in
anesthetized, paralyzed, mechanically ventilated dogs using the wedged bronchoscope
technique to measure resistance of the collateral system (Rcs). A 5-min hypocapnic challenge
produced a 161 +/- 19% (mean +/- SE) increase in Rcs. The magnitude of this response was
not diminished with repeated challenge or by atropine sulfate (1 mg base/kg iv),
chlorpheniramine maleate (5 mg base/kg iv), or indomethacin (5 mg/kg iv). The response was
reduced by 75% by isoproterenol (5 micrograms/kg iv) (P less than 0.01) and reduced by
80% by nifedipine (20 micrograms/kg iv) (P less than 0.05). During 30-min exposure to
hypocapnia the maximum constrictor response occurred at 4-5 min, after which the response
attenuated to approximately 50% of the maximum response (mean = 53%, range 34-69%).
Further 30-min challenges with hypocapnia resulted in significantly decreased peak
responses, the third response being 50% of the first (P less than 0.001). The inability of
indomethacin or propranolol to affect the tachyphylaxis or attenuation of the response
suggests that neither cyclooxygenase products nor beta-adrenergic activity was involved.
Hence, hypocapnia caused a prompt and marked constrictor response in the peripheral lung
not associated with cholinergic mechanisms or those involving histamine H1-receptors or
prostaglandins. With prolonged exposure to hypocapnia there was gradual attentuation of the
constrictor response with continued exposure and tachyphylaxis to repeated exposure both of
which would tend to diminish any compensatory effect of hypocapnic airway constriction on
the distribution of ventilation.106
Joulia, F., Steinberg et al. conducted a study to test the response to static apnea and to a 1-
min dynamic forearm exercise executed during apnea (dynamic apnea). The breath-hold
training program did not modify the maximal performances measured during an incremental
cycling exercise. After training, the duration of static apnea significantly lengthened and the
associated bradycardia was accentuated; we also noted a reduction of the post-apnea decrease
in venous blood pH and increase in lactic acid concentration, and the suppression of the post-
apnea oxidative stress (increased concentration of thiobarbituric acid reactive substances).
After dynamic apnea, the blood acidosis was reduced and the oxidative stress no more
occurred. These results suggest that the practice of breath-holding improves the tolerance to
hypoxemia independently from any genetic factor.107
M. J. Parkes conducted a study to evaluate the basic properties of breath-holding in humans
and the possible causes of the breath at breakpoint. The simplest objective measure of breath-
holding is its duration, but even this is highly variable. Breath-holding is a voluntary act, but
normal subjects appear unable to breath-hold to unconsciousness. A powerful involuntary
mechanism normally overrides voluntary breath-holding and causes the breath that defines
the breakpoint. The occurrence of the breakpoint breath does not appear to be caused solely
by a mechanism involving lung or chest shrinkage, partial pressures of blood gases or the
carotid arterial chemoreceptors. This is despite the well-known properties of breath-hold
duration being prolonged by large lung inflations, hyperoxia and hypocapnia and being
shortened by the converse manoeuvres and by increased metabolic rate.108
METHODOLOGY
METHODOLOGY
Source of Data:
Diagnosed COPD patients referred by the physician or pulmonologist were recruited for the
study with reference to the Physiotherapy Department at Dr. M.V. Shetty Surgical Nursing
Home.
Sample and sampling technique:
Fifty COPD patients were selected using purposive sampling technique
Instrumentation:
The following instruments have been used for the study
1. Spirometer
2. Weighing machine
3. Wrist watch
4. Tissue paper
Inclusion criteria:
• Informed consent
• Age group 40-60 yrs
• Clinical diagnosis of COPD confirmed by smoking history, physical examination and PFT
showing irreversible airflow limitation
• Medically stable COPD (No history of acute exacerbation for past 6 months)109 patients
• Males and females referral to the Physiotherapy Department with established COPD
Exclusion criteria:
• Musculoskeletal problems limiting mobility
• Rapid intensifying or unstable Angina
• Any alteration in the intake of medication
• Intermittent Claudication
• Neurological problems limiting cognition/mobility
• Resting O2 saturation <90 % with room air breathing
• Patient with viral infection
• Patients with heart disease, migraine headaches, and panic attacks
Collective data has been analyzed by paired “t” .The study was conducted during 2012 -2013,
at Dr. M.V. Shetty Surgical Nursing Home in the Region of Dakshina Kannada, Mangalore,
South India. The research was conducted after taking permission from Ethical Clearance
Community and the Administration of the hospital. All persons gave their informed consent
prior to their inclusion in the study.
Method of collection of data:
According to American Thoracic Society (ATS) Guideline for COPD diagnosis110, COPD
patients in the age group 40-60 yrs were recruited for the study. Diagnosed COPD patients
referred by the physician or pulmonologist were initially assessed in the Physiotherapy
Department for inclusion and exclusion criteria. The COPD patients were diagnosed as per
the GOLD criteria. Prior to participation patients are oriented to the study and informed
consent was taken in a written consent form. Instructions on how to perform the spirometer
test was demonstrated to the patient.
Spirometry Instructions:
The patient were either seated or standing. Patient were made comfortable and were asked to
loosen all restricting clothing.
The readings for each patient were taken in a relatively non stressful environment. The nose
clip was applied with a tissue and another tissue was handed to the patient for use while
removing the mouthpiece. Patient was asked to gently press the nose clip to test for leaks.
The patient was then handed the measuring device and asked to place the mouthpiece in the
mouth, chin slightly elevated, the neck stretched and patient was allowed to get accustomed
to breathing into the apparatus.
When the patient reached the end of a normal expiration, he was instructed to take a deep
slow breath without any pause and then instructed to blow as hard as possible. During
blowing, patient was encouraged to blow as long as possible for 6 seconds or more. The FVC
and FEV1 values were recorded. Patient was then asked to remove the mouthpiece, using the
tissue to collect any saliva. The nose clip was also removed.
Patients were then demonstrated and explained the “Buteyko breathing exercise” procedure
which subdivides in 3 main phases:-
Phase I - Pre exercise Phase (5-6mins)
Patients were advised to have an empty stomach, and sit in a chair in comfortable position
with spine erect.
STEP1 Patients were asked to nod head backwards and forwards slowly and coordinate the
nodding movement with breathing. Breathe in smoothly, gently and as quietly as possible as
head goes back and out as head comes forwards.
STEP2 Pulse was measured with resting two fingers about one centimeter below the wrist -
in line with the thumb-side of the hand.
Phase II - Exercise Phase (20-22mins)
STEP 1 To measure Control Pause - Patient was asked to take in a normal sized breath in
and out through nose. Nose is held gently. Stopwatch was used to keep track of time until
patient felt the first onset of a feeling of lack of air. Nose was released, breathing in gently
through nose and stopping the stopwatch. Time of Control Pause was noted.
STEP 2 Control pause was followed by relaxed breathing and this was continued for 3mins
followed by a short rest duration of 30 sec.
STEP 3 Same as above was repeated four times followed by a long rest duration of 2mins.
Phase III Post exercise Phase (5-6mins)
STEP1 Post exercise control pause (final control pause) was measured .
STEP2 Post exercise pulse was measured .
(Patient were advised to practice sets before breakfast, before lunch or dinner and before
sleep and to note down the readings in daily log. )
The above mentioned protocol was followed in first week of the study. Second week was
conducted following the same steps with key aim to become accustomed to a slight feeling of
“air hunger” lasting several minutes. One way to do this was using the Extended Pause
exercise - which introduces the concept of increasing air hunger. Patients were asked to hold
breath a little longer than is comfortable.
The last weeks of practice included learning how to fine-tune breathing to the point where
patient were hardly breathing at all when practicing the exercises.
In weeks 3, a further stage of Reduced Breathing was used called “Very Reduced Breathing”.
It included practicing reduced Breathing with hands on upper and lower chest and allowing
patient to breath to reduce to less than normal volume settle into this pattern.
Post exercise values were measured after completion of 3 weeks. The data obtained before
and after the intervention were analyzed by paired t test.
FIGURE 4.1 : PULMONARY FUNCTION TEST
FIGURE 4.2: EQUIPMENTS USED
RESULTS
RESULT
The subject participated in the study were diagnosed COPD patient. A total of 50 subjects
with the age group of 40 t0 60 years taken from wenlock district hospital and Dr. M. V.
Shetty hospital of Manglore were included in the study.
42% percent of the subjects were in the group 50-60 kg, 46% of the subjects were in the
group 61-70 kg and 6% were in group of 71-80kg . Mean weight was 62.56 kg with S.D
5.8385. Mean height was 1.6394 meters with S.D 0.0665 .
Based on age, subject were divided into three groups: Group (1) 40-46 year, Group (2)47-55
year, Group (3)54-60 years
TABLE 5.1: AGE- WISE DISTIBUTION OF SUBJECTS IN THREE AGE GROUP
Table 5.1 shows age wise distribution of subjects in three age groups. A total of 50 males and
females were included in the present study. The number of subjects in the group of 40-
46years of age were 14(28%) , age group 47-53 years of age were 14(28%), the number of
subject in the group of 54 to 60 years of age 22 (44%).
Age No of subject
40-46
47-55
54-60
14
14
22
TABLE 5.2: AGE- WISE DISTIBUTION OF SUBJECTS IN THREE AGE GROUP
Fig 5.1 shows age wise distribution of subjects in five age group
TABLE 5.2:PRE AND POST COMPARISION BETWEEN MEAN AND STANDARD
DEVIATION VALUE OF HEART RATE, RESPIRATORY RATE
FVC AND FEV1
PRE
POST
Mean S.D Mean S.D.
Heart rate
87.19
9.5426
81.02
9.3579
Respiratory rate
21.6
3.1558
15.28
2.4993
FVC
64.12
10.9575
65.08
10.5633
FEV1
42.34
6.9093
43.22
6.8431
Table 5.2 shows the pre and post comparision between mean and standard deviation values of
Heart rate, Respiratory rate, Force vital capacity, Force expiratory volume in one seconds.
The sample size was taken as 50 (N=50). In heart rate average pre reading was (mean) 87.19±
(standard deviation) 9.5426 and post reading was (mean) 81.02± standard deviation 9.3579.
In respiratory rate pre reading was (mean) 21.6± (standard deviation) 3.1558 and post
reading was(mean) 15.28± (standard deviation) 2.4993. In FVC average pre reading was(
mean)64.12± (standard deviation) 10.9575 and post reading was (mean) 65.08± standard
deviation10.5633.
In FEV1 average pre reading was (mean) 42.34± standard deviation6.9093 and post reading
was (mean) 43.22± standard deviation 6.8431
FIGURE 5.2:PRE AND POST COMPARISION BETWEEN MEAN AND STANDARD
DEVIATION VALUE OF HEART RATE, RESPIRATORY RATE
FVC AND FEV1
TABLE 5.3: AVERAGE DIFFERENCE IN HEART RATE, RESPIRATORY RATE,
FVC, FEV1
Average
improvement
t-value p-value result
Heart rate 6.17 3.1960 0.000943 P<0.05sig
Resp rate 6.32 11.0846 0.0000 P<0.05sig
FVC 0.96 -0.4396 0.332403 p>0.05 non sig
FEV1 0.88 -0.61113 0.271278 p>0.05 non sig
TABLE 5.3: AVERAGE IMPROVEMENT IN HEART RATE, RESPIRATORY
RATE, FVC, FEV1
Table 5.3 shows the average diference in heart rate, respiratory rate, FVC, FEV1. Pre and
post comparison was done with the help of paired t-test. Pre and post comparison of heart
rate and respiratory rate shows p<0.05 means there is significant improvement after
treatment. The average improvement in heart rate was 6.17 and in respiratory rate 6.32. Pre
and post comparison of FVC and FEV1 shows p>0.05 means there is no significant
improvement after treatment. The average value of FVC was0.96 and FEV1 was 0.88.
DISCUSSION
DISCUSSION
The present study was conducted on COPD patients at government wenlock government
district hospital and DR M V Shetty Hospital & Surgical Nursing Home in Mangalore.
Subjects have been taken from purposive sampling. Among 80 patients who participated in
the study were males and females suffering from COPD. GOLD staging system
classifications was then used to describe the severity of the obstruction or airflow limitation
of all patients. Patients of age range 40 to 60 years with mild COPD (FEV1≥ 80% normal) to
moderate COPD (FEV1 50-79% normal )(FEV1 \ FVC <0.70) were included for the study.
Most of the subjects had COPD symptom for more than a year.
Diagnosed COPD patients referred by the physician or pulmonologist were initially assessed
in the Physiotherapy Department for inclusion and exclusion criteria. We used a sample size
of fifty COPD patients. Subjects were taken from purposive sampling. The type of study done
was quasi experimental and collective data was analyzed with paired ‘t’ test. There was three
incident where patients had flu and throat infection hence were considered as dropout.
All the subjects were regularly checked for any droplet infection. All the subjects underwent
spirometric evaluation for FVC , FEV1 along with Resting heart rate and blood pressure
reading in supine position. Subjects were demonstrated the steps and technique of Buteyko
breathing exercise.
Buteyko method is a series of reduced-breathing exercises that focus on nasal-breathing,
breath-holding and relaxation. The Buteyko method is based on the concept that
hyperventilation is the underlying cause of numerous medical conditions, including asthma. It
is known that hyperventilation can lead to low carbon dioxide levels in the blood
(hypocapnea), which can subsequently lead to disturbances of the acid-base balance in the
blood and lower tissue oxygen levels. Advocates of this method believe that the effects
of chronic hyperventilation has effects which include bronchospasm, disturbance of cell
energy production via the Krebs cycle, as well as disturbance of numerous
vital homeostatic chemical reactions in the body.111
The Buteyko method is a purported method of "retraining" the body's breathing pattern to
correct for the presumed chronic hyperventilation and hypocapnea, and thereby treat or cure
the body of these medical problems.Buteyko has been found to be effective in management
of Asthma112.
The quality of evidence of the Buteyko Method according to an Australian Department of
Health report is stronger than any other complementary medicine treatment of asthma.113
There are now new definitions for both asthma and COPD that acknowledge the overlap and
highlight the similarities and differences between them. Asthma and COPD have important
similarities and differences114 Both are chronic inflammatory diseases that involve the small
airways and cause airflow limitation115, 116, 117, 118 both result from gene-environment
interactions and both are usually characterised by mucus and bronchoconstriction.
In our study daily Buteyko breathing exercise session of 35 to 40 mins was given to patients.
Progression of the exercise was made as per the exercise manual of Buteyko Institute of
Breathing & Health. A considerable improvement in controlling respiratory rate and heart
rate as seen by the end of each session was mainly because of relaxation given by the
exercise itself and added on intervals of relaxed breathing.
Similar technique as done on few volunteer non COPD males and females also showed a
reasonable decrease in respiratory rate after the session. Not much effect was seen in FVC
and FEV1 pre and post intervention readings.
An alternative study design would be to see the effect of same breathing technique for a
longer duration of course. A duration of three week has been sufficient to get considerable
effect on heart rate and respiratory rate but not FVC and FEV1 values.
Further studies can be done to see the effect of technique as per age and gender as the initial
values and improvement in respiratory rate, heart rate, FVC and FEV1 vary in different age
group and gender.
We are unable to explain the exact mechanism by which Buteyko breathing exercise reduces
respiratory rate, heart rate and not FVC, FEV1 however this study takes our knowledge
forwards with respect to application of the technique in variety of patients and conditions
similar to asthma and indeed may help refine criteria for future studies of COPD
In conclusion it was evident that Buteyko breathing exercise can be effective in management
of respiratory rate and heart rate in chronic obstructive pulmonary disease patients.
Limitations of the study:
We could not ascertain as to, in which stage of COPD, pursed lip breathing would be more
effective during exercise.
The efforts made during exercise were subjective and hence the amount of efforts made could
not be quantized and related to resultant improvement. Similarly the accuracy to which
spiromertic instruction were followed were also subjective.
Buteyko breathing exercise was performed as a group activity which made it prone to spread
of droplet infections but mask to prevent spread of infections could not be given as it would
have deviated us from following the procedure.
CONCLUSION
1) There was significant improvement in Heart rate post Buteyko breathing exercise for 3
weeks in patients with COPD.
2) There was significant improvement in Respiratory rate post Buteyko breathing exercise
for 3 weeks in patients with COPD.
3) There was no significant improvement in FVC post Buteyko breathing exercise for 3
weeks in patients with COPD.
4) There was no significant improvement in FEV1 post Buteyko breathing exercise for 3
weeks in patients with COPD.
SUMMARY
COPD is characterised by symptoms of breathlessness, wheeze, cough, sputum production and
exercise intolerance. A variety of techniques have been used to address limitation in breathing
and severe dyspnoea. One such technique is Buteyko breathing technique. In this study we have
tried to the effect of buteyko breathing technique in management of copd.
The current study was carried out on fifty COPD patients who underwent a 3 week course of
Buteyko breathing technique for 35-40 minutes daily. Respiratory rate, heart rate, forced vital
capacity and Forced expiratory volume in 1 second were measured before and after the
course.
There was a significant difference in heart rate and respiratory rate values while there was
not much improvement seen in forced vital capacity and Forced expiratory volume in 1
second.
It was concluded that Buteyko breathing technique improves can be taken into consideration
in the management of patients with in chronic obstructive pulmonary disease patients.
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ANNEXURE-1
CONSENT OF THE PATIENT
I ................................. hereby agree to provide my fullest consent and co-operation as
a subject for the dissertation work of Miss Ritu Chauhan, titled “Effect of Buteyko breathing
technique in management of chronic obstructive pulmonary disease (COPD) patients”
towards her post graduation in physiotherapy. The benefits and possible risks of the treatment
as well as the procedure and duration of the study have been explained to me. The questions
and queries I have posed have been answered to my satisfaction and I am aware that I can
discontinue the treatment at any time I wish to do so.
Place: Name of the participant.
Date: Signature of the participant.
ANNEXURE II
PFT ASSESMENT CHART
DEMOGRAPHIC DATA:
• NAME: ……………
• AGE : ……………..
• GENDER: .……………
• WEIGHT: ……………
• ADDRESS:
……………………………………………………………………………………..……………
…………………………………………………………………………………………………
………….………….
HISTORY
• History of any medical and surgical condition………………
• Drug History………………………..
• History of any acute or chronic illness………………..
VITAL SIGN EXAMINATION
• Blood Pressure: …………..
• Heart Rate: …………..
• Respiratory Rate: ………..
• Tempratur: ………….
RESPIRATORY EXAMINATION
• Breath Sound: …………..
• Added Sound: ………….
• Voice Sound: …
•
TEST EVALUATION
• FVC: …………
• FEV1: ………………..
ANNEXURE‐3
MASTER CHART
Pre Intervention Post Intervention
SR.NO AGE HEIGHT WEIGHT HEART RATE
RESPIRATORY RATE
FVC FEV1 HEART RATE
RESPIRATORY RATE
FVC FEV1
1 45 1.58 70 81 25 50 40 76 18 52 42 2 51 1.7 56 78 19 52 32 72 14 54 32 3 60 1.66 60 90 18 65 50 85 16 65 50 4 59 1.56 58 92 21 73 45 85 14 74 46 5 44 1.58 55 76 21 71 41 71 13 73 43 6 42 1.72 68 98 24 79 33 90 12 79 33 7 55 1.74 70 102 18 46 38 100 16 48 40 8 60 1.62 59 74 20 53 48 69 13 54 49 9 60 1.71 62 86 21 57 36 79 14 57 36 10 54 1.55 56 73 19 47 34 68 11 49 36 11 59 1.64 57 92 26 79 51 86 13 79 51 12 44 1.61 64 88 19 71 47 82 14 73 49 13 40 1.57 61 78 22 54 43 73 15 55 44 14 60 1.75 72 93 24 57 35 88 18 59 37 15 58 1.59 62 99 20 67 39 91 16 67 39 16 59 1.6 56 73 18 61 41 66 15 62 42 17 51 1.63 70 106 19 51 49 98 14 53 51 18 54 1.56 55 91 22 78 51 85 16 78 51 19 45 1.7 66 97 26 56 32 90 19 58 34 20 49 1.62 62 76 22 74 34 71 18 75 35 21 47 1.74 71 85 20 75 30 78 14 76 31 22 53 1.57 56 84 27 56 52 79 13 57 53 23 46 1.61 60 97 21 81 51 92 14 82 52 24 47 1.54 68 89 18 53 33 83 16 54 34 25 54 1.73 63 77 17 45 38 72 16 47 40 26 59 1.7 59 103 24 63 48 97 17 64 49 27 58 1.58 70 87 26 68 42 82 20 69 43 28 48 1.6 62 79 19 78 49 71 14 78 49 29 49 1.74 57 95 18 75 44 89 14 75 44 30 55 1.62 54 82 20 55 51 76 16 57 53
MASTER CHART
31 42 1.55 56 78 19 51 33 71 13 52 34 32 48 1.71 72 93 20 49 47 87 14 50 48 33 43 1.59 73 86 27 64 38 80 18 66 40 34 52 1.64 63 77 25 81 52 70 15 81 52 35 44 1.68 56 81 21 75 31 75 14 75 31 36 59 1.56 58 74 25 69 35 68 19 70 36 37 45 1.72 58 89 19 76 39 83 13 76 39 38 51 1.63 69 83 21 47 50 75 15 47 50 39 47 1.59 64 99 18 59 43 92 12 60 44 40 54 1.69 66 78 19 66 46 72 13 66 46 41 43 1.62 72 102 22 64 50 97 15 65 51 42 57 1.74 63 98 24 68 39 90 16 68 37 43 60 1.68 67 79 26 73 40 73 17 75 42 44 46 1.57 62 86 17 77 50 81 11 77 50 45 59 1.58 57 93 27 80 46 85 20 80 46 46 58 1.6 57 99 26 61 51 92 19 62 52 47 40 1.66 73 104 18 54 35 96 12 55 36 48 49 1.56 55 75 20 59 38 70 14 61 40 49 50 1.73 62 79 25 70 46 72 19 71 47 50 55 1.75 66 83 27 73 51 78 21 74 52
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