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