Despite effective pharmacotherapy, asthma continues to impair quality of life for most patients. Non-pharmacological approaches, including breathing retraining, are therefore of great interest to patients. A recent international guideline regarding physiotherapeutic management of adult patients having asthma recommends breathing exercises for patients to increase asthma control and quality of life. Physical training is advised to increase fitness and cardiorespiratory endurance, to decrease dyspnoea and improve quality of life. (https://www.sciencedirect.com/science/article/pii/S0954611112005045)
A large-scale randomized control trial done in 2018 showed many patients have concerns about taking regular medication, particularly corticosteroids, and expressed an interest in non-pharmacological self-management strategies, with up to 30% reporting that they use breathing techniques to help control their symptoms. Preliminary randomised trials have reported beneficial outcomes from breathing retraining in asthma, particularly from physiotherapy-based programmes. Such programmes are, therefore, now advocated in asthma guidelines as an adjuvant for patients whose symptoms remain uncontrolled despite standard pharmacological treatment.
The 2012 US Agency for Healthcare Research and Quality analysis study concluded that non-pharmacological techniques can improve asthma symptoms and reduce the need for reliever medication, and the 2013 Cochrane review reported that trends for improvement were encouraging, and advocated further studies. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5757422/)
Breath retraining techniques
Breathing techniques may have more benefit on mild-moderate asthma. The aim of breathing retraining is to normalise breathing patterns by stabilising respiratory rate and increasing expiratory airflow. The physiotherapist instructs following components for breath retraining:
Taking Smaller Breaths (Reducing Tidal Volume)
Deep Breathing (Diaphragmatic breathing through the use of abdominal muscles and lower thoracic chest movement)
Breathing through the Nose (Nasal Breathing)
Relaxation (Relaxed, controlled breathing)
Decreasing Air Leaving (Decreased expiratory flow through pursed lip breathing)
These retraining techniques help control breathing and reduce airflow turbulence, hyperinflation, variable breathing patterns and anxiety. (https://pubmed.ncbi.nlm.nih.gov/19406863/)
Decreasing Breaths Taken (Reducing Respiratory Rate)
Breathing pattern retraining aims to develop a more efficient pattern of respiration, thereby reducing breathlessness. This is usually accomplished by slowing the breathing rate and encouraging relaxed, ‘abdominal’ breathing (Bruton, 2006).
Buteyko breathing technique
The Buteyko breathing technique is another breathing retraining technique; however, it is specific to reducing hyperinflation. It was developed based on the theory that asthmatic bronchospasm is caused by hyperventilation, leading to a low PaCO2 and therefore all asthmatic symptoms are due to this. The narrowed airways induce an “air hunger” causing a switch to mouth-breathing and an increased respiratory rate leading to hyperinflation. Buteyko believes that this hyperinflation then also contributes to bronchoconstriction. The Buteyko technique aims to reduce ventilation and subsequently lung volume, as a treatment for asthma and other respiratory diseases. A qualified practitioner is necessary to train the patient. (https://pubmed.ncbi.nlm.nih.gov/18249107/)
Physical training
Physical training should be prescribed by physiotherapists for asthmatics to increase fitness and cardiorespiratory performance, reduce symptoms such as breathlessness and improve quality of life. Breathlessness, chest tightness and wheezing can occur when exercising, deterring patients from physical exertion. Fear-avoidance can contribute to a further deterioration of physical health and quality of life, leading to anxiety and depression. It has been shown that maintaining physical training in asthmatics improves disease symptoms and quality of life, making it a crucial management strategy. (https://pubmed.ncbi.nlm.nih.gov/17805077/)
A study protocol suggests behaviour change intervention focusing on increasing participation in physical activity may exert control over asthma and quality of life.
Physical training with asthma is advised with proper precautions guided by the American College of Sports Medicine (ACSM) to exercise safely.
Respiratory muscle training
Hyperinflation in asthma causes increased lung volume, leading to shortened sub-optimal length-tension relationship for inspiratory muscle contraction. There is a decreased capacity for tension generation when breathing, resulting in accessory muscles of inspiration being utilised.
Breathing exercises are carried out using an external device such as a spirometer, to make breathing more difficult. This helps to strengthen the inspiratory muscles, making it easier to breathe in everyday life.
Removal of secretions
There are different types of airway clearance techniques of which the most useful for asthma patients are:
Manual chest physiotherapy technique entails gently striking or clapping the chest wall with cupped hands or a percussion device. This rhythmic percussion helps to loosen and mobilize mucus trapped within the airways. The patient is positioned in various postures to facilitate mucus drainage from different lung segments. These positions typically include lying in different bed positions, such as head-down, head-up, side-lying, and prone positions. Gravity assists in moving mucus towards larger airways, where it can be cleared more effectively.
Active Cycle Breathing technique comprises several phases to regulate breathing patterns, expand the chest, mobilize mucus, and facilitate coughing to clear the airways. Patients initially focus on controlled breathing to regulate their respiratory rate and promote relaxation. Thoracic expansion exercises are then performed, involving deep inhalation to expand the chest and increase lung volume. Patients then perform forced expiratory efforts and controlled coughing to effectively mobilize and clear mucus from the airways. Afterward, the relaxation phase allows patients to rest and recover, promoting overall comfort and well-being. (https://www.ncbi.nlm.nih.gov/books/NBK604210/#:~:text=Postural%20drainage%20uses%20gravity%20by,mucus%20from%20the%20airway%20walls.)
Patient education about pathophysiology of asthma symptoms may help improve awareness and self-management. Information on use of bronchodilator and other medications may help reduce the frequency of attacks and breathlessness. Correct posture in standing and sitting assists in the management of asthma attacks by allowing the chest to expand appropriately and the lungs to function optimally.
