What makes difficult asthma difficult?
SCH Journal Club
Nicki Barker
2012
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Aim
To determine whether breathing
retraining improves quality of life for
children with dysfunctional breathing
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Objectives
• Clarify the problem identified
• Share an understanding of difficult asthma and
dysfunctional breathing
• Critically appraise a relevant piece of literature
• Assess the impact of the literature on current
practice
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Difficult asthma
‘persistent symptoms and/or frequent
exacerbations despite treatment
at step 4 or step 5’
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Difficult asthma?
• Compliance issues
• Incorrect diagnosis
• Asthma plus a co-morbidity
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BTS guidelines 2012
‘dysfunctional breathing should be
considered as part of a difficult
asthma assessment’
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BreathWorks
• Specialist assessment of
dysfunctional breathing
• Children aged 8-16
• Referral currently via
respiratory clinics
• Thursday afternoon in
physiotherapy O/P’s
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Dysfunctional breathing (DB)
Dysfunctional
breathing
HVS
June 2012
VCD
Dysfunctional breathing in children
Breathing pattern
disorder
8
DB: A model
HVS
VCD
BPD
DB: A paediatric model
HVS
VCD
BPD
Evidence for breathing ex’s
• Buteyko breathing technique may be considered to
help patients to control the symptoms of asthma
• Reduces symptoms and bronchodilator use
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The Clinical Question
Population
Children with dysfunctional breathing
Intervention
Breathing retraining
Comparison
Normal care
Outcome
QOL, symptom scores, changes in asthma medication,
objective measures
Design
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Intervention RCT
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Breathing retraining for
dysfunctional breathing in asthma: a
randomised
controlled trial
Thomas M, McKinley RK, Freeman E, Foy C, Prodger P,
Price D.
Thorax Feb 2003; 58(2):110-5
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The Clinical Question
Population
Adult asthma patients with dysfunctional breathing
Intervention
Breathing retraining
Comparison
Equivalent amount of professional attention
Outcome
QOL, symptom scores, changes in asthma medication
Design
Intervention RCT
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Methods
•
•
•
•
•
•
Patients aged 17 to 65
n=33
Diagnosis of currently treated asthma
Single semi-rural UK GP practice
Nijmegen questionnaire score of  23
Randomised to breathing retaining or asthma
education
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Study flow diagram
Thomas M et al. Thorax 2003;58:110-115
Outcome measures
• Primary
– Asthma specific health status (AQLQ)
– Nijmegen questionnaire scores
• Secondary
– Changes in asthma medication and medication usage
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Using the CASP tool
A/ Are the results of the trial valid?
Screening Questions
1 Did the trial address a clearly focused issue?
Yes Can't tell No
2 Was the assignment of patients to treatments randomized?
Yes Can't tell No
3 Were all of the patients who entered the trial properly accounted
for at its conclusion ?
Yes Can't tell No
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CASP cont.
Detailed Questions
4 Were patients, health workers and study personnel ‘blind’ to
treatment?
Yes Can't tell No
- Virtually impossible with physiotherapy interventions
5 Were the groups similar at the start of the trial?
Yes Can't tell No
- Control group appeared to have greater inhaled steroid dose
6 Aside from the experimental intervention, were the groups
treated equally?
Yes Can't tell No
- 75mins versus 60mins and in a different format
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CASP cont.
B/ What are the results?
7 How large was the treatment effect?
- Not clearly stated and no MCID available for Nijmegen Questionnaire
8 How precise was the estimate of the treatment effect?
- Confidence interval and limits not stated
C/ Will the results help locally?
9 Can the results be applied to the local population?
Yes Can't tell No
– Questionable choice of measures, adult to paediatric applicability
10 Were all clinically important outcomes considered?
- No objective measures used
Yes No
11 Are the benefits worth the harms and costs?
Yes No
- Minimal likelihood of harm. Costs – time of therapist and patient
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Key thoughts
•
•
•
•
•
•
•
50% benefitted at 1 month
25% benefitted at 6 months
Small numbers
Short duration intervention
Intervention not representative of clinical situation
Application of findings to children
Impact of co-existent asthma
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Quality of life as measured by PedsQL
MCID = minimal clinically important difference
Symptom score using Nijmegen
Questionnaire
Take home messages
• Consider dysfunctional breathing in cases of difficult
asthma
• Key signs of DB are:
• Frequent sighing, unsteadiness/irregularity of
breathing, upper chest dominated breathing, mouth
breathing, difficulty breathing in, throat tightness
• Refer appropriate cases to BreathWorks
• Support the research needed to better understand
DB in children
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