Cochrane Database of Systematic Reviews

Buteyko breathing for asthma (Protocol)

Campbell TG, Hoffmann T, Glasziou PP

Campbell TG, Hoffmann T, Glasziou PP.

Buteyko breathing for asthma.
Cochrane Database of Systematic Reviews 2011, Issue 6. Art. No.: CD009158.
DOI: 10.1002/14651858.CD009158.

www.cochranelibrary.com

Buteyko breathing for asthma (Protocol)

Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
 TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Buteyko breathing for asthma (Protocol) i

Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
[Intervention Protocol]

Buteyko breathing for asthma

Thomas G Campbell1 , Tammy Hoffmann2 , Paul P Glasziou3

1 Schoolof Medicine, University of Queensland, Brisbane, Australia. 2 Centre for Research in Evidence-Based Practice (CREBP), Bond
University, Gold Coast, Australia. 3 Centre for Research in Evidence Based Practice, Bond University, Gold Coast, Australia

Contact address: Paul P Glasziou, Centre for Research in Evidence Based Practice, Bond University, Gold Coast, Queensland, 4229,
Australia. pglaszio@bond.edu.au.

Editorial group: Cochrane Airways Group.

Publication status and date: New, published in Issue 6, 2011.

Citation: Campbell TG, Hoffmann T, Glasziou PP. Buteyko breathing for asthma. Cochrane Database of Systematic Reviews 2011,
Issue 6. Art. No.: CD009158. DOI: 10.1002/14651858.CD009158.

Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT

This is the protocol for a review and there is no abstract. The objectives are as follows:

To determine whether Buteyko breathing is effective in either the prevention or treatment of asthma when compared to a ’placebo’
(sham breathing training) or no treatment.

Clinically, asthma is characterised by acute episodes of dyspnoea,

BACKGROUND
Asthma is a debilitating, chronic disease characterised by airway
hyper-responsiveness and associated respiratory symptoms (Fauci
1998). Asthma is extremely common and is one of the leading
presenting complaints for patients in general practice in Australia
and the UK (Anderson 2007). It has been estimated that in the
USA, asthma management costs exceed $USA 12.7 billion per year
(in 1998 dollars) (Weiss 2001). Symptomatic treatments provide
short term relief from the symptoms of asthma but do not prevent
further episodes. A recent study of asthma patients (Shaw 2006)
reported that patients use a variety of alternative treatments for
asthma which have unknown or no efficacy including yoga, home-
opathy (McCarney 1999), kinesiology, massage therapy, osteopa-
thy, acupuncture (McCarney 1999a) and breathing techniques in-
cluding Buteyko breathing techniques.
Description of the condition
Buteyko breathing for asthma (Protocol)
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
cough, and wheezing generally lasting minutes to hours (Fauci
1998). Exceptionally, asthmatic episodes can lead to complete
airway obstruction and death.The pathophysiological mechanism
underlying the bronchial hyper-responsiveness that characterises
asthma is poorly understood, but is believed to involve airway
inflammation. As such, preventative treatments for asthma are
mainly immuno-modulators such as steroids or mast cell stabilisers
(Fauci 1998). Symptomatic treatment of asthma revolves around
relieving airway constriction by promoting airway smooth muscle
relaxation with beta-adrenergic agonists.
Description of the intervention
Several breathing techniques have been suggested to help control
asthma, but have substantially different techniques and proposed
mechanisms. Proponents of Buteyko breathing techniques have
suggested that asthma is the body’s normal defence mechanism
against chronic overbreathing. In particular it is believed that the
pathophysiology of asthma is mediated by hypocapnia secondary
1
to chronic hyperventilation. Buteyko breathing techniques aim to
increase awareness of breathing in general and to normalise venti-
lation by reducing tidal volume and respiratory rate. In addition
patients are encouraged to breath through symptoms and to only
use symptomatic control medication if symptoms persist.
How the intervention might work
Buteyko breathing aims to reduce minute volume and thus to
normalise carbon dioxide (CO2) levels. Those who practice
Buteyko breathing suggest that hyperventilation and hypocapnia
drive much, if not all, of the pathophysiology of asthma. As such
Buteyko breathing - which aims to reduce minute volume and
raises CO2 levels - could reverse or alleviate asthmatic symptoms
(Bowler 1998; Cooper 2003). The exact mechanism by which
hypocapnia contributes to the pathophysiology of asthma is not
well described.
Why it is important to do this review
A systematic review of the therapeutic potential of breathing tech-
niques in asthma (Holloway 2004) concluded that “... no reliable
conclusions can be drawn concerning the use of breathing exer-
cises for asthma in clinical practice. However trends for improve-
ment, notably in quality of life measurements, are encouraging”.
However there has been no systematic review specifically looking
at the evidence for Buteyko breathing techniques in asthma. This
proposed review will examine the evidence from randomised trials
for any benefits or downsides of Buteyko breathing techniques.
OBJECTIVES
To determine whether Buteyko breathing is effective in either the
prevention or treatment of asthma when compared to a ’placebo’
(sham breathing training) or no treatment.
METHODS
Criteria for considering studies for this review
Types of studies
To be eligible for inclusion studies must be randomised or quasi-
randomised trials that compare Buteyko breathing with a sham
breathing training, placebo, or to no treatment. Studies will be
eligible for inclusion regardless of publication status. Abstracts will
Buteyko breathing for asthma (Protocol)
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
not be included unless it is possible to obtain further experimen-
tal details from the investigators. Studies in any language will be
includable, with translation (e.g. from Russian) if required.
Types of participants
Adults (18 years or older) or children (17 years or younger) with a
diagnosis of asthma will be eligible for inclusion. However adults
and children will be analysed separately, if possible. Patients should
have no other acute illnesses or serious, chronic co-morbidities.
Studies in which the majority of patients have other respiratory
diseases will be excluded.
Types of interventions
Only breathing techniques specifically identified as Buteyko
breathing will be eligible for inclusion. Other breathing techniques
will be excluded. Trials in which the intervention group receives a
co-intervention, that is a treatment other than Buteyko breathing,
will be included only if the control group receives the same treat-
ment. Trials will not be excluded on the basis of training format,
however the precise nature of the training (frequency, duration,
supervision) will be recorded wherever possible
Types of outcome measures
Primary outcomes
1. Lung function measurements (Peak expiratory flow rates
(PEFR) will be the preferred measure but the one second forced
expiratory volume (FEV 1) will be substituted if PEFR was not
measured);
2. Quality of life (QOL) scores.
Secondary outcomes
1. The use of reliever medications for symptomatic control
(use only objective measurements e.g. from dispensed
medication or checks of puffers. Both the total dose per month
and the frequency of use are of interest);
2. The use of medication for prevention;
3. Symptom frequency, or severity;
4. Emergency visits or admissions.
Any reported adverse effects of Buteyko breathing will be compiled
across studies and, if possible, quantified.
Search methods for identification of studies
Electronic searches
2
We will search the Cochrane Airways Group Register of Trials,
MEDLINE, the Cochrane Central Register of Controlled Trials
(CENTRAL), EMBASE, and AMED (the Allied and Comple-
mentary Medicine Database). The following term will be used to
interrogate the databases:
Buteyko OR Buteyko breathing. (Note: a preliminary search of
MEDLINE suggests no methodological filters will be needed as
the number of hits is manageable).
There will be no language restriction.
We will also search the controlled trials registry - http://
www.controlled-trials.com/ - for missed or unpublished studies,
and write to authors if completed but unpublished studies are
identified.
Searching other resources
We will check the references of all identified relevant studies. We
will also do a forward search for articles that cite identified relevant
studies. Two review authors (TGC and PPG) will check the title
and abstracts of all articles from the electronic search to decide for
which articles the full text is required for assessment.
Data collection and analysis
Selection of studies
Two review authors (TGC, TH) will independently assess for in-
clusion all the potential studies we identify as a result of the search
strategy. We will resolve any disagreement through discussion or,
if required, we will consult a third reviewer (PG).
Data extraction and management
We will review trials that satisfy the inclusion criteria and record
the following information:
1. Patients: age of participant; gender of participants; co-
morbidities of participants;
2. Number of participants;
3. Selection of participants: Inclusion criteria; exclusion
criteria; treatment setting;
4. Treatment: duration of treatment; format of treatment;
5. Comparison Treatment: No treatment or sham technique;
6. Co-interventions: Other medications; other treatments;
7. Outcomes (see above).
We will request further information from the authors where re-
quired.
Assessment of risk of bias in included studies
Two review authors (TGC, TH) will independently assess risk
of bias for each study using the criteria outlined in the Cochrane
Buteyko breathing for asthma (Protocol)
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Handbook for Systematic Reviews of Interventions (Higgins 2008).
Any disagreement will be resolved by discussion or by involving a
third assessor (PPG). We will assess the risk of bias according to
the following domains:
1. Allocation sequence generation
2. Concealment of allocation
3. Blinding of participants and investigators
4. Incomplete outcome data
5. Selective outcome reporting
Other sources of bias will be noted. Each potential source of bias
was graded as yes, no or unclear, relating to whether the potential
for bias was low, high or unknown respectively.
Measures of treatment effect
We will use the standardized mean difference of lung function
tests, and quality of life scores.
Unit of analysis issues
The unit of analysis will be the individual patient.
Dealing with missing data
We will contact investigators or study sponsors in order to verify
key study characteristics and obtain missing numerical outcome
data where possible.
Assessment of heterogeneity
We will use the I2 statistic to measure heterogeneity among the tri-
als in each analysis. If we identify substantial heterogeneity (greater
than 50%) we will explore it by pre-specified subgroup analysis.
Assessment of reporting biases
Where we suspect reporting bias (see ’Selective reporting bias’
above), we will attempt to contact study authors asking them to
provide missing outcome data. Where this is not possible, and the
missing data are thought to introduce serious bias, the impact of
including such studies in the overall assessment of results will be
explored by a sensitivity analysis.
Data synthesis
Each outcome will be meta-analysed in Review Manager 5 if the
outcome measures are similar enough to allow such a comparison.
Alternatively we will use standardised mean differences to estimate
the overall effect size. If there is insufficient data to conduct a
meta-analysis on the adverse effects of Buteyko breathing we will
report the types of event, and, if available the rates of those effects
and a comparison of those rates between treatment groups.
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Subgroup analysis and investigation of heterogeneity
We plan to carry out the following subgroup analyses:
1. Adults versus children
2. Standard Buyteko training versus self-taught (video or
booklet)
If substantial differences are apparent in the intervention method,
then sub-group analyses stratified by training technique and train-
ing duration would be carried out. Subgroup analysis will be done
with the primary outcomes only.
REFERENCES
Additional references
Anderson 2007
Anderson HR, Gupta R, Strachan DP, Limb ES. 50 years of
asthma: UK trends from 1955 to 2004.. Thorax 2007;62:
85–90.
Bowler 1998
Bowler SD, Green A, Mitchell CA. Buteyko breathing
techniques in asthma: a blinded randomised controlled
trial.. The Medical journal of Australia 1998;169:575–8.
Cooper 2003
Cooper S, Oborne J, Newton S, Harrison V, Thomson
Coon J, Lewis S, et al. Effect of two breathing exercises
(Buteyko and pranayama) in asthma: a randomised
controlled trial.. Thorax 2003;58:674–679.
Fauci 1998
Fauci AS, Braunwald E, Isselbacher KJ, Wilson JD, Martin
JB, Kasper D, et al. Harrison’s Principles of Internal Medicine,
14th edition.. McGraw-Hill Companies, 1998.
Higgins 2008
Higgins JPT, Green S, editors. Cochrane Handbook for
Systematic Reviews of Interventions Version 5.0.1 [updated
September 2008]. The Cochrane Collaboration, Available
from www.cochrane-handbook.org, 2008.
Holloway 2004
Holloway E, Ram FS. Breathing exercises for asthma.
Cochrane Database of Systematic Reviews 2004, Issue 1.
[DOI: 10.1002/14651858.CD001277.pub2]
Buteyko breathing for asthma (Protocol)
Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Sensitivity analysis
We plan to assess the robustness of the outcomes by comparing
a meta-analyses of all the studies with meta-analyses leaving out
studies at high risk of bias.
ACKNOWLEDGEMENTS
We thank Emma Welsh and Elizabeth Arnold from the Airways
Group for their advice, supportive role and comments to the pro-
tocol.
McCarney 1999
McCarney RW, Linde K, Lasserson TJ. Homeopathy for
chronic asthma. Cochrane Database of Systematic Reviews
1999, Issue 1. [DOI: 10.1002/14651858.CD000353.pub2]
McCarney 1999a
McCarney RW, Brinkhaus B, Lasserson TJ, Linde K.
Acupuncture for chronic asthma. Cochrane Database
of Systematic Reviews 1999, Issue 1. [DOI: 10.1002/
14651858.CD000008.pub2]
Review Manager 5 [Computer program]
Copenhagen, The Nordic Cochrane Centre: The Cochrane
Collaboration. Review Manager (RevMan) Version 5.0.
Copenhagen, The Nordic Cochrane Centre: The Cochrane
Collaboration, 2008.
Shaw 2006
Shaw A, Thompson EA, Sharp D. Complementary therapy
use by patients and parents of children with asthma and the
implications for NHS care: a qualitative study. BMC health
services research 2006;6:76–88.
Weiss 2001
Weiss KB, Sullivan SD. The health economics of asthma
and rhinitis. I. Assessing the economic impact. The Journal
of allergy and clinical immunology 2001;107:3–8.
∗
Indicates the major publication for the study
4
CONTRIBUTIONS OF AUTHORS
PG initiated the study; PG, TGC, and TH wrote the protocol. TGC and PG will select articles from the search. TGC and TH will
enter data (if available). TGC will do the statistical analyses. All authors will draft the manuscript.

DECLARATIONS OF INTEREST
None declared.

Buteyko breathing for asthma (Protocol) 5

Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.