Breathing Exercises For Adults With Asthma

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Breathing exercises for adults with asthma (Review)
Santino TA, Chaves GSS, Freitas DA, Fregonezi GAF, Mendonça KMPP
Santino TA, Chaves GSS, Freitas DA, Fregonezi GAF, Mendonça KMPP.

Breathing exercises for adults with asthma.
Cochrane Database of Systematic Reviews 2020, Issue 3. Art. No.: CD001277.
DOI: 10.1002/14651858.CD001277.pub4.
www.cochranelibrary.com

Copyright © 2020 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
Cochrane Trusted evidence.
Informed decisions.

Library Better health. Cochrane Database of Systematic Reviews
TABLE OF CONTENTS
HEADER......................................................................................................................................................................................................... 1
ABSTRACT..................................................................................................................................................................................................... 1
PLAIN LANGUAGE SUMMARY....................................................................................................................................................................... 2
SUMMARY OF FINDINGS.............................................................................................................................................................................. 4
BACKGROUND.............................................................................................................................................................................................. 6
OBJECTIVES.................................................................................................................................................................................................. 7
METHODS..................................................................................................................................................................................................... 7
RESULTS........................................................................................................................................................................................................ 9
Figure 1.................................................................................................................................................................................................. 10
Figure 2.................................................................................................................................................................................................. 13
Figure 3.................................................................................................................................................................................................. 16
Figure 4.................................................................................................................................................................................................. 16
DISCUSSION.................................................................................................................................................................................................. 19
AUTHORS' CONCLUSIONS........................................................................................................................................................................... 20
ACKNOWLEDGEMENTS................................................................................................................................................................................ 20
REFERENCES................................................................................................................................................................................................ 21
CHARACTERISTICS OF STUDIES.................................................................................................................................................................. 28
DATA AND ANALYSES.................................................................................................................................................................................... 63
Analysis 1.1. Comparison 1 Breathing exercises versus inactive control, Outcome 1 Change in AQLQ (up to 3 months)............... 66
Analysis 1.2. Comparison 1 Breathing exercises versus inactive control, Outcome 2 Number of people who improved scores in 67
AQLQ (over 6 months)..........................................................................................................................................................................
Analysis 1.3. Comparison 1 Breathing exercises versus inactive control, Outcome 3 Change in SGRQ........................................... 67
Analysis 1.4. Comparison 1 Breathing exercises versus inactive control, Outcome 4 Change in ACQ (up to 3 months).................. 67
Analysis 1.5. Comparison 1 Breathing exercises versus inactive control, Outcome 5 Adjusted change in ACQ (over 6 months)...... 68
Analysis 1.6. Comparison 1 Breathing exercises versus inactive control, Outcome 6 Nijmegen (4 to 6 months)............................ 68
Analysis 1.7. Comparison 1 Breathing exercises versus inactive control, Outcome 7 Adjusted change in Nijmegen (over 6 69
months)..................................................................................................................................................................................................
Analysis 1.8. Comparison 1 Breathing exercises versus inactive control, Outcome 8 Lung function (FEV1 in litres; up to 3 69
months)..................................................................................................................................................................................................
Analysis 1.9. Comparison 1 Breathing exercises versus inactive control, Outcome 9 Lung function (FEV1 % of predicted; up to 70
3 months)...............................................................................................................................................................................................
Analysis 1.10. Comparison 1 Breathing exercises versus inactive control, Outcome 10 Adjusted change in lung function (FEV1 70
in litres; over 6 months).......................................................................................................................................................................
Analysis 1.11. Comparison 1 Breathing exercises versus inactive control, Outcome 11 Adjusted change in lung function (FEV1 71
% of predicted; over 6 months)...........................................................................................................................................................
Analysis 1.12. Comparison 1 Breathing exercises versus inactive control, Outcome 12 Lung function (PEFR; up to 3 months)....... 71
Analysis 1.13. Comparison 1 Breathing exercises versus inactive control, Outcome 13 Adjusted change in lung function (PEFR; 71
over 6 months)......................................................................................................................................................................................
Analysis 2.1. Comparison 2 Breathing exercises versus asthma education, Outcome 1 Change in AQLQ (up to 3 months)........... 72
Analysis 2.2. Comparison 2 Breathing exercises versus asthma education, Outcome 2 Change in AQLQ (4 to 6 months).............. 73
Analysis 2.3. Comparison 2 Breathing exercises versus asthma education, Outcome 3 Nijmegen (up to 3 months)...................... 73
Analysis 2.4. Comparison 2 Breathing exercises versus asthma education, Outcome 4 Nijmegen (4 to 6 months)........................ 73
ADDITIONAL TABLES.................................................................................................................................................................................... 73
APPENDICES................................................................................................................................................................................................. 77
WHAT'S NEW................................................................................................................................................................................................. 79
HISTORY........................................................................................................................................................................................................ 79
CONTRIBUTIONS OF AUTHORS................................................................................................................................................................... 80
DECLARATIONS OF INTEREST..................................................................................................................................................................... 80
SOURCES OF SUPPORT............................................................................................................................................................................... 80
DIFFERENCES BETWEEN PROTOCOL AND REVIEW.................................................................................................................................... 80
INDEX TERMS............................................................................................................................................................................................... 81
Breathing exercises for adults with asthma (Review) i

Informed decisions.

[Intervention Review]
Breathing exercises for adults with asthma
Thayla A Santino1, Gabriela SS Chaves2, Diana A Freitas3, Guilherme AF Fregonezi4, Karla MPP Mendonça5
1Department of Physical Therapy, Federal University of Rio Grande do Norte, Natal, Brazil. 2School of Kinesiology and Health Science,
York University, Toronto, Canada. 3Centro Universitário Facex (UNIFACEX), Natal, Brazil. 4PneumoCardioVascular Lab, Onofre Lopes
University Hospital, Brazilian Company of Hospital Services (EBSERH) & Department of Physical Therapy, Federal University of Rio
Grande do Norte, Natal, Brazil. 5PhD Program in Physical Therapy, Federal University of Rio Grande do Norte, Natal, Brazil
Contact address: Karla MPP Mendonça, PhD Program in Physical Therapy, Federal University of Rio Grande do Norte, Avenida Senador
Salgado Filho, 300, Bairro Lagoa Nova, Natal, Rio Grande do Norte, 59078-970, Brazil. karla-morganna@hotmail.com.
Editorial group: Cochrane Airways Group.

Publication status and date: New search for studies and content updated (conclusions changed), published in Issue 3, 2020.
Citation: Santino TA, Chaves GSS, Freitas DA, Fregonezi GAF, Mendonça KMPP. Breathing exercises for adults with asthma. Cochrane
Database of Systematic Reviews 2020, Issue 3. Art. No.: CD001277. DOI: 10.1002/14651858.CD001277.pub4.
ABSTRACT
Background
Breathing exercises have been widely used worldwide as a non-pharmacological therapy to treat people with asthma. Breathing exercises
aim to control the symptoms of asthma and can be performed as the Papworth Method, the Buteyko breathing technique, yogic breathing,
deep diaphragmatic breathing or any other similar intervention that manipulates the breathing pattern. The training of breathing usually
focuses on tidal and minute volume and encourages relaxation, exercise at home, the modification of breathing pattern, nasal breathing,
holding of breath, lower rib cage and abdominal breathing.
Objectives
To evaluate the evidence for the efficacy of breathing exercises in the management of people with asthma.
Search methods
To identify relevant studies we searched The Cochrane Library, MEDLINE, Embase, PsycINFO, CINAHL and AMED and performed
handsearching of respiratory journals and meeting abstracts. We also consulted trials registers and reference lists of included articles.
The most recent literature search was on 4 April 2019.
Selection criteria
We included randomised controlled trials of breathing exercises in adults with asthma compared with a control group receiving asthma
education or, alternatively, with no active control group.
Data collection and analysis

Two review authors independently assessed study quality and extracted data. We used Review Manager 5 software for data analysis based
on the random-effects model. We expressed continuous outcomes as mean differences (MDs) with confidence intervals (CIs) of 95%. We
assessed heterogeneity by inspecting the forest plots. We applied the Chi2 test, with a P value of 0.10 indicating statistical significance, and
the I2 statistic, with a value greater than 50% representing a substantial level of heterogeneity. The primary outcome was quality of life.
Main results
We included nine new studies (1910 participants) in this update, resulting in a total of 22 studies involving 2880 participants in the review.
Fourteen studies used Yoga as the intervention, four studies involved breathing retraining, one the Buteyko method, one the Buteyko
method and pranayama, one the Papworth method and one deep diaphragmatic breathing. The studies were different from one another
Breathing exercises for adults with asthma (Review) 1
Informed decisions.

in terms of type of breathing exercise performed, number of participants enrolled, number of sessions completed, period of follow-up,
outcomes reported and statistical presentation of data. Asthma severity in participants from the included studies ranged from mild to
moderate, and the samples consisted solely of outpatients. Twenty studies compared breathing exercise with inactive control, and two
with asthma education control groups. Meta-analysis was possible for the primary outcome quality of life and the secondary outcomes
asthma symptoms, hyperventilation symptoms, and some lung function variables. Assessment of risk of bias was impaired by incomplete
reporting of methodological aspects of most of the included studies. We did not include adverse effects as an outcome in the review.
Breathing exercises versus inactive control
For quality of life, measured by the Asthma Quality of Life Questionnaire (AQLQ), meta-analysis showed improvement favouring the
breathing exercises group at three months (MD 0.42, 95% CI 0.17 to 0.68; 4 studies, 974 participants; moderate-certainty evidence), and
at six months the OR was 1.34 for the proportion of people with at least 0.5 unit improvement in AQLQ, (95% CI 0.97 to 1.86; 1 study,
655 participants). For asthma symptoms, measured by the Asthma Control Questionnaire (ACQ), meta-analysis at up to three months was
inconclusive, MD of -0.15 units (95% CI −2.32 to 2.02; 1 study, 115 participants; low-certainty evidence), and was similar over six months
(MD −0.08 units, 95% CI −0.22 to 0.07; 1 study, 449 participants). For hyperventilation symptoms, measured by the Nijmegen Questionnaire
(from four to six months), meta-analysis showed less symptoms with breathing exercises (MD −3.22, 95% CI −6.31 to −0.13; 2 studies, 118
participants; moderate-certainty evidence), but this was not shown at six months (MD 0.63, 95% CI −0.90 to 2.17; 2 studies, 521 participants).
Meta-analyses for forced expiratory volume in 1 second (FEV1) measured at up to three months was inconclusive, MD −0.10 L, (95% CI −0.32
to 0.12; 4 studies, 252 participants; very low-certainty evidence). However, for FEV1 % of predicted, an improvement was observed in favour
of the breathing exercise group (MD 6.88%, 95% CI 5.03 to 8.73; five studies, 618 participants).
Breathing exercises versus asthma education
For quality of life, one study measuring AQLQ was inconclusive up to three months (MD 0.04, 95% CI -0.26 to 0.34; 1 study, 183 participants).
When assessed from four to six months, the results favoured breathing exercises (MD 0.38, 95% CI 0.08 to 0.68; 1 study, 183 participants).
Hyperventilation symptoms measured by the Nijmegen Questionnaire were inconclusive up to three months (MD −1.24, 95% CI −3.23 to
0.75; 1 study, 183 participants), but favoured breathing exercises from four to six months (MD −3.16, 95% CI −5.35 to −0.97; 1 study, 183
participants).
Authors' conclusions
Breathing exercises may have some positive effects on quality of life, hyperventilation symptoms, and lung function. Due to some
methodological differences among included studies and studies with poor methodology, the quality of evidence for the measured
outcomes ranged from moderate to very low certainty according to GRADE criteria. In addition, further studies including full descriptions
of treatment methods and outcome measurements are required.
PLAIN LANGUAGE SUMMARY
Breathing exercises for asthma
Background
Asthma is a lung disease. Asthma works in two ways. It that causes the airways to become inflamed (the body's response to injury and
infection) and it causes the small tubes of the airways to tighten (called airway obstruction). The tightening of the tubes can happen in
response to asthma triggers, such as animal fur or feathers, dust or pollen.
Asthma is very common worldwide and is a major public health problem due to the high healthcare costs associated with hospitalisation
and medication. Breathing exercises have been used to treat people with asthma as a way of controlling the symptoms of asthma without
medication. People use various breathing techniques to change their breathing pattern.
Review question
We wanted to find out how effective breathing exercises are for adults with asthma. We were most interested to know if breathing exercises
improved people's quality of life (our primary outcome), and also if they helped improve asthma symptoms, hyperventilation (over-
breathing), and lung function (our secondary outcomes).
Key results
We searched for randomised controlled trials. This means people were selected at random to try either breathing exercises or a control.
We included education about asthma or usual asthma care as the controls.
We found 22 studies involving 2880 adults with mild to moderate asthma. The studies used different breathing exercises. Fourteen studies
used yoga, four studies used breathing retraining, one study used Buteyko method, one study used Buteyko method and pranayama,
one study used Papworth method and one study used deep diaphragmatic breathing. Twenty studies compared breathing exercises with
normal asthma care and two compared breathing exercises with asthma education. Studies assessed quality of life, asthma symptoms

Informed decisions.

and hyperventilation symptoms, number of acute exacerbations (flare-ups), lung function (breathing tests), and general practitioner (GP)
appointments.
Several studies looked at our primary outcome, quality of life. The results showed an improvement in quality of life after three months in
the breathing-exercises group. We found that breathing exercises probably did not help to improve asthma symptoms. However, breathing
exercises did improve hyperventilation symptoms, when measured from four months after starting the exercises to six months. One lung
function test, percentage of predicted FEV1 (the amount of air you can force from your lungs in one second) showed some improvement
in the people who did breathing exercises.
Certainty of the evidence
We are moderately certain about the benefits of breathing exercises. However, we found some differences between the studies in terms of
type of breathing exercises performed, number of participants enrolled, number and duration of sessions completed, outcomes reported
and statistical presentation of data.
Conclusion
Breathing exercises may have positive effects on quality of life, hyperventilation symptoms, and lung function in adults with mild to
moderate asthma.
The evidence is current to April 2019.

SUMMARY OF FINDINGS

Summary of findings for the main comparison. Breathing exercises compared to inactive control for adults with asthma
Breathing exercises compared to inactive control for adults with asthma

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Patient or population: adults with asthma

Setting: outpatient
Intervention: breathing exercises (yoga, breathing retraining and Buteyko)
Comparison: inactive control
Outcomes Anticipated absolute effects* (95% CI) Relative ef- № of partici- Certainty of Comments
Better health.
fect pants the evidence

Trusted evidence.
(95% CI) (studies) (GRADE)

Informed decisions.
Risk with inactive Risk with breathing

control exercises

Change in AQLQ The mean change in MD 0.42 higher - 974 ⊕⊕⊕⊝ MCID for AQLQ is 0.5 units (Juniper 2004)
AQLQ was 0.14 units (0.17 higher to 0.68 Moderatea
Scores higher) (4 RCTs)
Range 1-7, with higher

scores indicating bet-
ter quality of life.
Follow-up: < 3 months
Change in ACQ The mean change in MD 0.15 lower - 115 ⊕⊕⊝⊝ MCID for ACQ is 0.5 units (Juniper 2005)
ACQ was minus 0.11 (2.32 lower to 2.02 (1 RCT) Lowa,b
Scores units higher)
Range 0-6 with lower
scores indicating bet-
ter control of asthma
symptoms.
Follow-up: < 3 months
Nijmegen Ques- The mean Nijmegen MD 3.22 points lower - 118 ⊕⊕⊕⊝ MCID has not been established for the
tionnaire score (4-6 Questionnaire score (6.31 lower to 0.13 (2 RCTs) Moderatec Nijmegen Questionnaire (van Dixhoorn
months) was 15.7 points lower) 2015)
Scores range 1-5 with

lower scores indicating
better control of asth-
ma symptoms.
4

Follow-up: between 4
and 6 months
Number of acute ex- See comment See comment - 952 ⊕⊝⊝⊝ The studies did not report sufficient data
acerbations Very lowd to allow us to include them in meta-analy-
(4 RCTs) sis.
Follow-up: between 2
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and 54 months
Cochrane
Inpatient hospitalisa- See comment See comment - - - No studies reported this outcome
tion episodes
Lung function (FEV1, The mean FEV1 was MD 0.1 L lower - 252 ⊕⊝⊝⊝ The accepted variability of change from
Better health.
L) 2.07 to 4.19 L (0.32 lower to 0.12 (4 RCTs) Very lowe 0.1 to 0.2 L is likely to have clinical rele-
Trusted evidence.
higher) vance (Enright 2004; Tepper 2012)

Informed decisions.
Follow up: < 3 months

Days off work See comment See comment - - - No studies reported this outcome
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and
its 95% CI).
ACQ: asthma control questionnaire; AQLQ: asthma quality of life questionnaire; CI: confidence interval; FEV1: forced expiratory volume in one second; MCID: minimal clini-
cally important difference; MD: mean difference
GRADE Working Group grades of evidence
High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is
substantially different.
Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.
Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.
aDowngraded one level because one study was high risk of bias for selective reporting.
bDowngraded one level because we included only one study with a small sample size in the analysis.
cDowngraded one level because of the small sample size and wide confidential interval presented.
dGraded as very low due to the impossibility of pooling the data into meta-analysis.
eDowngraded two levels because the included studies showed in general a high risk of bias and one level because of small sample size.

5

Informed decisions.

BACKGROUND individual issues that impair health-related quality of life and

treating them (Rimington 2001; Juniper 2004). So, the control of
Description of the condition asthma may be achieved by an individualised plan, considering the
factors that contribute to attaining and maintaining asthma control
Asthma is a chronic airway inflammatory disorder of the lungs
(Braido 2013).
that can lead to structural and functional changes, resulting in
bronchial hyperresponsiveness and airflow obstruction (Zhang Description of the intervention
2010; Brightling 2012; GINA 2018). Symptoms of asthma include
recurrent episodes of wheeze, cough, breathlessness and chest Although no cure for asthma is known, there are various
tightness, together with episodes of marked worsening of pharmacological and non-pharmacological interventions that may
symptoms, known as exacerbations (Zhang 2010; Brightling 2012; help people control their asthma symptoms (GINA 2018; Beasley
GINA 2018). Exacerbations can be fatal and they are more frequent 2016). For example, avoiding triggers (such as pollen or cold
and more serious in high-risk patients or patients with uncontrolled temperatures) and asthma education can also help people to
asthma (GINA 2018). Factors such as viral infections, allergens, control their asthma symptoms (Burgess 2011; Welsh 2011; Kew
tobacco smoke, physical exercise, stress, certain medications (non- 2016; GINA 2018).
steroidal anti-inflammatory drugs and beta-blockers) may trigger
or worsen asthma symptoms (GINA 2018; WHO 2018). Some Medications to treat asthma can be broadly divided into long-
phenotypes are already identified, such as allergic asthma, non- term controllers and short-term relievers (Arun 2012). Controller
allergic asthma, and late-onset asthma (GINA 2018). medications are taken daily on a long-term basis, and the relievers
are used to rapidly decrease bronchoconstriction and relieve its
The diagnosis of asthma is based on the individual's medical symptoms (GINA 2018). Such treatment can be administered in
history, physical examination findings and lung function and different ways (by inhalation, orally or parenterally; GINA 2018).
laboratory test results (Sveum 2012; National Asthma Council
Australia 2016; Gillis 2017). Measurement of lung function provides Non-pharmacological interventions have gained attention in the
an assessment of the severity of airflow limitation. These measures treatment of asthma. Those interventions include breathing
yield complementary information about different aspects of exercises, physical activity, and other strategies such as cessation
asthma control and are obtained by spirometry and by peak of smoking, avoidance of occupational exposure and indoor
expiratory flow measurement (GINA 2018). Assessment of airway allergens, and weight reduction, among others (GINA 2018).
responsiveness to factors that can cause asthma symptoms, Another approach comprises complementary and alternative
evaluation of airway inflammation and measurement of allergic medicine that includes non-conventional therapies such as
status may facilitate the diagnosis and management of people with homeopathy, acupuncture, aromatherapy, reflexology, massage,
asthma (GINA 2018). hypnotherapy, dietary supplements, and Alexander technique
(Blanc 2001; Torres-Llenza 2010; Dennis 2012; Mark 2015).
Asthma is a serious public health problem that is a major cause of Breathing exercises have been used by physiotherapists and
disability and health resource utilisation for those affected, which other professionals to control the symptoms of asthma (Bruton
may need emergency care including hospital admission (Bateman 2005; James 2016) and can be performed as the Papworth
2008; Eisner 2012; To 2012; Nunes 2017). Asthma affects around method, Buteyko breathing technique, yoga or any other similar
1% to 18% of the population worldwide. Annually, the number of intervention that manipulates the breathing pattern (Ram 2003;
asthma deaths is about 180,000 with a wide variation between age, Denehy 2016).
economic groups, continents and regions (GINA 2018; WHO 2018).
How the intervention might work
Some chronic respiratory diseases, such as asthma, have been
In people with asthma, the presence of dysfunctional breathing
commonly associated with dysfunctional breathing patterns
independently of hyperventilation can contribute to dyspnoea.
(Veidal 2017). The prevalence of dysfunctional breathing in people
Breathing exercises are a commonly used approach for correcting
with asthma was reported as ranging from 29% to 64% (Courtney
dysfunctional breathing. The breathing retraining programme
2017). Some of the mechanisms regarding the dysfunctional
aims to help people with asthma in their daily life or when
breathing include multiple dimensions. These dimensions are
experiencing dyspnoea by teaching them to breathe using a
biochemical, biomechanical and psychophysiological and refer to
better breathing pattern. The protocols for training of breathing
hyperventilation, to breathing pattern disorders and to interactions
usually pay attention to tidal and minute volume and encourage
of physiology with cognitive and emotional factors, respectively
relaxation, exercise at home, the modification of breathing pattern,
(Courtney 2017). Dysfunctional breathing may occur in different
nasal breathing, holding of breath, and lower rib cage and
forms, with hyperventilation syndrome one of the most well known
abdominal breathing (Courtney 2017; Sankar 2018). Breathing
forms, affecting a third of people with asthma (Grammatopoulou
training is usually a multi-component intervention that aims at
2014; Boulding 2016; Vidotto 2019). One of the major symptoms
behavioural change and involves many different methods and
is breathlessness that may occur associated with hyperventilation
techniques of breathing exercises such as Buteyko method, yogic
and respiratory alkalosis. However, the breathlessness is not
breathing, Papworth method and deep diaphragmatic breathing
always caused only by hyperventilation or the presence of an
(Bailey 2016). When breathing retraining appropriately targets the
abnormal breathing pattern. The changes in breathing pattern
biochemical, biomechanical or psychophysiological dimensions
are a result of a physiological response (Thomas 2001; Morgan
of dysfunctional breathing, asthma control, medication usage,
2002). In addition, psychological symptoms may interfere with the
dysfunctional breathing symptoms and quality of life can be
severity of the respiratory symptoms and may influence patients'
improved (Courtney 2019). The biochemical and biomechanical
quality of life (Rimington 2001; Juniper 2004; Lavoie 2005). Thus,
dimensions can respond to breathing protocols when they target
an important component of asthma management is identifying
Informed decisions.

hyperventilation, control of breathing volume, relaxation of Types of outcome measures

hypertonic respiratory muscles, and teach patients to adopt a
Primary outcomes
• Quality of life
more normal breathing pattern, whether they have dyspnoea or
not. Regarding the psychophysiological dimension of dysfunctional
breathing, breathing retraining can cover important aspects
Secondary outcomes
• Asthma symptoms and hyperventilation symptoms (e.g.
involving relaxation techniques, and emotional and mental self-
regulations tools to decrease hyperarousal and anxiety (Courtney
2017; Courtney 2019). measures of dyspnoea or breathlessness with Borg score or
• Number of acute exacerbations (mean number and number of

visual analogue scale)
Why it is important to do this review
• Inpatient hospitalisation episodes

The worldwide high prevalence of asthma has become a public participants experiencing one or more exacerbations)
health problem because of the high healthcare costs resulting
• Physiological measures: lung function and functional capacity
from hospitalisation and medication. It causes a high number of
• General practitioner (GP) or hospital outpatient appointments

missed work days and can result in early permanent disability and
premature death. In general, asthma-related costs are very high
• Days off work

(Giavina-Bianchi 2010; Nunes 2017). Breathing exercises have been or both
• Participant's subjective evaluation of the intervention

widely used as an adjunct therapy in the treatment of people with
asthma, generating considerable interest among researchers to
develop studies that seek to show evidence of the effectiveness of
this intervention. Search methods for identification of studies
This is an update of a review last published in 2013, in which Electronic searches

the review authors concluded that no conclusive evidence was We identified studies from the Cochrane Airways Trials Register,
provided to support or refute the benefits of breathing exercises in which is maintained by the Information Specialist for the Group.
people with asthma. Since 2013, new studies have been conducted The Cochrane Airways Trials Register contains studies identified
to evaluate the effects of breathing exercises on quality of life, from several sources:
symptom control and lung function in people with asthma. Thus,
within this review update, we aim to summarise and assess 1. monthly searches of the Cochrane Central Register of Controlled
evidence from randomised controlled trials (RCT) showing the Trials (CENTRAL), through the Cochrane Register of Studies;
efficacy of breathing exercises in the treatment of adults with 2. weekly searches of MEDLINE Ovid SP 1946 to date;
asthma. 3. weekly searches of Embase Ovid SP 1974 to date;
OBJECTIVES 4. Monthly searches of PsycINFO Ovid SP 1967 to date;
5. Monthly searches of CINAHL EBSCO (Cumulative Index to
To evaluate the evidence for the efficacy of breathing exercises in Nursing and Allied Health Literature) 1937 to date;
the management of people with asthma. 6. Monthly searches of AMED EBSCO (Allied and Complementary
Medicine) all years to date;
METHODS
7. handsearches of the proceedings of major respiratory
Criteria for considering studies for this review conferences.
Types of studies Studies contained in the Trials Register are identified through
search strategies based on the scope of Cochrane Airways. Details
RCTs of breathing exercises in adults with asthma. of these strategies, as well as a list of handsearched conference
proceedings are in Appendix 2. See Appendix 3 for search terms
Types of participants
used to identify studies for this review.
Adults with physician-diagnosed asthma or diagnosis by
internationally established criteria, or both: American Thoracic For the previous version of this review (Freitas 2013), searches
Society (ATS), European Respiratory Society (ERS) or British were conducted up to January 2013. For this version, the literature
Thoracic Society (BTS). Participants may be either community- or search has been updated to 4 April 2019. This review update
hospital-based. includes searches conducted in April 2003, February 2012, January
2013, December 2016, December 2017, and April 2019.
To operationalise the age criteria, the mean age of the participants
should be over 18 years old. Searching other resources
We looked for additional studies by consulting reference
Types of interventions
lists of relevant articles found by the above methods. We
Intervention: adults with asthma who have been assigned to searched the US National Institutes of Health Ongoing Trials
treatment comprising breathing retraining Register ClinicalTrials.gov (www.clinicaltrials.gov), and the World
Health Organization International Clinical Trials Registry Platform
Comparison: control group receiving asthma education or, (apps.who.int/trialsearch), to look for planned, ongoing and
alternatively, no active control group (e.g. waiting list control) unpublished studies.

Informed decisions.

Data collection and analysis Dealing with missing data

Selection of studies We wrote to authors of included studies to request additional data
as required.
Two review authors (KMPPM and TAS) independently assessed
studies for the possibility of inclusion in this review. We retrieved Assessment of heterogeneity
full-text articles and reviewed them to determine eligibility. We
resolved final decisions and disagreements by consultation with We assessed heterogeneity by inspecting the forest plots to detect
a third review author (DAF). We recorded the selection process in non-overlapping CIs, while applying the Chi2 test with a P value
sufficient detail to complete a PRISMA flow diagram (Moher 2009), of 0.10 indicating statistical significance. We also implemented
and 'Characteristics of excluded studies' table. the I2 statistic, with a value of 50% denoting moderate levels
of heterogeneity and above 50% indicating a substantial level of
Data extraction and management heterogeneity (Deeks 2017).
Two review authors (KMPPM and GAAF) independently extracted Assessment of reporting biases
data into Review Manager 5 (Review Manager 2014), by using a
standard data collection form. According to methods described If we had been able to meta-analyse sufficient data (10 studies
in the Cochrane Handbook for Systematic Reviews of Interventions or more), we planned to assess reporting bias among the
(Higgins 2011), we collected information from the studies, including studies using the funnel plot method discussed in the Cochrane
the following. Handbook for Systematic Reviews of Interventions (Sterne 2017).
• Methods (design, method of randomisation, method of

If asymmetry was noted, we planned to explore possible causes,
including publication bias, poor methodological quality and true
allocation concealment, outcome assessor blinding, withdrawal heterogeneity.
• Participants (country, health status, mean age, gender, total

and dropouts)
Data synthesis
• Interventions (methods and types of intervention, including

sample and exclusion criteria) We used Cochrane's statistical package, Review Manager 5, to
combine outcomes when possible (Review Manager 2014). We
number and duration of sessions and methods used for control used the random-effects method, which considers that different
• Outcomes (improvement in quality-of-life indices, asthma

group comparisons) studies are estimating different, yet related, intervention effects
(DerSimonian 1986). For studies with more than two arms, we split
symptoms, number of acute exacerbations, inpatient the control group to avoid double counting.
hospitalisation episodes, etc)
Subgroup analysis and investigation of heterogeneity
We resolved disagreements by discussion and consensus with a If we were able to combine sufficient data and identify substantial
third review author (GSSC).
heterogeneity (an I2 statistic value greater than 50%), we planned
Assessment of risk of bias in included studies to conduct the following subgroup analyses.
•
•
Two review authors (KMPPM and TAS) independently assessed Degree of asthma severity
•
the risk of bias using the Cochrane tool for assessing risk Age groups (adult versus elderly)
of bias, which includes the following items: random sequence
•
Duration of treatment
generation, allocation concealment, blinding of participants and
Type of breathing exercise
personnel, blinding of outcome assessment, incomplete outcome
data, selective reporting and other sources of bias. We classified Sensitivity analysis
risk of bias as high, low or unclear, according to the methods
described in Chapter 8 of the Cochrane Handbook for Systematic If we had been able to combine sufficient data, sensitivity analysis
Reviews of Interventions (Higgins 2017). We resolved disagreements would have been performed to explore the influence on the results
by discussion and consensus with a third review author (GSSC). of the following factors.
• Study quality (RCTs with poor methodology)

• Study size (stratified by sample size)
Measures of treatment effect
• Allocation concealment (high risk of bias versus low risk of bias

We expressed continuous outcomes as mean difference (MD) with
95% confidence interval (CI) when outcome measurements were
• Assessor blinding (high risk of bias versus low risk of bias versus
performed on the same scale. We planned to use standardised versus unclear risk of bias)
mean difference (SMD) with 95% CI if studies assessed an outcome
by using different methods. We expressed dichotomous outcomes unclear risk of bias)
as odds ratio (OR) with 95% CI.
Summary of findings and assessment of the certainty of the
We used intention-to-treat (ITT) analyses where they are reported evidence
instead of per-protocol/completer analyses. We created a 'Summary of findings' table that included the
following outcomes, according to the methods described in
Unit of analysis issues
Chapter 11 of the Cochrane Handbook for Systematic Reviews
We did not include studies with a cross-over or cluster-randomised of Interventions: change in quality of life measured by the
design in the review. Asthma Quality of Life Questionnaire (AQLQ), change in asthma

Informed decisions.

symptoms measured by the Asthma Control Questionnaire 1998; Thomas 2003; Holloway 2007; Sodhi 2009; Thomas 2009;
(ACQ), change in hyperventilation symptoms measured by the Vempati 2009; Grammatopoulou 2011; Bidwell 2012; Singh 2012;
Nijmegen Questionnaire, number of acute exacerbations, inpatient Prem 2013). For this 2019 update, the most recent search was 4 April
hospitalisation episodes, and lung function (Forced Expiratory 2019. The database searching returned 245 references, resulting
Volume in 1 second (FEV1)), and days off work. in 176 references after removing duplicates. Four additional
references were obtained by searching other sources, resulting in
We determined the quality of the evidence using the GRADE 180 references. Of these, we identified 19 as potentially relevant,
approach and GRADEproGDT software (GRADEpro GDT). We and we retrieved the full-text articles for closer inspection. We
justified all decisions to downgrade the quality of studies in added 11 of these (relating to nine studies) as new additions in the
footnotes, and made comments to aid readers' understanding of 2019 update (Aggarwal 2013; Gupta 2015; Prasanna 2015; Agnihotri
the review where necessary. 2016; Satpathy 2016; Thomas 2017; Agnihotri 2018; Malarvizhi 2018;
Pushpa 2018). See 'Figure 1' for full details on the results of the
RESULTS search.
Description of studies
Results of the search
The previous version of the review (Freitas 2013), included 13
studies (Nagarathna 1985; Girodo 1992; Fluge 1994; Vedanthan


Informed decisions.

Figure 1. Study flow diagram

Informed decisions.

Included studies the yoga exercises properly. In Aggarwal 2013 and Gupta 2015,
participants performed yoga for three months. In Satpathy 2016,
In total, 22 studies are included in this review (Nagarathna 1985;
participants in intervention group performed yogic exercises daily
Girodo 1992; Fluge 1994; Vedanthan 1998; Thomas 2003; Holloway
early in the morning under the guidance of a yoga instructor over
2007; Sodhi 2009; Thomas 2009; Vempati 2009; Grammatopoulou
four months. In Agnihotri 2016 and Agnihotri 2018, participants
2011; Bidwell 2012; Singh 2012; Aggarwal 2013; Prem 2013; Gupta
performed yoga sessions for 30 minutes per day, five days a
2015; Prasanna 2015; Agnihotri 2016; Satpathy 2016; Thomas 2017;
week over six months. In Malarvizhi 2018, participants received 30
Agnihotri 2018; Malarvizhi 2018; Pushpa 2018). Of these, two
minutes of yoga training for a week under a trained yoga teacher
included studies have one additional report that was collected
and were advised to practise at home daily once a day for six
under a single study ID (Sodhi 2009; Thomas 2017). Therefore, we
months. In Pushpa 2018, participants practised yoga exercises for
included 22 studies reported in 24 reports. We included 14 studies in
45 minutes a day over two weeks and were instructed to practise
the quantitative synthesis (Vedanthan 1998; Holloway 2007; Sodhi
at home for 45 minutes twice daily, regularly for the remaining six
2009; Thomas 2009; Vempati 2009; Grammatopoulou 2011; Bidwell
weeks and were instructed to maintain a diary record of each day
2012; Singh 2012; Aggarwal 2013; Prem 2013; Gupta 2015; Agnihotri
of yoga practice.
2016; Thomas 2017; Pushpa 2018). See 'Characteristics of included
studies' for full details on each study and Table 1 for an overview of In the Girodo 1992 study, participants undertook a 16-week
the characteristics of the included studies. programme of deep diaphragmatic breathing exercises and were
compared against a group of controls that were on a waiting
Setting and populations
list. Thomas 2003 compared participants who completed three
Thirteen studies were conducted in India (Nagarathna 1985; short breathing retraining sessions (total contact time 75 minutes),
Sodhi 2009; Vempati 2009; Singh 2012; Aggarwal 2013; Prem taught by a physiotherapist, with a control group that received
2013; Gupta 2015; Prasanna 2015; Agnihotri 2016; Satpathy 2016; asthma education from a nurse. In Holloway 2007, the intervention
Agnihotri 2018; Malarvizhi 2018; Pushpa 2018), one in Canada group completed five 60-minute individual sessions on the
(Girodo 1992), one in Germany (Fluge 1994), four in the UK Papworth method provided by a respiratory physiotherapist.
(Thomas 2003; Holloway 2007; Thomas 2009; Thomas 2017), two The control group received no additional treatment. In Thomas
in the USA (Vedanthan 1998; Bidwell 2012) and one in Greece 2009, the breathing training group attended three sessions (one
(Grammatopoulou 2011). All papers were written in English with small group session and two individual sessions) that provided
the exception of Fluge 1994, which was written in German. Seven an explanation of normal breathing and possible effects of
studies were conducted between 2014 and 2019, 11 studies were abnormal 'dysfunctional breathing'. During individual sessions,
conducted between 2003 and 2013, three were conducted between participants were taught diaphragmatic and nasal breathing
1992 and 1998 and one was conducted in 1985. The studies varied in techniques and were encouraged to practise these exercises for
size from 17 to 655 participants. Participants in the included studies at least 10 minutes per day. The control group received three
were older than 18 years of age, with the exception of Nagarathna sessions of nurse-provided asthma education. The intervention
1985 (aged 9 to 47), Thomas 2003 (aged 17 to 65) and Holloway 2007 group in the Grammatopoulou 2011 study received 12 individual
and Thomas 2017 (aged 16 to 70), Agnihotri 2016 and Agnihotri 2018 breathing retraining sessions, and the control group received
(aged 12 to 60). We included all studies as the mean age was over 18. usual asthma care. Prem 2013 divided 120 participants into
three groups: Buteyko, yoga and control. Participants assigned
Interventions and control groups to Buteyko or yoga groups received three to five days of
In fourteen studies (Nagarathna 1985; Fluge 1994; Vedanthan 1998; sessions totaling 60 minutes each day. Participants in the control
Sodhi 2009; Vempati 2009; Bidwell 2012; Singh 2012; Aggarwal group followed routine physician care involving pharmacological
2013; Gupta 2015; Agnihotri 2016; Satpathy 2016; Agnihotri 2018; management. Prasanna 2015 instructed participants to perform
Malarvizhi 2018; Pushpa 2018), participants undertook yoga Buteyko breathing exercises at least twice a day for a period of two
exercises that involved pranayama breathing exercises as the major months, and the control group used only inhaled corticosteroids.
component, and the control groups did not undergo yoga training Thomas 2017 divided participants into three groups: breathing
but continued taking their usual medication. In Nagarathna 1985, retraining group using DVD and booklet format, face-to-face
participants in the intervention group underwent training for two physiotherapy and a usual care group.
weeks and were told to practise these exercises for 65 minutes
Outcomes
daily. In Fluge 1994, participants underwent 15 yoga sessions over
three weeks. In Vedanthan 1998, yoga sessions were performed The primary outcome in seven studies (Holloway 2007; Thomas
three times a week over 16 weeks. In Sodhi 2009, each yoga 2009; Bidwell 2012; Prem 2013; Thomas 2017; Agnihotri 2018;
training session was of 45 minutes' duration per week with a Malarvizhi 2018), was quality of life, although the studies used
trained instructor for a period of eight weeks. In Vempati 2009, the different instruments (SGRQ in Holloway 2007 and Bidwell 2012,
intervention consisted of two-week supervised training in lifestyle AQLQ in Thomas 2009, Prem 2013, Thomas 2017, and Malarvizhi
modification and stress management based on yoga followed by 2018, and MiniAQLQ in Agnihotri 2018). Asthma symptoms as
closely monitored continuation of these practices at home for six measured by the Asthma Control Test (ACT) score were the main
weeks. In Bidwell 2012, yoga training consisted of two, one-hour outcome in Grammatopoulou 2011. In Vempati 2009, pulmonary
supervised yoga sessions per week for 10 weeks. In Singh 2012, function was the primary outcome.
participants attended yoga training provided by a yoga expert for
five to six days. Thereafter, participants were told to practise yoga Lung function was the secondary outcome for Holloway 2007,
for an average of 40 to 50 minutes daily at home for two months. Thomas 2009, Grammatopoulou 2011, and Thomas 2017. Asthma
Participants were called to the yoga centre regularly (about every symptoms measured by the Asthma Control Questionnaire (ACQ)
seven days) so investigators could see whether they were doing were a secondary outcome in Thomas 2009 and Thomas
Informed decisions.

2017. In addition, Thomas 2003, Thomas 2009, Holloway 2007 1998; Prasanna 2015), and lung function and quality of life (Sodhi
and Thomas 2017assessed hyperventilation symptoms by the 2009; Singh 2012).
Nijmegen Questionnaire. Grammatopoulou 2011 and Vempati 2009
assessed quality of life as a secondary outcome, measured by the Excluded studies
Short Form (SF)-36 v2 Health Survey and by the AQLQ, respectively. After we had retrieved the full text of potentially eligible studies,
we excluded a total of 48 studies from the review. Two previously
The other included studies did not specify primary and secondary
included studies had been excluded in the 2012 update (Bowler
outcomes, but the study authors reported several main outcome
1998; Opat 2000). We have described reasons for exclusion in the
measures, including pulmonary function (Fluge 1994; Aggarwal
Characteristics of excluded studies.
2013; Gupta 2015; Agnihotri 2016; Pushpa 2018), asthma symptoms
(Girodo 1992), number of acute exacerbations and pulmonary Risk of bias in included studies
function (Nagarathna 1985), quality of life and asthma symptoms
(Thomas 2003), asthma symptoms and lung function (Vedanthan Full details of 'Risk of bias' judgments can be found in
Characteristics of included studies and in Figure 2.


Informed decisions.

Figure 2. 'Risk of bias' summary: review authors' judgements about each 'Risk of bias' item for each included study


Informed decisions.

Figure 2. (Continued)

Allocation or asthma education, as compliance is critical to the study;
therefore we judged these studies to have a high risk of bias.
Nine studies reported adequate sequence generation and we
However, it is possible to blind the assessor who is analysing the
judged them to have low risk of bias (Thomas 2003; Holloway 2007;
results of the study. One study reported that participants were
Sodhi 2009 Grammatopoulou 2011; Prem 2013; Agnihotri 2016;
blinded, however due to the type of intervention used in the study
Thomas 2017; Agnihotri 2018; Malarvizhi 2018).
arms, it is likely that the blinding could have been broken. We
Thomas 2003 recruited individuals with high Nijmegen therefore judged this study to have a high risk of bias (Malarvizhi
Questionnaire scores who were currently being treated for asthma 2018).
at a general practice. They assigned volunteers randomly by
Only one study reported blinded outcome assessment, however
numbering them alphabetically and using random number tables
the outcome was patient-rated, which could introduce high risk of
to assign them to study groups. Holloway 2007, undertook
detection bias (Malarvizhi 2018). Six studies said that blinding was
randomisation by a computer-generated number sequence that
not possible; we judged these studies to have a high risk of bias,
assigned consecutive participant ID numbers a 1 or a 2 to
as we determined that the outcomes may have been influenced
denote intervention or a control condition. Sodhi 2009 randomised
by the lack of blinding (Thomas 2003; Holloway 2007; Thomas
participants in two groups (Yoga and control) using permuted
2009; Vempati 2009; Grammatopoulou 2011; Thomas 2017). Nine
block randomisation. Grammatopoulou 2011 undertook random
studies did not describe blinding and we considered the assessed
allocation with sealed envelopes. Prem 2013 assigned participants
outcomes to be patient-rated, so we judged them to have a high
to three groups (Buteyko, yoga and control) through block
risk of bias (Girodo 1992; Vedanthan 1998; Sodhi 2009; Bidwell 2012;
randomisation. Agnihotri 2016 and Agnihotri 2018 undertook
Singh 2012; Prem 2013; Prasanna 2015; Satpathy 2016; Agnihotri
randomisation by a computer-generated random number table.
2018). Six studies did not report any procedures intended to blind
Thomas 2017 used the web based Tenalea randomisation system.
the participants and outcome assessors (Nagarathna 1985; Fluge
Malarvizhi 2018 randomised participants by using a random
1994; Aggarwal 2013; Gupta 2015; Agnihotri 2016; Pushpa 2018), so
allocation software.
we judged them to have unclear risk of bias.
Thirteen studies reported that they were randomised but gave no
Incomplete outcome data
description of the methods used, and we therefore judged them
to be at unclear risk of bias (Nagarathna 1985; Girodo 1992; Fluge Seven studies did not describe the occurrence of withdrawals and
1994; Vedanthan 1998; Thomas 2009; Vempati 2009; Bidwell 2012; dropouts and we judged them to be at unclear risk of bias (Girodo
Singh 2012; Aggarwal 2013; Gupta 2015; Prasanna 2015; Satpathy 1992; Sodhi 2009; Aggarwal 2013; Gupta 2015; Prasanna 2015;
2016; Pushpa 2018). Satpathy 2016; Pushpa 2018). Nagarathna 1985 affirmed that in
total 25 participants dropped out of the study, however, we judged
Only four studies described adequate allocation concealment and this study to have an unclear risk of bias because it did not describe
we judged them to have low risk of bias (Grammatopoulou 2011; the reasons, nor how many participants dropped out of the study in
Prem 2013; Thomas 2017; Malarvizhi 2018). Grammatopoulou each group (intervention and control). Three studies did not report
2011 concealed allocation with sealed envelopes, and Prem 2013 any withdrawals or dropouts; we judged these studies to have a low
concealed allocation in sequentially numbered, sealed, opaque risk of bias (Vedanthan 1998; Grammatopoulou 2011; Bidwell 2012).
envelopes. Thomas 2017 randomly allocated participants to one of Seven studies described withdrawals and dropouts and we judged
the three study arms by using a telephone call service. Malarvizhi them to have a low risk of bias too, because the missing outcome
2018 randomly allocated participants to one of the two study arms data were balanced in numbers across intervention groups and
by using random allocation software. The other eighteen studies the reasons were similar (Thomas 2003; Holloway 2007; Thomas
gave no description of the methods of allocation concealment 2009; Thomas 2017) or because the reasons for missing outcome
used and we therefore judged them to have unclear risk of bias data were unlikely to be related to true outcomes (Fluge 1994;
(Nagarathna 1985; Girodo 1992; Fluge 1994; Vedanthan 1998; Singh 2012; Prem 2013). Four studies described withdrawals and
Thomas 2003; Holloway 2007; Thomas 2009; Vempati 2009; Sodhi dropouts. However, the reasons for missing outcome data were not
2009; Bidwell 2012; Singh 2012; Aggarwal 2013; Gupta 2015; clearly described. Thus, we judged them to be at unclear risk of bias
Prasanna 2015; Agnihotri 2016; Satpathy 2016; Agnihotri 2018; (Vempati 2009; Agnihotri 2016; Agnihotri 2018; Malarvizhi 2018).
Pushpa 2018).
Selective reporting
Blinding
Two studies were registered on clinicaltrials.gov, another one on
Blinding of the investigator and the participant involved is not ISRCTN register, and all of the prespecified primary and secondary
possible or practical in these studies. Participants in these studies outcomes were reported in the prespecified way (Holloway 2007;
must know whether or not they are undertaking breathing training Vempati 2009; Thomas 2017). We judged these studies to have a

Informed decisions.

low risk of selective reporting bias. Thirteen studies adequately the meta-analysis for the assessed outcomes by pooling the
reported outcome data for all outcomes as listed in the methods available data by the last time point of assessments after their
and were therefore assessed as low risk of bias, although none baseline. For all outcomes, we pooled data at up to three months,
of the protocols for these studies are available (Nagarathna 1985; from four to six months, and over six months.
Thomas 2003; Sodhi 2009; Thomas 2009; Grammatopoulou 2011;
Singh 2012; Aggarwal 2013; Gupta 2015; Agnihotri 2016; Satpathy Breathing exercises versus inactive control
2016; Agnihotri 2018; Malarvizhi 2018; Pushpa 2018). We judged six Primary outcome: quality of life
studies to be at high risk of bias because they reported one or more
outcomes of interest in the review incompletely (Girodo 1992; Fluge Ten studies involving 1706 participants reported quality of life
1994; Vedanthan 1998; Bidwell 2012; Prem 2013; Prasanna 2015). (Holloway 2007; Sodhi 2009; Vempati 2009; Grammatopoulou 2011;
Bidwell 2012; Singh 2012; Prem 2013; Thomas 2017; Agnihotri 2018;
Other potential sources of bias Malarvizhi 2018). We included six of these studies in meta-analysis
(Holloway 2007; Vempati 2009; Bidwell 2012; Prem 2013; Thomas
We were unable to identify any other potential biases in five studies
2017; Agnihotri 2018).
(Thomas 2003; Holloway 2007; Grammatopoulou 2011; Prem 2013;
Thomas 2017). We judged 17 studies to be at unclear risk of bias, For the outcome 'Change in AQLQ', which included Vempati
as they did not provide sufficient information to allow assessment 2009, Prem 2013, Thomas 2017 and Agnihotri 2018, meta-analysis
of whether an important risk of bias is present (Nagarathna showed significant differences favouring the intervention group
1985; Girodo 1992; Fluge 1994; Vedanthan 1998; Sodhi 2009; (MD 0.42, 95% CI 0.17 to 0.68; 4 studies, 974 participants; Analysis
Thomas 2009; Vempati 2009; Bidwell 2012; Singh 2012; Aggarwal 1.1; Figure 3), however we observed substantial heterogeneity (Chi2
2013; Gupta 2015; Prasanna 2015; Agnihotri 2016; Satpathy 2016;
= 20.85, df = 5 (P = 0.0009); I2 = 76%). Thomas 2017 reported that
Agnihotri 2018; Malarvizhi 2018; Pushpa 2018).
64.4% of participants in the physiotherapy group, 61.7% in the
Effects of interventions DVD group and 55.7% in the control group reported a clinically
significant improvement on AQLQ assessment after six months,
See: Summary of findings for the main comparison Breathing higher than the minimal clinically important difference (MCID)
exercises compared to inactive control for adults with asthma of 0.5 (Juniper 2004). However, due to an improvement in both
the intervention and control groups, there was uncertainty in the
The included studies had different durations, with multiple time between-group difference (OR 1.34, 95% CI 0.97 to 1.86, P = 0.07; 1
points. So, to deal with methodological differences, we performed study, 655 participants; Analysis 1.2; Figure 4).


Informed decisions.

Figure 3. Forest plot of comparison 1. Breathing exercises versus inactive control, outcome 1.1: change in AQLQ (up
to 3 months)

Figure 4. Forest plot of comparison 1. Breathing exercises versus inactive control, outcome 1.2: change in AQLQ
(over 6 months)

Thomas 2017 also reported the number needed to treat for one quality of life of 7 and 8 for the physiotherapy and DVD arm,
participant to have a clinically relevant improvement (NNTB: respectively, compared with the usual-care arm.
number needed to treat for an additional beneficial outcome) in

Informed decisions.

The outcome 'Change in SGRQ', included Holloway 2007 and was not shown (MD 0.63, 95% CI −0.90 to 2.17; 2 studies, 521
Bidwell 2012 in two different time points (six months and three participants; Analysis 1.7).
months, respectively). However, due to the high heterogeneity, we
could not pool data. Higher scores in SGRQ indicate worse quality Four studies (Girodo 1992; Vedanthan 1998; Prasanna 2015;
of life and a change of 4 units was established as a MCID (Jones Satpathy 2016), did not report sufficient data to enter the meta-
2002). In Bidwell 2012, the mean score change after three months analysis. Of these, one study reported no clear difference in asthma
from baseline was very large and was higher than the MCID (16.01 symptoms between yoga and control groups mean 7.0 (SD 10.16)
units in the breathing exercises group and 31.85 units in the control and mean 1.75 (SD 24.24); P > 0.05 (Vedanthan 1998). Girodo 1992
group). In order to visualise the data, we included the second time did not observe significant changes in frequency of symptoms
point of 12 months, evaluated in Holloway 2007, in the graphic and on the Asthma Symptom Checklist in any group. Prasanna
it shows a tendency to an improvement of quality of life favouring 2015 reported improvement of asthma symptoms between the
the breathing exercises group (Analysis 1.3). intervention and control groups (P < 0.05). Satpathy 2016 showed
a difference in the proportion of participants, in both groups, who
We were not able to include the other four studies in the presented lower frequency of asthma symptoms assessed by the
meta-analysis (Sodhi 2009; Grammatopoulou 2011; Singh 2012; Asthma Symptom Score.
Malarvizhi 2018). Of these, Sodhi 2009 found improvement in
three domains (symptoms, activities and environment) and in Secondary outcome: number of acute exacerbations
total scores of the AQLQ in the yoga group compared with the Four studies reported this outcome (Nagarathna 1985; Sodhi
control group (P < 0.01). Grammatopoulou 2011 showed that the 2009; Satpathy 2016; Thomas 2017), however they did not report
group that performed breathing exercises improved the physical sufficient data to enter the meta-analysis. Nagarathna 1985 showed
component of the SF-36 quality-of-life questionnaire compared a decrease in the number of exacerbations per week between
with controls in all assessments (two, three and six months after intervention and control groups, with mean 0.83 (SD 2.49) and
intervention, with P value of 0.003, 0.0002 and 0.066, respectively). mean 2.1 (SD 2.7), (P < 0.005). Sodhi 2009 found a decrease in
Singh 2012 observed a significant difference favouring the group the number of acute exacerbations per week between intervention
submitted to the intervention, with P < 0.001 for all four domains and control groups from baseline up to eight weeks, with mean
of the AQLQ. Agnihotri 2018 reported AQLQmini at six months 0.38 (SD 0.48) and mean 0.58 (SD 0.53); P < 0.05. Satpathy 2016
as well as three months, but we could not combine data from showed a decrease (P < 0.01) in the number of participants who
Agnihotri 2018 with Thomas 2017 at six months. Agnihotri 2018 had acute exacerbation between baseline and four months post-
found an improvement between breathing exercise and control intervention in the intervention group. Thomas 2017 assessed
group (mean 5.72 (standard deviation (SD) 0.38) and mean 5.43 (SD asthma exacerbations by the use of oral corticosteroids. Results
0.34) respectively). Finally, we could not include Malarvizhi 2018 from Thomas 2017 showed no statistically significant difference
in the meta-analysis due to a discrepancy between the graphical between the intervention and control groups. In Thomas 2017, the
presentation and the data provided by correspondence. percentage of participants of the physiotherapy, DVD and control
groups that showed more than one oral corticosteroid courses
Secondary outcome: asthma symptoms and hyperventilation
(asthma exacerbations) after 12 months was 11.36%, 9.20% and
symptoms
14.89%, respectively.
Six studies involving 1055 participants reported asthma symptoms
(Girodo 1992; Vedanthan 1998; Prem 2013; Prasanna 2015; Secondary outcome: physiological measures
Satpathy 2016; Thomas 2017). Of these, two studies used the Sixteen studies involving 1951 participants assessed lung function
Asthma Control Questionnaire (ACQ) (Prem 2013; Thomas 2017), (Nagarathna 1985; Fluge 1994; Vedanthan 1998; Holloway 2007;
and we included them in the meta-analysis. Three studies involving Sodhi 2009; Vempati 2009; Grammatopoulou 2011; Bidwell 2012;
780 participants reported hyperventilation symptoms (Holloway Singh 2012; Aggarwal 2013; Prem 2013; Gupta 2015; Prasanna 2015;
2007; Grammatopoulou 2011; Thomas 2017), by using the Nijmegen Agnihotri 2016; Thomas 2017; Pushpa 2018). Of these, we included
Questionnaire. 11 studies in meta-analysis (Vedanthan 1998; Holloway 2007; Sodhi
2009; Vempati 2009; Singh 2012; Aggarwal 2013; Prem 2013; Gupta
For the outcome 'Change in ACQ', we performed meta-analysis
2015; Agnihotri 2016; Thomas 2017; Pushpa 2018). Five studies did
including data from up to three months and over six months.
not report sufficient data to enter the meta-analysis (Nagarathna
However, we included only one study for each analysis (Prem 2013
1985; Fluge 1994; Grammatopoulou 2011; Bidwell 2012; Prasanna
and Thomas 2017, respectively); note that each study has three
2015).
arms. The differences between the intervention and control groups
from up to three months (MD −0.15, 95% CI −2.32 to 2.02; 1 study, For FEV1 (L) measured at up to three months, we observed no clear
115 participants; Analysis 1.4), and over six months (MD −0.08, 95%
difference between intervention and control groups (MD −0.10 L,
CI −0.22 to 0.07; 1 study, 449 participants; Analysis 1.5) were both
95% CI −0.32 to 0.12; I2 = 61%; 4 studies, 252 participants; Analysis
uncertain.
1.8). Although the MCID in FEV1 has not been rigorously established
For the outcome 'Change in Nijmegen', we performed meta- for asthma, the magnitude of the MD found of 0.1 L is likely to
analysis including data from four to six months (Holloway 2007; have a clinical relevance (Enright 2004; Tepper 2012). For FEV1
Grammatopoulou 2011), and over six months (Holloway 2007; % of predicted, we found a difference favouring the intervention
Thomas 2017). Meta-analysis showed differences favouring the group (MD 6.88 % predicted, 95% CI 5.03 to 8.73; 5 studies, 618
intervention group for hyperventilation symptoms from baseline participants; Analysis 1.9). When measured at over six months, no
to four to six months (MD −3.22, 95% CI −6.31 to −0.13; 2 studies, clear differences were observed in FEV1 in litres (MD −0.02 L, 95% CI
118 participants; Analysis 1.6). For over six months, improvement −0.08 to 0.04; 2 studies, 491 participants; Analysis 1.10), and in % of
Informed decisions.

predicted (MD 0.49 % predicted, 95% CI −2.48 to 3.46; 1 study, 424 Thomas 2003 showed that the median (IQR) changes in overall
participants; Analysis 1.11). asthma quality-of-life score at one month were 0.6 (IQR 0.05 to
1.12) and 0.09 (IQR −0.25 to 0.26) for the breathing retraining and
For the outcome peak expiratory flow rate, measured at up to three education groups, respectively (P = 0.018) after one month. After six
months, we observed a difference favouring the intervention group, months, only the improvement in the activities domain of the AQLQ
however there was substantial heterogeneity among the studies was clearly greater in the breathing retraining than in the education
(Analysis 1.12). We were able to perform a meta-analysis including group (0.83 (IQR −0.10 to 1.71) and −0.05 (IQR −0.74 to 0.34), P =
two studies with data measured at over six months (Holloway 0.018).
2007; Thomas 2017). Results from this analysis showed no clear
difference favouring the intervention group comparing to control Thomas 2009 showed no clear between-group differences in four
group (MD −1.07, 95% CI −14.89 to 12.74; 2 studies, 491 participants; subdomains, symptoms (MD 0.18, 95% −0.19 to 0.55, P = 0.34),
Analysis 1.13). activities (MD 0.10, 95% CI −0.22 to 0.43, P = 0.53), emotion (MD
−0.07, 95% CI −0.46 to 0.32, P = 0.72), and environment (MD −0.10,
Two studies also assessed capnography (Holloway 2007; 95% CI −0.46 to 0.25, P = 0.56), and for the total score of the AQLQ
Grammatopoulou 2011). Holloway 2007 did not find differences at up to three months' assessment (MD 0.04, 95% CI −0.26 to 0.34;
between intervention and control groups regarding end-tidal 1 study, 183 participants; Analysis 2.1). From four to six months,
carbon dioxide. However, values for relaxed breathing rate over there were greater improvements in the intervention group in terms
a 10-minute period, in breaths per minute (bpm), showed better of the subdomains of symptoms (P = 0.01), activities (P = 0.01)
results in the intervention group than in the control group: mean and emotions (P = 0.05) but not in the environment subdomain (P
10.0 bpm (SD 3.0) and mean 15.3 bpm (SD 2.4); P < 0.001, at = 0.40) compared with controls, with a between-group difference
six months post-baseline, respectively; and mean 9.6 bpm (SD favouring the intervention group (P = 0.01) for the total score (MD
3.7) and mean 15.3 bpm (SD 2.7); P < 0.001 at 12 months post- 0.38, 95% CI 0.08 to 0.68; 1 study, 183 participants; Analysis 2.2).
baseline assessment, respectively. In Grammatopoulou 2011, the
intervention group compared with the control group showed Secondary outcome: asthma symptoms and hyperventilation
increased end-tidal carbon dioxide (mean 37.95 mmHg (SD 2.70) symptoms
and mean 34.90 mmHg (SD 2.91); P = 0.002 for one month post
One study involving 183 participants assessed asthma symptoms
baseline; mean 38.50 mmHg (SD 1.88) and mean 35.15 mmHg (SD
(Thomas 2009). Thomas 2009 carried out assessment of symptoms
2.58); P < 0.0001 for two months post-baseline; and mean 37.90
at baseline and one month and six months after the intervention
mmHg (SD 3.54) and mean 34.60 mmHg (SD 2.91); P = 0.003 for six
which was inconclusive for the ACQ (MD −0.17, 95% CI −0.38 to 0.04,
months post-baseline. The intervention group showed a decreased
P = 0.12).
respiratory rate compared with the control group (P < 0.0001) in all
time point assessments. Two studies, involving 216 participants, used the Nijmegen
Questionnaire to assess hyperventilation symptoms (Thomas 2003;
One study (Thomas 2017), also assessed airway inflammation by
Thomas 2009). In Thomas 2003, the between-group difference
the fraction of exhaled nitric oxide (FeNO) measured in parts
favouring the intervention was statistically significant only after
per billion (ppb). In Thomas 2017, there was no clear difference
six months (median −9.50 (IQR −11.75 to 0), 1.00 (IQR −5.75 to 2),
in the comparison between physiotherapy and control groups
P = 0.01, breathing exercise and education group, respectively).
regarding baseline and 12-month values (P = 0.28; median 19 ppb
We could not use data from Thomas 2003 in the meta-analysis
(interquartile range (IQR) 13 to 33) and median 20 ppb (IQR 13 to
because only median and interquartile range were available.
31). However, a small difference was observed between DVD and
Thomas 2009 found no clear difference favouring the intervention
control groups (P = 0.02; median 20 ppb (IQR 13 to 33) and median
group up to three months (MD −1.24, 95% CI −3.23 to 0.75; 1 study,
20 ppb (IQR 13 to 31), respectively).
183 participants; Analysis 2.3), whereas a difference favoured the
Secondary outcomes: general practitioner (GP) appointments intervention group from four to six months (MD −3.16, 95% CI −5.35
to −0.97; 1 study; 183 participants; Analysis 2.4).
Only one study (Thomas 2017), assessed GP appointments,
from baseline to a 12-month follow-up. Thomas 2017 found no Secondary outcome: physiological measures
clear difference in consultation rates between the physiotherapy
Only one study assessed spirometric values (Thomas 2009). This
intervention group (P = 0.87) or the DVD intervention group than the
study assessed FEV1 (L) and found no clear difference (MD −0.06 L,
control group (P = 0.69).
95% CI −0.13 to 0.00; P = 0.07) between the intervention and control
Secondary outcomes: inpatient hospitalisation episodes, days groups.
off work and subjective evaluation of the intervention
Thomas 2009 also assessed resting end-tidal carbon dioxide
None of the included studies reported these outcomes. concentration, showing that values for this outcome were uncertain
within and between groups (MD 0.08 mmHg, 95% CI −0.15 to 0.30;
Breathing exercises versus asthma education P = 0.51).
Primary outcome: quality of life
Secondary outcomes: numbers of acute exacerbations, inpatient
Two studies involving 216 participants assessed this outcome hospitalisation episodes, general practice (GP) appointments,
(Thomas 2003; Thomas 2009). Both studies had follow-up periods days off work, and subjective evaluation of the intervention
of one and six months.
Neither of these two studies reported these outcomes.

Informed decisions.

DISCUSSION Certainty of the evidence

The certainty of the evidence ranges from moderate to very low
Summary of main results
according to GRADE criteria and we have presented our GRADE
This Cochrane Review assessed available evidence for the efficacy judgements in the 'Summary of findings' table. We downgraded
of breathing exercises in the treatment of adults with asthma. A the evidence for quality of life due to one study being at high
total of 22 studies involving 2880 participants satisfied the inclusion risk of bias for selective reporting. For the outcome asthma
criteria. Although these studies met the inclusion criteria, they symptoms, we downgraded the certainty of evidence because
differed in terms of intervention characteristics, such as type of we included in the analysis only one study with a small sample
breathing exercise, number of participants, number and duration size, and that we considered to be at high risk of bias for
of sessions, reported outcomes and statistical presentation of data. selective reporting. We downgraded the certainty of evidence for
These differences limited the inclusion of several studies in our symptoms of hyperventilation due to the small sample size and
meta-analyses. wide confidence interval presented. For the outcome lung function,
we downgraded the certainty of evidence because the included
We found a probable effect favouring the breathing exercises over studies showed in general a high risk of bias and small sample size.
inactive control in quality of life assessed by AQLQ up to three
months. The mean difference for AQLQ showed in this review was Potential biases in the review process
slightly lower than the MCID of 0.5 (Juniper 2004). For asthma
symptoms, we found no clear difference between the breathing Although we attempted to apply a systematic process for including
exercises and control group. However, the very large confidence and excluding studies in this review, alongside following the
interval includes both clinically relevant benefits and harm. We also criteria prespecified in the protocol, with robust methods for data
found a probable effect for the breathing exercises over inactive collection and 'Risk of bias' assessment, final decisions are open
control and asthma education in symptoms of hyperventilation, to interpretation or criticism. It is also not clear whether some
measured by the Nijimegen Questionnaire from four to six months. of the participants in Agnihotri 2016 were included in the quality
However, the MCID has not been established for the Nijmegen of life reporting in Agnihotri 2018, so although there is no risk of
Questionnaire (van Dixhoorn 2015). For lung function parameter, double counting individuals for the outcomes, the total number of
we found a possible effect for the breathing exercises over inactive individuals studied may have been overstated.
control in FEV1 % of predicted up to three months. No clear effect Incomplete outcome data may be considered a potential source
was found between breathing exercises and inactive control in FEV1 of bias of this review. It is difficult to quantify the impact of
(L) up to three months. this potential bias as we were unable to enter the data from
these studies into a meta-analysis. Also related to meta-analysis,
Overall completeness and applicability of evidence sensitivity analysis was not possible because we were unable to
Despite the broad spectrum of breathing exercises, the findings obtain sufficient data. This would have allowed us to investigate
of this review were based on the techniques that were used in possible effect modifiers such as degree of asthma severity, age
the included studies, which were some of the most commonly groups and duration of treatment. Moreover, sensitivity analysis
used techniques. Those studies included the Papworth method, could have identified the influence of some factors (such as study
Buteyko, diaphragmatic breathing, yoga and breathing retraining quality and study size) on the results; thus, revealing the source
exercises. We found that breathing exercises showed some of the substantial heterogeneity that we found among studies on
probable improvements in quality of life and hyperventilation quality of life and lung function.
symptoms. The types of delivery differed between face-to-face
or by using an audio-visual media self-guided programme.
Agreements and disagreements with other studies or
The self-guided programme is convenient and low-cost (Arden- reviews
Close 2017). Some included studies involved group sessions in The current review update included nine new RCTs. Although
which participants were able to talk to each other and share there is a large number of available studies on this topic, it is
their experiences. This can also be considered as a therapeutic important to emphasise that we found no recent or updated
procedure that may affect the sensation of well-being (Evans systematic review. A previous review performed by Bruurs 2013
1993). Awareness of participation in the study, the sensation of assessed the effectiveness of breathing exercises as physiotherapy
increased care and cure and the specialists' recommendations to in the treatment of people with asthma. The outcomes assessed
continue regular asthma medication, and educational approaches by Bruurs 2013 were based on those measures used in the
are characteristics that must be considered when the findings of an Cochrane Reviews, Dennis 2000 and Holloway 2004, which they
experimental study are interpreted (Grammatopoulou 2011). classified as subjective and objective patient-relevant outcomes
for asthma. Bruurs 2013 reported improvement in quality of
Moreover, asthma severity of participants from the included studies
life and symptoms, and reduction of medication use, but the
ranged from mild to moderate, so it was not possible to assess the
breathing exercises did not affect lung function. The findings of
effects of breathing exercises on participants with severe asthma.
this current review update, based on meta-analysis results, are
The samples from studies consisted solely of outpatients. Besides
consistent with the improvement in asthma symptoms favouring
that, three of the eight outcomes proposed by this review were not
the breathing exercises groups. However, the review of Bruurs 2013
addressed: inpatient hospitalisation episodes, days off work and
presented some methodological differences, regarding the age of
participants' subjective evaluation of the intervention.
participants and the inclusion of other types of physiotherapy,
such as inspiratory muscle training, physical exercises, and airway
clearance techniques. Moreover, Bruurs 2013 did not assess the

Informed decisions.

risk of bias, perform meta-analysis or assess the quality of the investigated. Furthermore, in the future, much more attention
evidence. One Cochrane Review that assessed the effects of yoga in needs to be paid to good reporting and high-quality study design,
people with asthma analysed data from 15 RCTs, where five of them including items such as adequate random sequence generation
included yogic breathing alone and the other studies assessed and allocation concealment, blinding of outcome assessor and
yoga interventions that included breathing exercises, posture, determination of the study sample size before the study is begun.
and meditation (Yang 2016). Similar to our findings, despite the
limitations in the quality of the included studies, Yang 2016 found ACKNOWLEDGEMENTS
improvements in quality of life and symptoms of asthma.
The review authors would like to thank Emma Dennett (the
AUTHORS' CONCLUSIONS Managing Editor of Cochrane Airways) for providing assistance
throughout the review process and Elizabeth Stovold (the
Implications for practice Information Specialist of Cochrane Airways) for performing the
search. We acknowledge the assistance of Christopher Cates in
Breathing exercises may have positive effects on quality of life, relation to the statistical support.
hyperventilation symptoms, and lung function. Due to some
methodological differences among included studies and studies We would also like to thank all the study authors who responded to
with poor methodology, the certainty of evidence for the measured our enquiries.
outcomes ranged from moderate to very low according to GRADE
criteria. In addition, no data are available regarding the effects of The current review authors would like to thank Elizabeth Holloway
breathing exercises on inpatient hospitalisation episodes, days off for the development of the original review and her clinical
work and participants' subjective evaluation of the intervention. expertise, and Selma S Bruno for her previous input into the
development of the 2013 update of this review.
Implications for research
The review authors and Cochrane Airways editorial team are
Well conducted randomised controlled trials are still needed grateful to the following peer reviewers for their time and
to assess the clinical benefit of breathing exercises in the comments:
management of asthma, including people with severe asthma,
and those outcomes that were not assessed by the studies Amanda Roberts, UK (consumer);
included in this review such as inpatient hospitalisation episodes,
days off work and participants' subjective evaluation of the Eleanor Fairbank, UK (consumer);
intervention. It is also important to emphasise the need for
studies with a clear report of the sample age, asthma severity, Negar Jamshidi, RMIT University, Australia (consumer);
and a specific description of the breathing exercise used rather
Johannes C van der Wouden, Amsterdam UMC, Vrije Universiteit,
than the combined interventions. As the Nijimegen Questionnaire
The Netherlands; and
is an important outcome-reported measurement instrument to
assess hyperventilation symptoms, further research is needed Alice Jones, The University of Sydney and The University of
to determine a minimal clinically important difference for this Queensland, Australia.
questionnaire in people with asthma.
The Background and Methods sections of this review are based on
Researchers are encouraged to conduct studies to investigate in the a standard template used by Cochrane Airways.
asthma population the effects of other interventions that were not
covered in this review, such as pursed-lip breathing. The effects of This project was supported by the National Institute for Health
the breathing exercises on different mechanisms (hyperventilation, Research (NIHR), via Cochrane Infrastructure funding to Cochrane
breathing pattern disorders, cognitive and emotional factors Airways. The views and opinions expressed therein are those of
related to biochemical, biomechanical and psychophysiological the authors and do not necessarily reflect those of the Systematic
dimensions of dysfunctional breathing in asthma) should also be Reviews Programme, NIHR, NHS, or the Department of Health.

Informed decisions.

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CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]

Aggarwal 2013
Methods Design: RCT
Participants Country: India
Setting: outpatient - department of physiology at SN Medical College
Health status: not described
Diagnosis criteria: not described
Total sample: 100 participants, 50 in each group
Mean age, years: not described
Age range, years: not described
Gender: men or women
Inclusion criteria: men or women aged between 20-45 years; people with bronchial asthma practising
pranayama with medical treatment; people with bronchial asthma under medical treatment but not
practising pranayama
Exclusion criteria: unwilling to participate in study; history of cigarette smoking, hypertension, dia-
betes and chronic chest infections like T.B. (X- ray and sputum examination done, if needed) and chest
deformity
Interventions Intervention group: pranayama (anuloma-viloma and kapalbhati pranayama) for 3 months. Anulo-
ma-Viloma: Done 3-3 round by both nostril and one round of anuloma-viloma include: inhale through
left nostril, closing the right with the thumb, to the count of 4; hold the breath, closing both nostrils
to the count of 16; exhale through the right nostril, closing the left with the ring and little finger to the
count of 8; inhale through the right nostril, closing the left nostril with ring and little finger to the count
of 4; hold the breath, closing both nostrils, to the count of 16; exhale through the left nostril, keeping
the right closed with the thumb, to the count of 8. Kapalbhati pranayama: also k/as breath of fire is
used as a 'cleaning breathing exercise'. The technique uses a forced exhalation with the premise of rid-
ding lower lungs of stale air allowing the intake of O2-rich air, thereby purifying the body.
Frequency of intervention: not described
Control group: not practising pranayama
Outcomes Lung function (FVC, FEV1, FEV1/FVC, PEFR)
Notes Funding: not described
Register number: not described
Risk of bias
Bias Authors' judgement Support for judgement

Informed decisions.

Aggarwal 2013 (Continued)
Random sequence genera- Unclear risk The method of sequence generation was not described
tion (selection bias)
Allocation concealment Unclear risk Insufficient information to permit judgement of 'low risk' or 'high risk'
(selection bias)
Blinding of participants High risk This study has not reported any procedures intended to blind the participants
and personnel (perfor- and personnel, and blinding was probably not possible due to the nature of
mance bias) the intervention, so we judged it to have high risk of bias
All outcomes
Blinding of outcome as- Unclear risk Insufficient information to permit judgement of 'low risk' or 'high risk'
sessment (detection bias)
All outcomes
Incomplete outcome data Unclear risk Insufficient information to permit judgement of 'low risk' or 'high risk'
(attrition bias)
All outcomes
Selective reporting (re- Low risk Study protocol was not available, but the published reports included all ex-
porting bias) pected outcomes, including those that were prespecified
Other bias Unclear risk Insufficient information to permit judgement of 'low risk' or 'high risk'

Agnihotri 2016
Methods Design: RCT
Setting: outpatient
Health status: mild to moderate persistent bronchial asthma
Total sample: 276 (138 in intervention group and 138 in control group)
Age range, years: 12-60
Gender: not described
Inclusion criteria: mild to moderate persistent bronchial asthma severity according to GINA 2009, with
age ranging from 12-60 years. They were nonsmokers or ex smokers who had not smoked for at least 6
months with reversible airflow limitation of > 12% and > 200 mL (post bronchodilator FEV1 > 12% and >
200 mL)
Exclusion criteria: severe airflow limitation or more (FEV1 < 60%), pregnant or lactating women, any as-
sociated chronic respiratory diseases and having major psychiatric illnesses and current smokers
Interventions Intervention group: participants in the yoga group received yogic intervention (asanas, pranayama,
and meditation) for 30 min/day, 5 days/week for a period of 6 months along with standard medical
treatment
Control group: standard medical treatment

Informed decisions.

Agnihotri 2016 (Continued)
Notes Funding: ICMR, New Delhi
Risk of bias
Random sequence genera- Low risk Random sequence generation was undertaken by a computer-generated ran-
tion (selection bias) dom number table
Allocation concealment Unclear risk The method of concealment was not described
(selection bias)
All outcomes
All outcomes
Incomplete outcome data Unclear risk Missing outcome data balanced in numbers across intervention groups, how-
(attrition bias) ever the reasons for the missing data were not clearly described
All outcomes
Selective reporting (re- Low risk The study protocol is not available, but the published reports include all ex-
porting bias) pected outcomes
Other bias Unclear risk Insufficient information to assess whether an important risk of bias exists

Agnihotri 2018
Methods Design: RCT

Setting: outpatient
Health status: mild‑to‑moderate persistent asthma (FEV1 > 60%)
Total sample: 300 (150 in intervention group and 150 in control group)
Inclusion criteria: mild to moderate persistent bronchial asthma severity according to GINA, with age
ranging from 12-60 years. They were nonsmokers or ex smokers who had not smoked for at least 6
months with reversible airflow limitation of > 12% and > 200 mL (post bronchodilator FEV1 > 12% and >
200 mL).
Exclusion criteria: severe airflow limitation or more (FEV1 > 60%), pregnant or lactating women, any
associated chronic respiratory diseases and having major psychiatric illnesses and current smokers
Interventions Intervention group: participants in the yoga group received yogic intervention (asanas, pranayama,
and meditation) for 30 min/day, 5 days/week for a period of 6 months along with standard medical
treatment

Informed decisions.

Outcomes QoL (assessed by the MiniAQLQ at baseline and then after 3 and 6 months from baseline)
Notes Funding: ICMR, New Delhi

Risk of bias
Random sequence genera- Low risk Random sequence generation was undertaken by a computer-generated ran-
tion (selection bias) dom number table
(selection bias)
Blinding of participants High risk No blinding of participants and personnel, and the outcome is likely to be in-
and personnel (perfor- fluenced by lack of blinding
mance bias)
All outcomes
Blinding of outcome as- High risk Some outcomes were participant-rated, which could introduce high risk of de-
sessment (detection bias) tection bias
All outcomes
All outcomes

Bidwell 2012
Methods Design: RCT
Participants Country: USA

Setting: Human Performance Laboratory
Health status: mild to moderate asthma

This trial included 2 arms (yoga and control group)
Total sample: 19 female participants
Mean age, years: 40 ± 4 (control group) and 43 ± 4 (yoga group)
Inclusion criteria: not described

Exclusion criteria: participants were excluded if they were smokers, participated in yoga therapy in the
previous 12 months, were diagnosed as having hypertension or major orthopaedic injuries prohibiting
the performance of various yoga postures and/or were currently taking any medications that would al-
ter autonomic function

Informed decisions.

Bidwell 2012 (Continued)
Interventions Intervention group: yoga training consisted of 2 x 1-h supervised yoga sessions/week for 10 weeks. Ad-
ditionally, participants were required to perform 1 x 30-min session/week at home, which was based
on a written lesson plan (5 min of deep breathing, 20 min of asanas and 5 min of meditation and relax-
ation)
Control group: participants were instructed not to participate in yoga or related breathing practices for
the duration of the study
Outcomes QoL (SGRQ)
Lung function
We have written to the study author for further clarification regarding total sample size and the values
of the SGRQ and the pulmonary function test
Risk of bias
Random sequence genera- Unclear risk The method of sequence generation is not described
Allocation concealment Unclear risk The method of concealment is not described

(selection bias)
mance bias)
All outcomes
sessment (detection bias) tection bias.
All outcomes
Incomplete outcome data Low risk No missing outcome data

(attrition bias)
All outcomes
Selective reporting (re- High risk ≥ 1 outcomes of interest in the review are reported incompletely, so that they
porting bias) cannot be entered into a meta-analysis

Fluge 1994
Methods Design: RCT over 3 weeks
(This paper was translated from German)
Participants Country: Germany

Setting: community
Health status: mild asthma
This trial included 3 arms (yoga, physiotherapy and physical exercises, and control group). 2 arms were
included in the review (yoga and control groups)

Informed decisions.

Fluge 1994 (Continued)
Total sample: 36 participants (12 participants in each group)
Mean age, years: 48.8 ± 1.8
Gender: 14 men and 22 women
Exclusion criteria: cardiopulmonary complications due to asthma, exacerbation 8 weeks before the be-
ginning of the study, smoke
Interventions Intervention group: yoga consisted of asana, mudra, pranayama, kriya and yoga nidra
Frequency of intervention: 3 weeks' training of 3 h, 15 times total
Control group received no additional treatment

Participants were re-evaluated after 15 sessions
Outcomes Lung function
Notes Register number: not described
We have written to the study author for further clarification
Risk of bias

(selection bias)
All outcomes
All outcomes
Incomplete outcome data Low risk Reasons for missing outcome data unlikely to be related to true outcome
(attrition bias)
All outcomes
Selective reporting (re- High risk One outcome of interest in the review is reported incompletely
porting bias)

Girodo 1992
Participants Country: Canada

Setting: community

Informed decisions.

Girodo 1992 (Continued)
Total sample: 92 participants to 4 groups
2 deep diaphragmatic breathing (DDB) groups, 1 taught by a singing instructor, the other by a 25-year-
old participant with asthma. Physical education (PE) group led by student with PE experience. Control
group: waiting list participants. 3 arms were included in the review (the deep diaphragmatic breathing
groups and the control groups)
Mean age, years: 28.61 ± 11.21 (DDB group); 34.92 ± 10.53 (PE group); 32.9 ± 6.55 (control group)
Gender: 20 (62%) female (DDB group); 8 (66%) female (PE group); 13 (56%) female (control group)
Inclusion criteria: detailed examination of the history of their condition - doctor's approval and in-
formed consent
Exclusion criteria: history of allergies, severe asthma, chest disease, diabetes, inability to make 26-
week commitment
Interventions Intervention group (breathing groups): physical and respiratory exercises to enlarge the thoracic cage
and increase the capacity for maximum lung efficiency during expiration
Frequency of intervention: 16 weeks' training of 1 h three times/week

PE group: physical exercises with no emphasis on deep diaphragmatic breathing
Control group: waiting list controls had pretest assessment of 'chronicled' medication use and asthma
symptoms
Re-evaluated after 8 and 16 weeks
Co-intervention: no information given
We combined data from the 2 breathing groups
Outcomes Asthma symptom checklist
We have written to the study author to ask for information on randomisation methods and further data
Risk of bias
Random sequence genera- Unclear risk Method of sequence generation not described
Allocation concealment Unclear risk Method of allocation concealment not described

(selection bias)
mance bias)
All outcomes
All outcomes
(attrition bias)
Informed decisions.

Girodo 1992 (Continued)
All outcomes
Selective reporting (re- High risk One outcome of interest in the review is reported incompletely, so that it can-
porting bias) not be entered into a meta-analysis

Grammatopoulou 2011
Methods Design: RCT over 6 months
Participants Country: Greece
Setting: outpatient
Total sample: 40 participants (20 in each group)
Mean age, years: 45.45 ± 12.67 (control group) and 48.15 ± 14.63 (intervention group)
Gender: 10 men and 10 women (control group), 13 men and 7 women (intervention group)
Exclusion criteria: individuals > 60 years, smokers, use of oral corticosteroids in the previous 3 months,
heart disease, participation in a prior asthma education programme
Interventions The intervention consisted of 2 phases:
1. first phase (one month) consisted of a 60-min, small-group session (5 participants/group) in which
participants were educated in (1) the 'normal' breathing pattern, as well as the pattern during ex-
acerbations, (2) recognising asthma symptoms, and (3) comprehending their ability to modify their
breathing pattern while targeting self-management of the symptoms and expressing their perceived
severity of asthma and the benefits and barriers of adapting a modified breathing pattern for a 6-
month period. This phase also included 12 individual sessions (3/week), each of nearly 1-h duration,
comprising education and practise of (1) diaphragmatic breathing, (2) nasal breathing, (3) short hold
of breath (2-3 s) and (4) adaptation of the speech pattern (speaking, singing), in any position, during
physical activity and in asthma exacerbation
2. second phase (5 months) consisted of instructions regarding the duration (20 min at least) and fre-
quency (2-3 times/day) of training at home for the remaining months, as well as adaptation of breath-
ing behavior during leisure-time physical activities
Control group: no additional treatment
Outcomes QoL (as measured by the SF-36 questionnaire)
Asthma control was measured by the ACT, whose score ranges from 5 (poorly controlled) to 25 (com-
pletely controlled)
NQ (used to screen for the hyperventilation syndrome)
Lung function
Capnography

Informed decisions.

Grammatopoulou 2011 (Continued)
Study author responded to our request regarding further clarification about the scores of the SF-36
questionnaire
Risk of bias
Random sequence genera- Low risk Random allocation was undertaken with sealed envelopes
Allocation concealment Low risk Allocation concealment was undertaken with sealed envelopes
(selection bias)
mance bias)
All outcomes
All outcomes
Incomplete outcome data Low risk No missing outcome data

(attrition bias)
All outcomes
Selective reporting (re- Low risk The study protocol was not available, but the published reports include all ex-
Other bias Low risk The study appears to be free of other sources of bias

Gupta 2015
Setting: outpatient
Inclusion criteria: either sex, aged between 20-55 years; bronchial asthma patients practising yoga with
medical treatment; bronchial asthma patients under medical treatment but not practising yoga.

Informed decisions.

Gupta 2015 (Continued)
Exclusion criteria: unwilling to participate in study; history of cigarette smoking, hypertension, dia-
betes and chronic chest infections like TB (X-ray and sputum examination done, if needed) and chest
deformity
Interventions Intervention group: various yogic exercises, which included anuloma-viloma and kapalbhati bhramari
pranayama suryanamaskar
Control group: not practising yoga
Risk of bias

(selection bias)
All outcomes
All outcomes
(attrition bias)
All outcomes
Selective reporting (re- Low risk Study protocol was not available, but the published report included all expect-
porting bias) ed outcomes, including those that were prespecified

Holloway 2007
Methods Design: RCT over 5 sessions
Participants Country: England, UK
Setting: semi-rural GP practice
Total sample: 85 participants (46 in control group and 39 in intervention group)

Informed decisions.

Holloway 2007 (Continued)
Gender: 18 men and 28 women (control group), 18 men and 21 women (intervention group)
Inclusion criteria: participants aged 16-70 years; able to understand, read and write English, with a
commitment to participate for possibly 8 attendances; willing to give written informed consent and
with no serious comorbidity
Exclusion criteria: not described
Interventions Intervention group: 5 x 60-min individual sessions on the Papworth method from a respiratory physio-
therapist. The Papworth method consisted of 5 components: breathing training, education, relaxation
training, integration of 'appropriate' breathing and relaxation techniques into daily living activities and
home exercises (audiotape or CD containing reminders of the breathing and relaxation techniques)
Assessments took place at baseline and at 6 and 12 months after baseline
Outcomes QoL as measured by the SGRQ, which assesses impaired respiratory symptoms and QoL related to
these
Hypocapnic symptoms as assessed by the NQ
HADS
Lung function (VC, FEV1, FVC, PEFR)
Capnography
Notes Funding: this study was not sponsored but was undertaken as part fulfilment of a PhD degree at Univer-
sity College London. A study author's post was funded by Cancer Research UK
Risk of bias
Random sequence genera- Low risk Randomisation was undertaken by a computer-generated number sequence
tion (selection bias) assigning consecutive participant ID numbers a 1 or a 2 to denote intervention
or control condition
Allocation concealment Unclear risk Insufficient information to permit judgement of 'low risk' or 'high risk”
(selection bias)
mance bias)
All outcomes
All outcomes
Incomplete outcome data Low risk Missing outcome data balanced in numbers across intervention groups (7 from
(attrition bias) the intervention group and 6 from the control group), with similar reasons for
All outcomes missing data across groups
Selective reporting (re- Low risk The study protocol is available, and all of the study's prespecified (primary and
porting bias) secondary) outcomes that are of interest in the review have been reported in
the prespecified way

Informed decisions.

Holloway 2007 (Continued)

Malarvizhi 2018
Methods Design: RCT

Setting: outpatient Department of Respiratory Medicine in Sri Ramachandra Medical hospital
Severity of asthma: mild or moderate bronchial asthma
Diagnosis criteria: GINA criteria
Gender: 69 men and 56 women (control group); 70 men and 55 women (yoga group)
Inclusion criteria: the inclusion criteria consisted of either sex, aged 21-60 years, who met GINA criteria,
minimum of 2 years, able to understand either English or Tamil and willing to participate in the study.
Exclusion criteria: participants were excluded if they had severe airflow limitation (FEV1 > 60%), smok-
ers, history of co-morbid illness (medical, neurologic and psychiatric, orthopaedics) associated chronic
respiratory diseases such as TB, autoimmune lung diseases and practised yoga or any other similar dis-
cipline.
Interventions Intervention group: yoga group received 30 min of yoga training for a week under a trained yoga
teacher and advised to practise at home daily once a day for 6 months. It consisted of basic asanas
(posture) like bhujangasana (cobra pose), tadasana (tree pose) and gomukhasana (cow face pose) for
10 min and simple pranayama (breathing exercise), nadi sudhi pranayama and bhastrika for 10 min fol-
lowed by relaxation ('om' chanting and shavasana). A yoga checklist booklet was given to the partici-
pants to assess the level of performance and monitor the practice. On the regular visits to the outpa-
tient's department days, participants
were asked to show return demonstration and their doubts were clarified. During this period at 3 and
6 months, participants were assessed through yoga performance checklist for their level of practice on
yoga techniques. Lacunas made during the practice were corrected and reinforced.
Control Group: conventional care
Frequency of intervention: daily once a day for 6 months
Outcomes QoL (using AQLQ at baseline, 3 and after 6 months interval)

The study author responded to our request regarding additional data from AQLQ total scores. Howev-
er, due to a discrepancy between the graphical presentation and the data provided by correspondence,
we were unable to include the data in the analysis.
Risk of bias
Random sequence genera- Low risk Randomisation was undertaken by using random allocation software. Ran-
tion (selection bias) domisation was performed by 1 of the authors who was not involved in any
part of the assessment
Allocation concealment Low risk Participants were randomly allocated to 1 of the 2 study arms by using random
(selection bias) allocation software

Informed decisions.

Malarvizhi 2018 (Continued)
Blinding of participants High risk The presence of participant blinding was reported and is likely that the blind-
and personnel (perfor- ing could have been broken due the type of intervention used in the study
mance bias) arms
All outcomes
Blinding of outcome as- High risk The outcome was participant-rated, which could introduce high risk of detec-
sessment (detection bias) tion bias
All outcomes
All outcomes
porting bias) pected outcomes, including those that were pre-specified

Nagarathna 1985
Setting: Yoga Therapy and Research Centre
Diagnosis criteria: satisfying the clinical criteria of Crotton, Douglas and Shivpuri
Mean age, years: 26.41 (control group) and 26.36 (intervention group)
Age range, years: 9-47 (control group) and 9-47 (intervention group)
Gender: 15 (28%) women (control group) and 15 (28%) women (intervention group)
Inclusion criteria: established bronchial asthma

Interventions Intervention group: training programme over 2 weeks with 2.5 h daily. Included were breathing exercis-
es associated with simple movements; yoga loosening exercises; various physical postures combined
with slow breathing and exercise; relaxation and slow deep breathing; meditation and devotional ses-
sion including chanting; weekly traditional voluntary nose and stomach wash techniques; yoga philos-
ophy lectures and discussions
Participants were instructed to continue the practices daily during the follow-up period of 30 months
Control group: continued taking the usual drugs during the study. Participants in this group reported
for checkups every 6 months
Co-intervention: no inhalers used; continued with usual, self-regulated bronchodilators and injections.
The doctor decided whether a change in the 'brand' of drug was required
Participants kept diaries recording drug usage, number and severity of attacks of airway obstruction
Outcomes Lung function (PEF)

Number and severity of attacks (1 = mild, but did not disturb sleep or daily routine; 2 = moderate, dis-
turbed sleep and daily routine and relieved by oral drugs; 3 = severe, required injection or admission to
hospital)

Informed decisions.

Nagarathna 1985 (Continued)
Wrote to author for clarification
Risk of bias

(selection bias)
All outcomes
All outcomes
Incomplete outcome data Unclear risk Insufficient reporting of attrition/exclusions to permit judgement of 'low risk'
(attrition bias) or 'high risk'
All outcomes
Selective reporting (re- Low risk Published reports include all expected outcomes
porting bias)
Blinding of participants and personnel (performance bias)
Days off work

Prasanna 2015
Setting: outpatient
Total sample: 100 participants
Mean age, years: 40.4 ± 9.1 (intervention group) and 37.36 ± 7.9 (control group)
Gender: 64% of women in the intervention group and 60% in the control group
Inclusion criteria: newly diagnosed patients of both sexes in the age group of 25-60 years were selected

Informed decisions.

Prasanna 2015 (Continued)
Exclusion criteria: smokers and people with chronic asthma were excluded
Interventions Intervention group: Buteyko breathing exercise. The participants were instructed to do the breathing
exercise at least twice in a day (morning and evening) for 2 months.
Control group: ICS
Outcomes Lung function (FEV1 and PEFR at the beginning and at the of the 1st and 2nd month)
Subjective improvements of symptoms at the beginning and at the end of 1st and 2nd month of the
study measured using a pretested, structured, close-ended questionnaire in the local language. The
questionnaire assessed the severity the severity of symptoms, frequency of exacerbations, changes in
the lung capacity, and side effects of medication.
Notes Funding: ICMR
Risk of bias

(selection bias)
mance bias)
All outcomes
All outcomes
(attrition bias)
All outcomes
Selective reporting (re- High risk One outcome of interest in the review is reported incompletely, so that it can-

Prem 2013
Methods Design: RCT

Setting: conducted at an outpatient department of chest medicine

3 arms in this trial (Buteyko, pranayama and control group). We included all 3 arms in the review

Informed decisions.

Prem 2013 (Continued)
Mean age, years: 38 ± 13 (Buteyko group), 35 ± 13 (pranayama group) and 41 ± 14 (control group)
Inclusion criteria: participants aged 18-60 years, AQLQ 24 < 5.5, FEV1 increase by 12% following bron-
chodilator administration, usage of bronchodilator for 6 months and patients without exacerbation in
the preceding 8 weeks
Exclusion criteria: participants were excluded if they had medical conditions that impaired the perfor-
mance of breathing techniques, had a previous history of breathing retraining, were pregnant and non-
compliant with exercise for more than 15% of study period
Interventions Intervention group: Buteyko and pranayama
Frequency of intervention: 3-5 days with a session of 60 min/day. Participants were then followed up
for 3 months and were instructed to practise the exercise for 15 min twice daily
Control group received no additional treatment
Outcomes QoL (AQLQ)
Asthma symptoms (ACQ)
Lung function (FEV1, FEV1/FVC)
Notes Funding: this research received no specific grant from any funding agency in the public, commercial, or
not-for-profit sectors
The study author responded to our request regarding asthma severity of participants and the values on
AQLQ, ACQ and pulmonary function tests
Risk of bias
Random sequence genera- Low risk Participants were assigned to 3 groups through block randomisation
Allocation concealment Low risk The method of allocation was concealed by sequentially numbered, sealed,
(selection bias) opaque envelopes
mance bias)
All outcomes
All outcomes
(attrition bias)
All outcomes
Selective reporting (re- High risk ≥ 1 outcomes of interest in the review are reported incompletely, so that we
porting bias) cannot enter them into a meta-analysis

Informed decisions.


Pushpa 2018
Methods Design: RCT

Setting: outpatient − Department of Physiology, Bangalore Medical College and Research Institute,
Bengaluru
Severity of asthma: mild-moderate bronchial asthma
Age range, years: 18-50 years
Gender: 10 men and 20 women (in each group)
Inclusion criteria: the study included diagnosed cases of bronchial asthma, aged 18−50 years with an
established diagnosis for at least 6 months, mild-moderate cases meeting NAEPP classification. Partic-
ipants on inhaled beta2-agonist (short-acting and long-acting) with stable medication dose for past 1
month.
Exclusion criteria: study excluded smokers, patients with concomitant lung disease, those who prac-
tised yoga or any other similar discipline during 6 months preceding the study, pregnancy, any chronic
medical condition that required a treatment with oral/systemic steroids in the past months, any med-
ical condition that contraindicated exercise, history of TB, diabetes mellitus, renal failure, coronary
artery disease, musculoskeletal deformities, and status asthmaticus.
Interventions Intervention group: yoga training group practised yoga exercises along with the medication, yogic exer-
cises used by the participants included pranayamas (deep breathing exercises), kapalabhati (cleaning
breath), bhastrika (rapid and deep respiratory movements like that of the bellows), ujjayi (loud sound
producing pranayama) and sukhapurvaka pranayama (easy comfortable breathing), meditation, and
shavasana (relaxation technique) under the guidance of trained yoga teacher.
Control group: only pharmacological therapy
Frequency of intervention: 45 min/day for 2 weeks and instructed to practise at home for 45 min twice
daily, regularly for remaining 6 weeks and were instructed to maintain a diary record of each day of yo-
ga practice.
Outcomes Lung function (FVC, FEV1, FEV1/FVC, PEFR, FEF25-75%)

Airway resistance (RAW)
Specific airway conductance (sGAW)
Notes Funding: none

Risk of bias
(selection bias)
Blinding of participants High risk This study did not report any procedures intended to blind the participants
All outcomes

Informed decisions.

Pushpa 2018 (Continued)
All outcomes
(attrition bias)
All outcomes

Satpathy 2016
Setting: outpatient
Health status: persistent, chronic asthma
Diagnosis criteria: bronchial asthma confirmed by the physician/chest physician as mentioned in diag-
nostic criteria
Gender: 71 men
Inclusion criteria: cases of bronchial asthma confirmed by the physician/chest physician as mentioned
in diagnostic criteria; with symptoms of asthma persisting for at least 6 months
Exclusion criteria: history of smoking within the last 1 year; acute infection or infections within the past
6 weeks; serious systemic illness − hepatic, renal, cardiac or CNS diseases; cardiovascular diseases in-
cluding hypertension
Interventions Intervention group: yoga including 5 yogic exercises daily, along with the same medication. The yogic
exercises included were tadashana, tiryaka tadasana, simhagarjanashana, kastatakshyasana and bhas-
trika pranayama, followed by relaxation or shavasana. Initially breathing exercises were performed 10
times and then extended to 15-20 times after 2 weeks. Simhagarjanasana was started with 3-4 times at
first and then extended after 2 weeks as per comfort.
Control group: only drugs
Initially they were stabilised on drugs (ICS and bronchodilators) till no further symptomatic improve-
ment occurred
Outcomes Acute exacerbation of asthma
Dyspnoea (assessed by dyspnoea grading system)
Asthma symptom score
Use of bronchodilators
Use of ICS

Informed decisions.

Satpathy 2016 (Continued)
Risk of bias

(selection bias)
mance bias)
All outcomes
All outcomes
(attrition bias)
All outcomes
Selective reporting (re- Low risk Study protocol was not available, but the published report included all expect-
porting bias) ed outcomes, including those that were pre-specified

Singh 2012
Methods Design: RCT

Setting: Department of Physiology, University College of Medical Sciences
Diagnosis criteria: the diagnosis was based on paroxysms of dyspnoea, wheezing and cough, which im-
proved either spontaneously or with drug therapy.
2 arms in this trial (yoga and control groups)
Total sample: 60 participants (30 participants in each group)
Inclusion criteria: non smokers, in the age group of 18-60 years with mild to moderate grades of
bronchial asthma as per GINA guidelines
Exclusion criteria: individuals with a history of an exacerbation or respiratory tract infection, current
smokers, pregnant or lactating women and those with any other disorder were excluded
Interventions Intervention group: yoga sessions included pranayama (30-35 min), asanas (10 min), meditation (10
min) and lifestyle modification for 5-6 days

Informed decisions.

Singh 2012 (Continued)
Frequency of intervention: participants were practising yoga for an average of 40-50 min daily at home
for 2 months
Outcomes QoL (AQLQ)
Lung function (FVC, FEV1, FEV1/FVC, PEFR, MVV, SVC)
We have written to the study author to ask for further clarification regarding total sample size and total
score on the AQLQ
Risk of bias

(selection bias)
mance bias)
All outcomes
All outcomes
(attrition bias)
All outcomes
porting bias)

Sodhi 2009
Setting: Departments of Medicine and Physiology, Christian Medical College & Hospital
Informed decisions.

Sodhi 2009 (Continued)
Age range, years: 17-50 (control group) and 20-50 (intervention group)
Gender: 37 men and 23 women (control group) and 34 men and 26 women (intervention group)
Inclusion criteria: non-smokers in the age group of 17-50 years with mild to moderate asthma
Exclusion criteria: individuals with a history of TB, COPD, diabetes, renal failure, coronary artery dis-
ease and musculoskeletal chest deformities, respiratory tract infection within the previous 6 weeks and
engagement in any regular exercise/training
Interventions Intervention group: 45-min yoga training sessions/week with a trained instructor, which included
pranayamas (deep breathing exercises), kapalabhati (cleaning breath), bhastrika (rapid and deep res-
piratory movements), ujjayi (loud sound-producing pranayama) and sukha purvaka pranayama (easy
comfortable breathing). Participants were instructed to practise at home, 45 min twice daily, on all
days of the week. Participants maintained a diary record of each day of the yoga practice
Control group: conventional treatment
Pulmonary function tests were performed on all participants at baseline and after 4 and 8 weeks
QoL (AQLQ)
The study author responded to our request regarding control group treatment.
Risk of bias
Random sequence genera- Low risk Randomisation was undertaken by using permuted block randomisation

(selection bias)
mance bias)
All outcomes
All outcomes
(attrition bias)
All outcomes
Selective reporting (re- Low risk The study protocol is not available, but published reports include all expected
porting bias) outcomes


Informed decisions.

Thomas 2003
Methods Design: RCT
Participants Country: UK
Setting: semi-rural general practice
Health status:
Diagnosis criteria: study authors searched medical notes of participants with a diagnosis of asthma
made by a GP and at least 1 prescription for an inhaled or oral bronchodilator or a prophylactic an-
ti-asthma medication in the previous year
Total sample: 33 participants (17 in intervention group and 16 in control group)
Mean age, years: 48.8 ± 10.9 (intervention group) and 48.9 ±15.6 (control group)
Gender: 7 (21%) male participants
Inclusion criteria: patients aged 17−65 years with a diagnosis of asthma who had received at least 1 pre-
scription for an inhaled or oral bronchodilator or prophylactic anti-asthma medication in the previous
year were identified from the medical records; with NQ > 23, which suggests a
diagnosis of dysfunctional breathing.
Interventions Intervention group: breathing retraining with a chartered physiotherapist. Initial group treatment for
45 min followed by 2 individual training sessions lasting 15 min each, which were 1 and 2 weeks apart.
Explanation and training given in relaxed diaphragmatic breathing. Participants were assessed at 1 and
6 months post-intervention
Control group: 60-min group session with asthma nurse teaching asthma education. Participants invit-
ed to attend for further individual asthma review if they wished
Outcomes QoL (AQLQ)
Hyperventilation symptoms measured by the NQ
Notes Funding: Royal College of GPs' Scientific Foundation Board. Minchinhampton Surgery is a funded R&D
practice under the NHS Executive South & West R&D General Practice Scheme
The study author responded with further information regarding non-parametric data, method of ran-
domisation, etc
Risk of bias
Random sequence genera- Low risk Volunteers were randomly assigned by alphabetical numbering and by use of
tion (selection bias) random number tables for assignment to trial groups
Allocation concealment Unclear risk Randomisation was supervised by a statistician, but the paper does not fully
(selection bias) describe the method of allocation concealment
Blinding of participants High risk No blinding of participants and personnel or of the outcome is likely to be in-
mance bias)
All outcomes
Blinding of outcome as- High risk Some outcomes were participant-rated which could introduce high risk of de-
sessment (detection bias) tection bias. The questionnaires were scored blind by the investigator

Informed decisions.

Thomas 2003 (Continued)
All outcomes
Incomplete outcome data Low risk Missing outcome data were balanced in numbers across intervention groups,
(attrition bias) with similar reasons for missing data across groups
All outcomes
porting bias)

Thomas 2009
Methods Design: single-blind RCT over 3 sessions
Setting: not described
Total sample: 183
Median age, years: 46.0 (35-57) (control group) and 46.0 (33-57.3) (intervention group)
Inclusion criteria: non-smokers, patients treated for asthma at 10 UK primary care general practices in
Leicester, UK, and having moderate impairment of asthma-related health status (AQLQ score < 5.5)
Interventions Both groups consisted of an initial 60-min small group session (2-4 participants) followed by 2 individ-
ual sessions of 30-45 min with 2-4 weeks between attendances
Intervention group: explanation of normal breathing and possible effects of abnormal 'dysfunction-
al breathing'. During individual sessions, participants were taught diaphragmatic and nasal breathing
techniques and were encouraged to practise these exercises for at least 10 min each day
Control group: 3 sessions of nurse-provided asthma education
Outcomes QoL (AQLQ)
Asthma control questionnaire (ACQ) and asthma symptoms measured by the NQ
HADS
Spirometry
Capnography
Notes Funding: this study was funded by a grant from Asthma UK (03/014). 1 study author is in receipt of an
Asthma UK Senior Research Fellowship

Informed decisions.

The study author has responded to our enquiries with further details
Risk of bias
(selection bias)
mance bias)
All outcomes
All outcomes
Incomplete outcome data Low risk Missing outcome data balanced in numbers across intervention groups with
(attrition bias) similar reasons for missing data across groups
All outcomes

Thomas 2017
Methods Design: parallel-group randomised trial over 12 months
Setting: outpatient
Health status: mild and moderate asthma
Diagnosis criteria: a physician diagnosis of asthma
Total sample: 655
Median age, years: 57 (46−64)
Gender: female (419 - 64%), male (236 - 36%)
Inclusion criteria: 16–70 years, be registered at a medical practice for at least 12 months, have asth-
ma diagnosed by a physician, have been prescribed at least 1 asthma medication in the previous year,
achieve an AQLQ < 5.5, and to provide written informed consent
Exclusion criteria: concomitant COPD diagnosis with FEV1 < 60% predicted
Interventions Intervention group

Informed decisions.

• DVD and booklet (DVDB) intervention: (the exercises comprised an illustration of, and training in, di-
aphragmatic breathing, nasal breathing, slow breathing, controlled breath holds, and simple relax-
• Face-to-face physiotherapy (also received the booklet and worked to a standardised intervention
ation exercises)
schedule and were seen by a respiratory physiotherapist who was trained and skilled in providing
breathing retraining)
Control group: usual medical care, with no additional attention to the baseline assessment
Frequency of intervention: for face-to-face physiotherapy group, 3 x one-to-one sessions, approximate-

ly once every 2 weeks after randomisation
Intensity and timing of intervention: for face-to-face physiotherapy group, each about 40-min duration
Outcomes Primary:
• QoL (AQLQ)
Secondary:
•
•
questionnaire measures of asthma control (ACQ);
•
measurements of airway physiology (FEV1, PEFR, FVC);
•
airway inflammation (FENO) measurements with Nioxx Mino);
•
respiratory-related GP consultations;
•
asthma-related health resource use;
•
health-economic assessment;
•
hyperventilation symptoms (NQ);
•
psychological state (HADS);
generic QoL (EQ-5D)
Notes Funding: UK National Institute of Health Research, Health Technology Assessment
Register number: ISRCTN88318003
The study author responded to our enquiries with further details
Risk of bias
Random sequence genera- Low risk Randomisation was undertaken by a telephone randomisation service using
tion (selection bias) random number generators
Allocation concealment Low risk Participants were randomly allocated to 1 of the 3 study arms by using a tele-
(selection bias) phone call service
mance bias)
All outcomes
All outcomes
Incomplete outcome data Low risk Missing outcome data balanced in numbers across intervention groups with
(attrition bias) similar reasons for missing data across groups
All outcomes

Informed decisions.

porting bias)

Vedanthan 1998
Participants Country: USA
Setting: University, Allergy and Asthma Clinic. Health centre
Diagnosis criteria: based on guidelines established by the National Asthma Education Panel
Total sample: 17 students
Mean age, years: 25.11 (control group) and 28.12 (yoga group)
Gender: 6 women (75%) (control group) and 3 women (33%) (yoga group)
Recruitment: student volunteers from a university asthma and allergy clinic

Inclusion criteria: mild to moderate asthma
Interventions Intervention group: training programme of yoga techniques, including various breath-slowing exercis-
es (pranayama) together with physical exercises; these were performed without breath holding: also
physical postures, meditation, exercises and lectures on yoga philosophy
Participants given audio cassettes and written information for home practice
Duration: 45 min, 3 times a week for 16 weeks
Control group: no information given
Both groups were given peak flow meters to record daily am and pm readings
Participants from both groups regularly attended the Health Center
Outcomes Lung function (FVC, FEV1)

Symptom questionnaire, which included severity and frequency of attack scores
The author has responded to our enquiries with further details
Risk of bias

(selection bias)

Informed decisions.

Vedanthan 1998 (Continued)
mance bias)
All outcomes
All outcomes
Incomplete outcome data Low risk No dropouts reported

(attrition bias)
All outcomes
Selective reporting (re- High risk ≥ 1 outcomes of interest in the review are reported incompletely, so they can-

Vempati 2009
Setting: Integral Health Clinic, All India Institute of Medical Sciences (2 weeks) and intervention at
home (6 weeks)
Diagnosis criteria: the ATS spirometry criteria
Total sample: 57 participants (28 in control group and 29 in intervention group)
Inclusion criteria: age ≥ 18 years; an established diagnosis of mild to moderate asthma for at least 6
months (meeting ATS spirometry criteria for mild to moderate asthma; taking at least 1 of the follow-
ing: inhaled β-agonists, methyl-methylxanthines, anticholinergics, ICS; and stable medication dosing
for the past month
Exclusion criteria: individuals who smoked currently (or in the past year) or had a smoking history of > 5
pack-years; had a concomitant lung disease; were taking leukotriene inhibitors or receptor antagonists,
or mast cell–stabilising agents for at least 6 months; practised yoga or any other similar discipline dur-
ing 6 months preceding the study; were pregnant; had a chronic medical condition that required treat-
ment with oral or systemic corticosteroids in the past month; had a medical condition that contraindi-
cated exercise; or had an unstable medical condition
Interventions Intervention: yoga group underwent a yoga-based lifestyle modification and stress management pro-
gramme for 4 h/day over 2 weeks and an additional 6 weeks of home practice. The programme consist-
ed of lectures and practical sessions on asanas (postures), pranayamas (breathing techniques), kriyas
(cleansing techniques), meditation and shavasana (a relaxation technique)
Control group: conventional care
Outcome measures were performed on all participants at baseline and after 2, 4 and 8 weeks

Informed decisions.

Vempati 2009 (Continued)
Outcomes QoL (AQLQ)
Lung function (FVC, FEV1, FEV1/FVC, PEFR)
Notes Funding: Central Council for Research in Yoga and Naturopathy (CCRYN), Department of AYUSH, Min-
istry of Health, Government of India and Wellpark College of Natural Therapies, New Zealand
Risk of bias

(selection bias)
mance bias)
All outcomes
All outcomes
Incomplete outcome data Unclear risk Missing outcome data were balanced in numbers across intervention groups,
(attrition bias) however the reasons for the missing data were not clearly described
All outcomes
Selective reporting (re- Low risk The study protocol is available, and all of the study's prespecified (primary and
porting bias) secondary) outcomes that are of interest in the review have been reported in
the prespecified way
ACT: Asthma Control Test; QOL: Asthma Quality of Life; AQLQ: Asthma Quality of Life Questionnaire; ATS: American Thoracic society; CNS:
central nervous system; COPD: chronic obstructive airway disease; FEF25-75: forced expiratory flow averaged over the middle portion
of forced vital capacity; FENO: fraction of exhaled nitric oxide; FEV1: forced expiratory volume during the first second; FVC: forced vital
capacity; GINA: global initiative for asthma; GP: general practitioner; HADS: Hospital Anxiety and Depression Scale; ICMR: Indian Council
of Medical Research; ICS: inhalational corticosteroids; MMV: maximum voluntary ventilation; NAEPP: National Asthma Education and
Prevention Program; NHS: National Health Service; NQ: Nijmegen (Hyperventilation) Questionnaire; PEFR: peak expiratory flow rate;
QoL: quality of life; R&D: research and development; RCT: randomised controlled trial; SF-36: 36-Item Short Form; SGRQ: St George's
Respiratory Questionnaire; SVC: slow vital capacity; TB: tuberculosis; VC: vital capacity

Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion
Aleksandrov 1990 Not an RCT
Anonymous 1968 Investigation comparing the active group treated with hypnosis and the control group treated with
breathing plus relaxation training

Informed decisions.

Asher 1990 Each treatment preceded by nebulised salbutamol. Multiple intervention treatments
Berlowitz 1995 Not an RCT
Bobokhodzhaev 1984 Not an RCT
Bowler 1998 The control group was given relaxation techniques
Cambach 1997 Mixed population of COPD and asthma in programme

Multiple interventions
Cambach 1999 Not an RCT
Coll 1994 Journal letter only. Not an RCT
Cooper 2003 Device used
Cowie 2008 Comparison between Buteyko and chest physiotherapy. No control group
Emtner 1998 Not an RCT. 3 studies included in dissertation. Physical training principal component in all studies
Erskine 1979 No breathing training. Comparison of muscular relaxation with muscular and mental relaxation
training in participants with asthma. No control group
Falkenbach 1993 Not an RCT. Participants acted as their own control in a before-after trial. A control group was not
established for satisfactory statistical analyses because of the small numbers involved
Gallefoss 1999 Breathing training not a major component of the physiotherapy intervention
Gosselink 1993 Not an RCT
Hoang 2015 Not an RCT
Holmes 1990 Not an RCT
Johansson 2017 Not an RCT
Joseph 1999 Not an RCT
Karam 2017 Not an RCT
Khanam 1996 Not an RCT
Kotses 1978 No breathing training. Examining muscle tension relationships with bronchial airways resistance
Kurabayashi 1998 Not an RCT, no control group, COPD not asthma
Lacasse 1997 Not an RCT
Loew 1996 Not RCT. Comparison of the effects of treatment with terbutaline and relaxation. Breathing plus
movement therapy in 2 groups of asthmatic participants
Manocha 2002 Breathing retraining not included as part of intervention
Mass 1991 Device used for breathing training

Informed decisions.

McFadden 1986 Not a study of breathing exercises. Study was set up to observe thermal effects on the airways in
exercise-induced asthma
McHugh 2003 The control group was given relaxation techniques
Mussell 1986 Device used for reducing bronchospasm
Opat 2000 The control group was given a placebo relaxing video
Paleev 1988 Not an RCT
Pryor 1979 Thesis. Treatments randomly assigned, not participants. Evaluation of postural drainage time for
evacuation of secretions with and without the addition of FET, in addition to other physiotherapeu-
tic modalities
Raghavendra 2016 Comparison between yoga and deep breathing
Redchits 1986 Not an RCT
Sabina 2005 Comparison between yoga and stretching. No control group
Saxena 2009 Comparison between yoga and meditation. No control group
Schulze 2000 Not an RCT. Children
Shaw 2011 Device used for diaphragmatic breathing training
Singh 1987 A device was used to alter the breathing pattern. Description of device amended in 2003 update in
response to researcher's comment that the device does not increase muscle strength but imposes
components of pranayamic breathing
Singh 1990 Device used
Slader 2006 Comparison of 2 breathing techniques. No control group
Smyth 1999 Not an RCT. Relaxation training, not breathing, as principal component
Tandon 1978 Study involved participants with COPD, not asthma
Van der Schans 1997 No breathing exercises. Study used propranolol to induce bronchoconstriction and then reversed
its effect using pursed-lip breathing
Weiner 1992 Device used
Wilson 1975 Transcendental meditation, not breathing training
COPD: chronic obstructive pulmonary disease; FET: forced expiratory technique; RCT: randomised controlled trial

Characteristics of studies awaiting assessment [ordered by study ID]

Agnihotri 2013
Methods Design: RCT
Method of randomisation: not described

Informed decisions.

Method of allocation concealment: not described
Total number of withdrawals/dropouts: 35 participants
Total duration of study: not described
Outcome assessor blinding: not described
Severity of asthma: moderate asthma
Total sample: 206
Interventions Intervention group: yoga (asanas, pranayama and meditation), in addition to standard medical
treatment
Outcomes Asthma QoL scores in both groups over the period of 6 months and in yoga group in comparison to
control group

Divya 2013
Methods Design: not described
Total number of withdrawals/dropouts: not described
Total duration of study: 8 weeks
Outcome assessor blinding: not described
Participants Country: not described

Informed decisions.

Divya 2013 (Continued)
Mean age: not described
Age range: not described
Severity of asthma: mild to moderate bronchial asthma
Interventions Intervention group: yoga along with pharmacological treatment
Intensity and timing of intervention: not described
Control group: only pharmacological treatment
Outcomes Airway resistance and specific airway conductance were measured by using a body plethysmo-
graph
We have written to the study author to ask for further clarification, however have not had an an-
swer.

Kant 2013
Methods Design: RCT
Blinding/masking: not described
Setting: outpatients - Department of Pulmonary Medicine, King George's Medical University, Luc-
know, UP
Mean age: not described
Age range: not described
Severity of asthma: mild or moderate bronchial asthma

Informed decisions.

Kant 2013 (Continued)
Interventions Intervention group: yoga (asanas, pranayama and meditation), in addition to standard medical
treatment
Control group: only standard medical treatment
Both groups were assessed at baseline, 3rd and 6th month
Outcomes Asthma QoL scores
Pulmonary function
Bio-chemical changes
Asthma symptom scores
Rescue medication uses
We have written to the study author to ask for further clarification, however we have not had an an-
swer.
QoL: quality of life; RCT: randomised controlled trial

Characteristics of ongoing studies [ordered by study ID]

Andreasson 2017
Trial name or title Breathing exercises in asthma targeting dysfunctional breathing (BEAT_DB)
Methods Design: multicentre RCT
Method of allocation concealment: parallel assignment
Total duration of study: 12 months
Outcome assessor blinding: double (investigator, outcomes assessor)
Participants Country: Denmark
Setting: Naestved Hospital
Total sample: 220
Age range: ≥ 18 years
Severity of asthma: not described
Inclusion criteria: pulmonologist-diagnosed asthma, ≥ 2 consultations at pulmonologist previously

ACQ6 ≥ 1.5, able to provide written informed consent
Exclusion criteria: patients who have had breathing exercises treatment or similar before
Interventions Intervention: breathing exercises (Papworth method; Buteyko technique)

Informed decisions.

Andreasson 2017 (Continued)
Frequency of intervention: 10 min of home exercise twice daily with 3 physiotherapist-sessions of
breathing exercises (BrEX) with duration of 60 min (the initial) and 30 min (other sessions) at week
1, 4, and 9
Intensity and timing of intervention: 6 months' follow-up
Secondary endpoints will be 3 and 12 months' follow-up
Outcomes Primary outcome: QoL measured by MiniAQLQ at 6 months' follow-up
Secondary outcomes: changes in ACQ6, NQ, HADS, accelerometry (physical activity level, number
of steps), 6 min walk distance, and FEV1, besides response of GPE rate in asthma-related QOL and
asthma control
Starting date 25 April 2017
Contact information Karen Hjerrild Andreasson, Ph.D.-Student, PT, Naestved Hospital
Register number: NCT03127059

Elahi 2016
Trial name or title Effect of breathing exercises on indicators of clinical, spirometric parameters and quality of life of
patients with asthma referred to allergic asthma clinic of Imam Khomeini in Ahwaz
Methods Design: quasi-experimental study
Method of allocation concealment: parallel
Total duration of study: 4 weeks
Outcome assessor blinding: not blinded
Participants Country: Iran
Setting: Imam Khomeini Hospital
Total sample: 60
Diagnosis criteria: specialist physician diagnosis of asthma
Inclusion criteria: age range 50-25 years, specialist physician diagnosis of asthma, passing at least a
year of diagnosis, willingness to co-operate in the study
Exclusion criteria: patients with cardiovascular, neuromuscular or chronic diseases (cancer and di-
abetes), and patients with other respiratory diseases.
Patients with communication problems and with 3 or 4 consecutive days of intermittent breathing
exercises will not be excluded.
Interventions Intervention group: breathing exercises
Frequency of intervention: 20 min daily for 4 weeks

Informed decisions.

Elahi 2016 (Continued)

Control group did not receive any training
Outcomes Primary outcomes: spirometric parameters and QoL
Secondary outcomes: blood pressure, heart beat, respiratory rate
Starting date 10 August 2016 (expected date)
Contact information Nasrin Elahi, Ahvaz Jundishapur University of Medical Sciences
elahi-n@ajums.ac.ir
Notes Funding: Ahvaz University Of Medical Sciences
Register number: RCT2016072629086N1

Murthy 2010
Trial name or title Effect of naturopathy interventions in bronchial asthma
Methods Design: randomised wait-listed control clinical study
Method of randomisation: computer-generated randomisation
Method of allocation concealment: open list of random numbers
Blinding/masking: not applicable
Participants Individuals aged 18-65 years, with mild to moderate persistent asthma; non-smokers/stopped
smoking 6 months previously
Interventions Intervention: naturopathy and yoga interventions

Control Intervention: waiting list control
Outcomes Primary outcomes
• Nyugen asthma severity index

• Juniper asthma QoL
• Asthma control score
Secondary outcomes
•
•
Lung function
•
Perceived control of asthma questionnaire
•
Asthma diary
Epworth daytime sleepiness scale
Starting date 01 October 2009 (date of first enrolment)
Contact information INYS-Medical Research Society. Jindal Nagar
Notes N/A


Informed decisions.

Vagedes 2017
Trial name or title Effectiveness of a Buteyko-based breathing technique for asthma patients
Methods Design: randomised clinical trial
Method of allocation concealment: cross-over assignment
Total duration of study: 6 months
Outcome assessor blinding: none (open-label)
Participants Country: Germany
Setting: ARCIM Institute Academic Research in Complementary and Integrative Medicine University
Hospital Tuebingen
Total sample: 64
Inclusion criteria: written informed consent, regular intake of prescribed asthma medication ac-
cording to the AWMF scheme level 1, native speaker of German
Exclusion criteria: participation in another study, comorbidities (heart diseases, cancer still under
treatment, psychiatric diseases)
Interventions Intervention group: Buteyko breathing technique
Control group: standard care as usual
Outcomes Primary outcomes: change in end-tidal CO2, change in NQ score, change in Buteyko Control Pause
Secondary outcomes: spirometry, heart rate variability, vascular stiffness, blood pressure, haemo-
dynamics stroke volume, haemodynamics pleth variability, oxygen saturation, ACQ, AQLQ, ARCIM
Questionnaire, STAI Questionnaire, ASF questionnaire, asthma medication
Starting date 25 January 2017
Contact information Jan Vagedes, Dr. MD. ARCIM Institute Academic Research in Complementary and Integrative Medi-
cine. University Hospital Tuebingen
Notes Funding: ARCIM Institute Academic Research in Complementary and Integrative Medicine
Register number: NCT03098849
ACQ: Asthma Control Questionnaire; AQLQ: Asthma Quality of Life Questionnaire; ARCIM: Institute of Academic Research in
Complementary and Integrative Medicine; ASF: Asthma Short Form; FEV1: forced expiratory volume in first second; GPE: Global perceived
effect; HADS: Hospital Anxiety and Depression Scale: NQ: Nijmegen (Hyperventilation) Questionnaire; QoL: quality of life; RCT: randomised
controlled trial; STAI: State-Trait Anxiety Inventory

DATA AND ANALYSES

Informed decisions.

Comparison 1. Breathing exercises versus inactive control
Outcome or subgroup title No. of No. of Statistical method Effect size

studies partici-
pants
1 Change in AQLQ (up to 3 months) 4 974 Mean Difference (IV, Ran- 0.42 [0.17, 0.68]
dom, 95% CI)
1.1 Buteyko 1 59 Mean Difference (IV, Ran- 0.98 [0.55, 1.41]

dom, 95% CI)
1.2 Pranayama 1 56 Mean Difference (IV, Ran- 0.5 [0.04, 0.96]

dom, 95% CI)
1.3 Yoga 2 357 Mean Difference (IV, Ran- 0.47 [-0.33, 1.27]
dom, 95% CI)
1.4 Breathing retraining by physio 1 218 Mean Difference (IV, Ran- 0.30 [0.02, 0.58]
dom, 95% CI)
1.5 Breathing retraining DVD 1 284 Mean Difference (IV, Ran- 0.20 [-0.07, 0.47]
dom, 95% CI)
2 Number of people who improved scores in 1 655 Odds Ratio (M-H, Random, 1.34 [0.97, 1.86]
AQLQ (over 6 months) 95% CI)
2.1 Physio versus usual care 1 263 Odds Ratio (M-H, Random, 1.44 [0.88, 2.36]
95% CI)
2.2 DVD versus usual care 1 392 Odds Ratio (M-H, Random, 1.28 [0.84, 1.96]
95% CI)
3 Change in SGRQ 2 Mean Difference (IV, Ran- Totals not selected

dom, 95% CI)
3.1 3 months post baseline 1 Mean Difference (IV, Ran- 0.0 [0.0, 0.0]
dom, 95% CI)
dom, 95% CI)
dom, 95% CI)
4 Change in ACQ (up to 3 months) 1 115 Mean Difference (IV, Ran- -0.15 [-2.32, 2.02]
dom, 95% CI)
4.1 Buteyko 1 59 Mean Difference (IV, Ran- -0.21 [-2.92, 2.50]

dom, 95% CI)
4.2 Pranayama 1 56 Mean Difference (IV, Ran- -0.04 [-3.65, 3.57]

dom, 95% CI)
5 Adjusted change in ACQ (over 6 months) 1 449 Mean Difference (Random, -0.08 [-0.22, 0.07]
95% CI)
5.1 Physio versus usual care 1 193 Mean Difference (Random, -0.06 [-0.28, 0.16]
95% CI)

Informed decisions.


studies partici-
pants
5.2 DVD versus usual care 1 256 Mean Difference (Random, -0.09 [-0.28, 0.10]
95% CI)
6 Nijmegen (4 to 6 months) 2 118 Mean Difference (IV, Ran- -3.22 [-6.31, -0.13]
dom, 95% CI)
7 Adjusted change in Nijmegen (over 6 2 521 Mean Difference (Random, 0.63 [-0.90, 2.17]
months) 95% CI)
7.1 Papworth versus usual care 1 72 Mean Difference (Random, -2.3 [-6.42, 1.82]
95% CI)
7.2 Physio versus usual care 1 193 Mean Difference (Random, 1.28 [-0.92, 3.48]
95% CI)
7.3 DVD versus usual care 1 256 Mean Difference (Random, 0.9 [-1.07, 2.87]
95% CI)
8 Lung function (FEV1 in litres; up to 3 4 252 Mean Difference (IV, Ran- -0.10 [-0.32, 0.12]
months) dom, 95% CI)
9 Lung function (FEV1 % of predicted; up to 3 5 618 Mean Difference (IV, Ran- 6.88 [5.03, 8.73]
months) dom, 95% CI)
10 Adjusted change in lung function (FEV1 in 2 491 Mean Difference (Random, -0.02 [-0.08, 0.04]
litres; over 6 months) 95% CI)
10.1 Papworth versus usual care 1 67 Mean Difference (Random, 0.1 [-0.26, 0.46]
95% CI)
95% CI)
95% CI)
11 Adjusted change in lung function (FEV1 % 1 424 Mean Difference (Random, 0.49 [-2.48, 3.46]
of predicted; over 6 months) 95% CI)
11.1 Physio versus usual care 1 187 Mean Difference (Random, 0.44 [-3.96, 4.84]
95% CI)
11.2 DVD versus usual care 1 237 Mean Difference (Random, 0.53 [-3.49, 4.55]
95% CI)
12 Lung function (PEFR; up to 3 months) 5 Mean Difference (IV, Ran- Totals not selected
dom, 95% CI)
13 Adjusted change in lung function (PEFR; 2 491 Mean Difference (Random, -1.07 [-14.89, 12.74]
over 6 months) 95% CI)
13.1 Papworth versus usual care 1 67 Mean Difference (Random, 31.4 [-23.41, 86.21]
95% CI)

Informed decisions.


studies partici-
pants
95% CI)
95% CI)

Analysis 1.1. Comparison 1 Breathing exercises versus
inactive control, Outcome 1 Change in AQLQ (up to 3 months).
Study or subgroup Breathing exercises Inactive control Mean Difference Weight Mean Difference
N Mean(SD) N Mean(SD) Random, 95% CI Random, 95% CI
1.1.1 Buteyko
Prem 2013 39 1.1 (0.8) 20 0.1 (0.8) 14.54% 0.98[0.55,1.41]
Subtotal *** 39 20 14.54% 0.98[0.55,1.41]
Heterogeneity: Tau2=0; Chi2=0, df=0(P<0.0001); I2=100%
Test for overall effect: Z=4.45(P<0.0001)

1.1.2 Pranayama
Prem 2013 36 0.6 (0.9) 20 0.1 (0.8) 13.8% 0.5[0.04,0.96]
Subtotal *** 36 20 13.8% 0.5[0.04,0.96]
Heterogeneity: Not applicable
Test for overall effect: Z=2.14(P=0.03)

1.1.3 Yoga
Agnihotri 2018 150 4.9 (0.4) 150 4.8 (0.6) 24.03% 0.13[0.02,0.24]
Vempati 2009 29 5.5 (1.1) 28 4.5 (1.5) 8.85% 0.96[0.28,1.64]
Subtotal *** 179 178 32.88% 0.47[-0.33,1.27]
Heterogeneity: Tau2=0.28; Chi2=5.51, df=1(P=0.02); I2=81.84%

1.1.4 Breathing retraining by physio
Thomas 2017 105 5.2 (1) 113 4.9 (1.1) 19.26% 0.3[0.02,0.58]
Subtotal *** 105 113 19.26% 0.3[0.02,0.58]

1.1.5 Breathing retraining DVD
Thomas 2017 171 5.1 (1.2) 113 4.9 (1.1) 19.51% 0.2[-0.07,0.47]
Subtotal *** 171 113 19.51% 0.2[-0.07,0.47]

Total *** 530 444 100% 0.42[0.17,0.68]
Heterogeneity: Tau2=0.07; Chi2=20.85, df=5(P=0); I2=76.01%
Test for overall effect: Z=3.29(P=0)
Test for subgroup differences: Chi2=9.74, df=1 (P=0.05), I2=58.94%
Inactive control -2 -1 0 1 2 Breathing exercises

Informed decisions.


Analysis 1.2. Comparison 1 Breathing exercises versus inactive control,
Outcome 2 Number of people who improved scores in AQLQ (over 6 months).
Study or subgroup Breathing Inactive control Odds Ratio Weight Odds Ratio
exercises
n/N n/N M-H, Random, 95% CI M-H, Random, 95% CI
1.2.1 Physio versus usual care
Thomas 2017 85/132 73/131 42.43% 1.44[0.88,2.36]
Subtotal (95% CI) 132 131 42.43% 1.44[0.88,2.36]
Total events: 85 (Breathing exercises), 73 (Inactive control)

1.2.2 DVD versus usual care
Thomas 2017 161/261 73/131 57.57% 1.28[0.84,1.96]
Subtotal (95% CI) 261 131 57.57% 1.28[0.84,1.96]

Total (95% CI) 393 262 100% 1.34[0.97,1.86]
Heterogeneity: Tau2=0; Chi2=0.12, df=1(P=0.73); I2=0%
Test for subgroup differences: Chi2=0.12, df=1 (P=0.73), I2=0%
Inactive control 0.5 0.7 1 1.5 2 Breathing exercises

Analysis 1.3. Comparison 1 Breathing exercises versus inactive control, Outcome 3 Change in SGRQ.
Study or subgroup Breathing exercises Inactive control Mean Difference Mean Difference
1.3.1 3 months post baseline
Bidwell 2012 12 16 (10.4) 8 31.9 (14.1) -15.84[-27.27,-4.41]

Holloway 2007 33 15.9 (14) 45 16.3 (12.2) -0.4[-6.36,5.56]

Holloway 2007 32 15.2 (10.9) 40 16.7 (11.6) -1.5[-6.71,3.71]
Breathing exercises -40 -20 0 20 40 Inactive control

Analysis 1.4. Comparison 1 Breathing exercises versus inactive control, Outcome 4 Change in ACQ (up to 3 months).
1.4.1 Buteyko
Prem 2013 39 1 (1.8) 20 1.2 (6.1) 63.98% -0.21[-2.92,2.5]
Subtotal *** 39 20 63.98% -0.21[-2.92,2.5]

Informed decisions.


1.4.2 Pranayama
Prem 2013 36 1.2 (7.5) 20 1.2 (6.1) 36.02% -0.04[-3.65,3.57]
Subtotal *** 36 20 36.02% -0.04[-3.65,3.57]

Total *** 75 40 100% -0.15[-2.32,2.02]

Analysis 1.5. Comparison 1 Breathing exercises versus inactive
control, Outcome 5 Adjusted change in ACQ (over 6 months).
Study or subgroup Breathing Inactive Mean Dif- Mean Difference Weight Mean Difference
exercises control ference
N N (SE) IV, Random, 95% CI IV, Random, 95% CI
Thomas 2017 96 97 -0.1 (0.11) 43.6% -0.06[-0.28,0.16]
Subtotal (95% CI) 43.6% -0.06[-0.28,0.16]

Thomas 2017 159 97 -0.1 (0.097) 56.4% -0.09[-0.28,0.1]
Subtotal (95% CI) 56.4% -0.09[-0.28,0.1]

Total (95% CI) 100% -0.08[-0.22,0.07]

Analysis 1.6. Comparison 1 Breathing exercises versus inactive control, Outcome 6 Nijmegen (4 to 6 months).
Grammatopoulou 2011 20 14 (6.8) 20 16.4 (7.4) 48.88% -2.4[-6.82,2.02]
Holloway 2007 33 11 (9.7) 45 15 (9.5) 51.12% -4[-8.32,0.32]

Total *** 53 65 100% -3.22[-6.31,-0.13]

Informed decisions.


control, Outcome 7 Adjusted change in Nijmegen (over 6 months).
1.7.1 Papworth versus usual care
Holloway 2007 32 40 -2.3 (2.104) 13.02% -2.3[-6.42,1.82]
Subtotal (95% CI) 13.02% -2.3[-6.42,1.82]

Thomas 2017 96 97 1.3 (1.12) 39.78% 1.28[-0.92,3.48]
Subtotal (95% CI) 39.78% 1.28[-0.92,3.48]

Thomas 2017 159 97 0.9 (1.006) 47.21% 0.9[-1.07,2.87]
Subtotal (95% CI) 47.21% 0.9[-1.07,2.87]

Total (95% CI) 100% 0.63[-0.9,2.17]
Test for subgroup differences: Chi2=2.34, df=1 (P=0.31), I2=14.54%

control, Outcome 8 Lung function (FEV1 in litres; up to 3 months).
Prem 2013 36 -0.1 (0.5) 20 0.2 (0.4) 25.91% -0.28[-0.51,-0.05]
Prem 2013 39 0.1 (0.4) 20 0.2 (0.4) 27.34% -0.11[-0.32,0.1]
Pushpa 2018 30 2.3 (0.7) 30 2.1 (0.6) 21.19% 0.24[-0.07,0.55]
Singh 2012 30 2.8 (0.7) 30 2.8 (0.6) 20.31% 0[-0.33,0.33]
Vedanthan 1998 9 3.3 (0.8) 8 4.2 (1.1) 5.24% -0.9[-1.8,0]

Total *** 144 108 100% -0.1[-0.32,0.12]

Informed decisions.


Outcome 9 Lung function (FEV1 % of predicted; up to 3 months).
Aggarwal 2013 50 81.9 (6.3) 50 74.6 (6.8) 22.77% 7.37[4.79,9.95]
Agnihotri 2016 121 74.8 (4.9) 120 69.3 (6.1) 33.15% 5.44[4.04,6.84]
Gupta 2015 50 82.6 (5.3) 50 75.2 (6.5) 24.76% 7.39[5.05,9.73]
Sodhi 2009 60 83.2 (10.5) 60 77.3 (9.9) 15.82% 5.9[2.26,9.54]
Vempati 2009 29 77.9 (17.2) 28 59.9 (19.1) 3.51% 18[8.55,27.45]

Total *** 310 308 100% 6.88[5.03,8.73]
Test for overall effect: Z=7.28(P<0.0001)

Outcome 10 Adjusted change in lung function (FEV1 in litres; over 6 months).
Holloway 2007 30 37 0.1 (0.183) 2.67% 0.1[-0.26,0.46]
Subtotal (95% CI) 2.67% 0.1[-0.26,0.46]

Thomas 2017 92 95 -0 (0.043) 49.01% -0.04[-0.12,0.04]
Subtotal (95% CI) 49.01% -0.04[-0.12,0.04]

Thomas 2017 143 94 -0 (0.043) 48.33% -0[-0.09,0.08]
Subtotal (95% CI) 48.33% -0[-0.09,0.08]

Total (95% CI) 100% -0.02[-0.08,0.04]
Inactive control -0.5 -0.25 0 0.25 0.5 Breathing exercises

Informed decisions.


Analysis 1.11. Comparison 1 Breathing exercises versus inactive control, Outcome
11 Adjusted change in lung function (FEV1 % of predicted; over 6 months).
Thomas 2017 92 95 0.4 (2.247) 45.43% 0.44[-3.96,4.84]
Subtotal (95% CI) 45.43% 0.44[-3.96,4.84]

Thomas 2017 143 94 0.5 (2.05) 54.57% 0.53[-3.49,4.55]
Subtotal (95% CI) 54.57% 0.53[-3.49,4.55]

Total (95% CI) 100% 0.49[-2.48,3.46]
Heterogeneity: Tau2=0; Chi2=0, df=1(P=0.98); I2=0%
Test for subgroup differences: Chi2=0, df=1 (P=0.98), I2=0%

control, Outcome 12 Lung function (PEFR; up to 3 months).
Study or subgroup Breathing exercises Inactive control Mean Difference Mean Difference
Aggarwal 2013 50 59.7 (6) 50 47.1 (6.1) 12.68[10.31,15.05]
Agnihotri 2016 121 72.1 (5.6) 120 69.6 (5.5) 2.47[1.07,3.87]
Gupta 2015 50 84 (20.2) 50 56.2 (22) 27.8[19.52,36.08]
Sodhi 2009 60 82.5 (10.2) 60 79.4 (8.3) 3.03[-0.29,6.35]
Vempati 2009 29 85.3 (20.7) 28 56.2 (22) 29.1[18,40.2]

Outcome 13 Adjusted change in lung function (PEFR; over 6 months).
Holloway 2007 30 37 31.4 (27.966) 6.35% 31.4[-23.41,86.21]
Subtotal (95% CI) 6.35% 31.4[-23.41,86.21]


Informed decisions.

Thomas 2017 92 95 -4.8 (10.751) 42.97% -4.79[-25.86,16.28]
Subtotal (95% CI) 42.97% -4.79[-25.86,16.28]

Thomas 2017 143 94 -2 (9.9) 50.68% -1.99[-21.39,17.41]
Subtotal (95% CI) 50.68% -1.99[-21.39,17.41]
Heterogeneity: Tau2=0; Chi2=0, df=0(P<0.0001); I2=100%

Total (95% CI) 100% -1.07[-14.89,12.74]

Comparison 2. Breathing exercises versus asthma education

studies partici-
pants
1 Change in AQLQ (up to 3 months) 1 Mean Difference (IV, Random, Totals not selected
95% CI)
2 Change in AQLQ (4 to 6 months) 1 Mean Difference (IV, Random, Totals not selected
95% CI)
3 Nijmegen (up to 3 months) 1 Mean Difference (IV, Random, Totals not selected
95% CI)
4 Nijmegen (4 to 6 months) 1 Mean Difference (IV, Random, Totals not selected

95% CI)

Analysis 2.1. Comparison 2 Breathing exercises versus asthma
education, Outcome 1 Change in AQLQ (up to 3 months).
Study or subgroup Breathing exercises Education Mean Difference Mean Difference
Thomas 2009 94 0.9 (1) 89 0.9 (1) 0.04[-0.26,0.34]
Education -1 -0.5 0 0.5 1 Breathing exercises


Informed decisions.

Analysis 2.2. Comparison 2 Breathing exercises versus

asthma education, Outcome 2 Change in AQLQ (4 to 6 months).
Thomas 2009 94 1.1 (1) 89 0.7 (1.1) 0.38[0.08,0.68]
Education -2 -1 0 1 2 Breathing exercises

Analysis 2.3. Comparison 2 Breathing exercises versus asthma education, Outcome 3 Nijmegen (up to 3 months).
Thomas 2009 94 -5.5 (6.9) 89 -4.3 (6.9) -1.24[-3.23,0.75]
Breathing exercises -20 -10 0 10 20 Education

Analysis 2.4. Comparison 2 Breathing exercises versus asthma education, Outcome 4 Nijmegen (4 to 6 months).
Thomas 2009 94 -6.7 (7.6) 89 -3.5 (7.6) -3.16[-5.35,-0.97]
Breathing exercises -10 -5 0 5 10 Education

ADDITIONAL TABLES

Table 1. Characteristics of the included studies
Study N ran- Interven- Comparator Outcomes Duration Fol- Participants' baseline characteristics
(coun- domised tion low-up
try) of inter- Mean Male Asthma severity
vention (%)
agea
(years)
Library
Cochrane
Aggar- 100 Yoga Inactive control (not prac- LF 3 months NF NR NR Mild to moderate
wal tising yoga) persistent
2013
(India)
Better health.
Agni- 276 Yoga Usual care LF 6 months NF NR NR Mild to moderate

Trusted evidence.
hotri persistent
Informed decisions.
2016

(India)
Agni- 300 Yoga Usual care QoL 6 months NF NR NR Mild to moderate

hotri persistent
2018
(India)
Bid- 19 Yoga Inactive control (not prac- QoL, LF 10 weeks NF 40.0 to 0 Mild to moderate
well tising yoga or any breath- 43.0
2012 ing exercise)
(USA)
Fluge 36 Yoga Inactive control (no addi- LF 3 weeks NF 48.8 38.9 Mild
1994 tional treatment)
(Ger-
many)
Girodo 55 Deep di- Inactive control (waiting Asthma symptoms 16 weeks 8 weeks 28.6 to 40.0 NR
1992 aphragmat- list) 32.9
(Cana- ic breathing
da)
Gram- 40 Breathing Inactive control (no addi- QoL, asthma control, hyper- 6 months NF 45.4 to 57.5 Mild to moderate
matopoulou retraining tional treatment) ventilation symptoms, LF, 48.1
2011 capnography
(Greece)
Gupta 100 Yoga Usual care LF 3 months NF NR NR NR

2015
74

Table 1. Characteristics of the included studies (Continued)
(India)
Hol- 85 Papworth Usual care QoL, hyperventilation 6 months 6 49.3 to 42.3 Mild to moderate
loway symptoms, LF, capnography months 50.2
2007
(UK)
Library
Cochrane
Malarvizhi 250 Yoga Usual care QoL 6 months NF NR 55.6 Mild to moderate
2018
(India)
Na- 106 Yoga Usual care LF, exacerbations 54 months NF 26.4

Better health.
garath-
Trusted evidence.
Informed decisions.
na
1985

(India)
Prasan- 100 Buteyko Usual care LF, asthma symptoms 2 months NF 37.4 to 38.0 NR
na 40.4
2015
(India)
Prem 120 Buteyko and Usual care QoL, asthma symptoms, LF 3 months NF 35 to 41 39.2 Mild to moderate
2013 pranayama
(India)
Push- 60 Yoga Usual care LF 8 weeks NF 31.0 to 33.3 Mild to moderate

pa 32.7
2018
(India)
Sat- 71 Yoga Usual care Exacerbations, dyspnoea, 4 months NF 25.0 to 100.0 Persistent, chronic
pathy asthma symptoms 25.3
2016
(India)
Singh 60 Yoga Inactive control (no addi- QoL, LF 2 months NF NR NR Mild to moderate
2012 tional treatment)
(India)
Sodhi 120 Yoga Usual care QoL, LF 8 weeks NF 35.5 to 59.2 Mild to moderate
2009 38.8
(India)
75

Table 1. Characteristics of the included studies (Continued)
Thomas 33 Breathing Asthma education QoL, hyperventilation 6 months NF 48.8 to 21.2 NR
2003 retraining symptoms 48.9
(UK)
Thomas 183 Breathing Asthma education QoL, asthma control, hyper- 6 months NF 46.0b 45.9 Mild to moderate
Library
2009 retraining ventilation symptoms, LF,

Cochrane
(UK) capnography
Thomas 655 Breathing Usual care QoL, asthma control, airway 12 months NF 57.0 36.0 Mild to moderate
2017 retraining inflammation, hyperventila-
(UK) tion symptoms
Better health.
Trusted evidence.
Vedan- 17 Yoga Usual care LF, asthma symptoms 16 weeks NF 26.5 47.0 Mild to moderate
Informed decisions.
than

1998
(USA)
Vem- 57 Yoga Usual care QoL, LF 8 weeks NF 33.4 to 36.8 Mild to moderate
pati 33.5
2009
(India)
LF: lung function; N: number of participants; NF: no follow-up; NR: not reported; QoL: quality of life
aRange across treatment arms reported where overall data were not reported.
bMedian and IQR.

76

Informed decisions.


APPENDICES
Appendix 1. Description of terms

Buteyko method is a breathing exercise that uses a combination of slow and reduced-volume breathing with breath control and breath-
holding exercises to normalise the breathing pattern (Bruton 2005; Courtney 2008). This method aims to help people normalise their
breathing patterns and to avoid their tendency to hyperventilate (Austin 2013; Chaitow 2014).
Diaphragmatic breathing emphasises the contraction of the diaphragm, expansion of the belly, and a deep inhale and exhale of breath
(Ma 2017). Initially, people should be trained in this technique by 'tactile stimulation' by placing the therapist's (or patient's) hand over
the patient's abdomen and on the upper chest, and by 'visual stimulation' by looking at abdominal and chest movement. The patient
should be in a comfortable and appropriate position, and the therapist must tell the patient to breathe deeply, and then exhale. During the
inhale, the hand placed on the abdomen should rise. In the exhale, the patient should be instructed to actively contract their abdominal
muscles. Pursed-lip breathing can be included during the exhalation. Diaphragmatic breathing aims to improve ventilation and decrease
the activity of the respiratory muscle by minimising the work of breathing (Watchie 2010; Bandy 2012). This technique is also referred to
as belly, deep or abdominal breathing (Varvogli 2011; Ma 2017).
Papworth method is focused on a sequence of components that includes integrated breathing and relaxation exercises combined with
education. This method aims to improve breathing patterns and minimise hyperventilation by using diaphragmatic breathing, with a slow
nasal expiration (Holloway 2007).
Spirometry is a non-invasive physiological test that measures the maximal volume of air inspired and expired with maximal effort (Graham
2019). The test can be performed by using a spirometer with different techniques. The person is asked to take a complete breath in, press
their lips around a mouthpiece, then perform a full fast expiration, and follow with an inspiration. To ensure no air escape, a nose clip must
be used. The spirometry test has been used to assess ventilatory function and as a tool to detect the presence of lung disease (Barreiro
2004; Moore 2012). The forced vital capacity (FVC) is the total volume of air exhaled during a forced and complete expiration. The expiratory
volume in the first second (FEV1) is the volume of air exhaled in the first second under force after a maximal inhalation. The percentage
of the FVC expired in one second is expressed as FEV1/FVC. The vital capacity (VC) is the total volume of air that can be exhaled as fast as
possible. The forced expiratory flow (FEF), also known as mid-expiratory flow, is the average flow that can be recorded at 25%, 50% and
75% of the FVC (Graham 2019).
Yoga has been described as techniques used for relaxation and is known as therapy for mind and body improvements (Bernardi 2000). Yoga
includes a combination of body postures (asanas), breathing exercises (pranayamas or yogic breathing exercises), and meditation (dhyana)
(Riley 2004; Hakked 2017). Many yoga breathing exercises have been described in the literature. These exercises can have different pace
(rate and depth of respiration), alteration of nostrils or breath-hold, and they also combine abdominal, thoracic and clavicular breathing
phases (Muktibodhananda 2002; Lopes 2018).
Appendix 2. Sources and search methods for the Cochrane Airways Specialised Register (CAGR)
Electronic searches: core databases

Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane From inception Monthly
Register of Studies (CRS)
MEDLINE (Ovid SP) 1946 onwards Weekly
Embase (Ovid SP) 1974 onwards Weekly
PsycINFO (Ovid SP) 1967 onwards Monthly
CINAHL (EBSCO) 1937 onwards Monthly
AMED (EBSCO) From inception Monthly

Informed decisions.

Handsearches: core respiratory conference abstracts

Conference Years searched
American Academy of Allergy, Asthma and Immunology (AAAAI) 2001 onwards
American Thoracic Society (ATS) 2001 onwards
Asia Pacific Society of Respirology (APSR) 2004 onwards
British Thoracic Society Winter Meeting (BTS) 2000 onwards
Chest Meeting 2003 onwards
European Respiratory Society (ERS) 1992, 1994, 2000 onwards
International Primary Care Respiratory Group Congress (IPCRG) 2002 onwards
Thoracic Society of Australia and New Zealand (TSANZ) 1999 onwards
MEDLINE search strategy used to identify studies for the Cochrane Airways Specialised Register
Asthma search
1. exp Asthma/
2. asthma$.mp.
3. (antiasthma$ or anti-asthma$).mp.
4. Respiratory Sounds/
5. wheez$.mp.
6. Bronchial Spasm/
7. bronchospas$.mp.
8. (bronch$ adj3 spasm$).mp.
9. bronchoconstrict$.mp.
10. exp Bronchoconstriction/
11. (bronch$ adj3 constrict$).mp.
12. Bronchial Hyperreactivity/
13. Respiratory Hypersensitivity/
14. ((bronchial$ or respiratory or airway$ or lung$) adj3 (hypersensitiv$ or hyperreactiv$ or allerg$ or insufficiency)).mp.
15. ((dust or mite$) adj3 (allerg$ or hypersensitiv$)).mp.
16. or/1-15
Filter to identify randomised controlled trials

1. exp "clinical trial [publication type]"/

Informed decisions.

2. (randomised or randomised).ab,ti.
3. placebo.ab,ti.
4. dt.fs.
5. randomly.ab,ti.
6. trial.ab,ti.
7. groups.ab,ti.
8. or/1-7
9. Animals/
10. Humans/
11. 9 not (9 and 10)
12. 8 not 11
The MEDLINE strategy and randomised controlled trial filter are adapted to identify studies in other electronic databases.
Appendix 3. Search strategy to identify relevant studies from the Cochrane Airways Specialised Register
Via the Cochrane Register of Studies (CRS)
#1 AST:MISC1
#2 MeSH DESCRIPTOR Asthma Explode All
#3 asthma*:ti,ab
#4 #1 or #2 or #3
#5 MeSH DESCRIPTOR Breathing Exercises
#6 (breath*) NEAR5 (technique* or exercise* or re-train* or train* or re-educat* or educat* or physiotherap* or "physical therapy" or
"respiratory therapy")
#7 buteyko or "qigong yangsheng" or pranayama* OR yoga*
#8 "breathing control"
#9 #5 or #6 or #7 or #8
#10 #4 and #9
In search line #1, MISC1 denotes the field in the record where the reference has been coded for condition, in this case, asthma.
WHAT'S NEW

Date Event Description
4 April 2019 New citation required and conclusions Nine studies and 1910 participants added. The background and
have changed review text has been updated partially throughout. Added details
of study funder to characteristics included studies.
4 April 2019 New search has been performed Literature search run

HISTORY
Protocol first published: Issue 4, 1998
Review first published: Issue 3, 2000

Informed decisions.

Date Event Description
30 January 2013 New citation required and conclusions Eight new studies included; two formerly included studies ex-
have changed cluded. New author team. Title changed to specify that the re-
view pertains to adults only. Summary of findings table added.
21 July 2008 Amended Converted to new review format
16 September 2003 New citation required and conclusions Substantive amendment

have changed

CONTRIBUTIONS OF AUTHORS
Thayla Santino: selected the studies, assessed the risk of bias, entered data into Review Manager 5, interpreted data and drafted the final
review.
Gabriela Chaves: extracted data, assessed the risk of bias, entered data into Review Manager 5, carried out the analysis, interpreted data
and drafted the final review.
Diana Freitas: selected the studies, entered data into Review Manager 5, carried out the analysis, interpreted data and drafted the final
review.
Guilherme Fregonezi: extracted data
Karla Mendonça: co-ordinated the review, made an intellectual contribution, extracted data, assessed the risk of bias, interpreted data
and drafted the final review.
Contributions of editorial team

Rebecca Fortescue (Co-ordinating Editor): edited the review.
Chris Cates (Co-ordinating Editor) checked the data entry prior to the full write-up of the review, advised on methodology, interpretation
and content; approved the final review prior to publication.
Anne Holland (Editor): edited the review; advised on methodology, interpretation and content.
Emma Dennett (Managing Editor): co-ordinated the editorial process; advised on interpretation and content; edited the review.
Emma Jackson (Assistant Managing Editor): conducted peer review; edited the Plain language summary and reference sections of the
protocol and the review.
Elizabeth Stovold (Information Specialist): designed the search strategy; ran the searches; edited the search methods section.
DECLARATIONS OF INTEREST
TAS: none known
GSSC: none known
DAF: none known
GAFF: none known
KMPPM: none known
SOURCES OF SUPPORT
Internal sources
• The review authors declare that no such funding was received for this systematic review, Other.
External sources
• Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), Brazil.
TAS is a PhD scholarship holder funded by CAPES (Finance Code 001).
DIFFERENCES BETWEEN PROTOCOL AND REVIEW
For the 2019 update, we have included one new author in the current version of this review. We have amended the 'Type of interventions'
description, to make clearer that all participants assigned to treatment comprising breathing retraining were included. We included studies

Informed decisions.

with participants with a mean age of over 18 years old, rather than studies enrolling only people aged over 18 years. We felt that the studies
were reflective of a relevant, adult population. We have included an additional description regarding the age in the 'Type of participants'
section. We have introduced the type of breathing exercise as a subgroup analyses criteria.
We included the change in asthma symptoms measured by asthma control questionnaire (ACQ), change in hyperventilation symptoms
measured by the Nijmegen Questionnaire in the 'Summary of findings' table. We have added 'hyperventilation symptoms' as a
complementary information to the original secondary outcome 'asthma symptoms'.
We initially stated that we used a fixed-effect model unless there was substantial heterogeneity and for this 2019 update we used the
random-effects method, which considers that different studies are estimating different, yet related, intervention effects. We included a
statement to make clearer that we used intention-to-treat analyses instead of per-protocol/completer analyses, when both were reported.
INDEX TERMS
Medical Subject Headings (MeSH)

*Breathing Exercises; Asthma [physiopathology] [*rehabilitation]; Disease Progression; Quality of Life; Randomized Controlled Trials
as Topic; Respiratory Function Tests
MeSH check words

Adult; Humans


Breathing Exercises For Adults With Asthma

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Santino TA, Chaves GSS, Freitas DA, Fregonezi GAF, Mendonça KMPP.

Breathing exercises for adults with asthma (Review) i

Breathing exercises for adults with asthma

Editorial group: Cochrane Airways Group.

The most recent literature search was on 4 April 2019.

Data collection and analysis

Breathing exercises versus inactive control

Breathing exercises versus asthma education

Breathing exercises for asthma

Breathing exercises for adults with asthma (Review) 2

Certainty of the evidence

The evidence is current to April 2019.

Breathing exercises for adults with asthma (Review) 3

Breathing exercises compared to inactive control for adults with asthma

Patient or population: adults with asthma

fect pants the evidence

(95% CI) (studies) (GRADE)

Risk with inactive Risk with breathing

Breathing exercises for adults with asthma (Review)

Range 1-7, with higher

Follow-up: < 3 months

Scores range 1-5 with

higher) vance (Enright 2004; Tepper 2012)

Follow up: < 3 months

Breathing exercises for adults with asthma (Review)

GRADE Working Group grades of evidence

BACKGROUND individual issues that impair health-related quality of life and

hyperventilation, control of breathing volume, relaxation of Types of outcome measures

• Number of acute exacerbations (mean number and number of

• Inpatient hospitalisation episodes

• General practitioner (GP) or hospital outpatient appointments

• Days off work

• Participant's subjective evaluation of the intervention

This is an update of a review last published in 2013, in which Electronic searches

Breathing exercises for adults with asthma (Review) 7

Data collection and analysis Dealing with missing data

• Methods (design, method of randomisation, method of

• Participants (country, health status, mean age, gender, total

• Interventions (methods and types of intervention, including

• Outcomes (improvement in quality-of-life indices, asthma

• Study quality (RCTs with poor methodology)

• Allocation concealment (high risk of bias versus low risk of bias

Breathing exercises for adults with asthma (Review) 8

Breathing exercises for adults with asthma (Review) 9

Figure 1. Study flow diagram

Breathing exercises for adults with asthma (Review) 10

Breathing exercises for adults with asthma (Review) 12

Breathing exercises for adults with asthma (Review) 13

Breathing exercises for adults with asthma (Review) 14

Breathing exercises for adults with asthma (Review) 15

Breathing exercises for adults with asthma (Review) 16

Breathing exercises for adults with asthma (Review) 18

DISCUSSION Certainty of the evidence

Breathing exercises for adults with asthma (Review) 19

Breathing exercises for adults with asthma (Review) 20

Breathing exercises for adults with asthma (Review) 21

Breathing exercises for adults with asthma (Review) 24

Bateman 2008 Courtney 2008

Boulding 2016 Denehy 2016

Gillis 2017 Juniper 2004

GRADEpro GDT [Computer program] Kew 2016

Grammatopoulou 2014 Lopes 2018

Hakked 2017 Ma 2017