Medical Manuscript

American Journal of Hospice

& Palliative Medicine®
The Efficacy of a Single Session of 20-Minute 1-7
ª The Author(s) 2020
Article reuse guidelines:
Mindful Breathing in Reducing Dyspnea sagepub.com/journals-permissions
DOI: 10.1177/1049909120934743
Among Patients With Acute journals.sagepub.com/home/ajh

Decompensated Heart Failure:

A Randomized Controlled Trial

Diana Leh-Ching Ng, MMED1, Chee-Shee Chai, MMED1,

Kok-Leng Tan, MMED2, Kok-Han Chee, MMED3,
Yu-Zhen Tung, MBBS3, Suet-Yen Wai, MBBS3,
Wei-Ting Joyce Teo, MBBS3, Bin-Ting Ang, MBBS3,
Min-Ai Lim, MBBChBAO3, and Seng-Beng Tan, MRCP3

Abstract
Heart failure is the leading cause of morbidity and mortality worldwide. Standard treatment for heart failure includes
pharmacotherapy and cardiac device implants. However, supportive approaches in managing dyspnea in heart failure are
limited. This study aimed to test the efficacy of 20-minute mindful breathing in reducing dyspnea among patients admitted for
acute decompensated heart failure. We conducted a parallel-group, non-blinded, randomized controlled trial of a single session of
20-minute mindful breathing plus standard care versus standard care alone among patients admitted for moderate to severe
dyspnea due to acute decompensated heart failure, using the dyspnea score based on the Edmonton Symptom Assessment System
(ESAS), at the Cardiology Unit of University Malaya Medical Centre in Malaysia. Thirty participants were randomly assigned to a
single session of 20-minute mindful breathing plus standard care (n ¼ 15) or standard care alone (n ¼ 15), with no difference in
their demographic and clinical characteristics. There was statistically significant reduction in dyspnea in the intervention group
compared to the control group at minute 20 (U ¼ 49.5, n1 ¼ 15, n2 ¼15, median reduction in ESAS dyspnea score 1 ¼ 2, median
reduction in ESAS dyspnea score 2 ¼ 0, mean rank 1 ¼ 11.30, mean rank 2 ¼ 19.70, z ¼ 2.692, r ¼ 0.4, P ¼ 0.007). Our results
provided evidence that a single session of 20-minute mindful breathing was efficacious in reducing dyspnea for patients admitted
for acute decompensated heart failure.

Keywords
mindfulness, mindful breathing, dyspnea, heart failure, palliative care

Introduction training to improve functional status.1,6,7 There is also usage

Heart failure is the leading cause of morbidity and mortality
worldwide with a prevalence of 26 million.1 Comparing to its
incidence that has plateaued, the prevalence of heart failure is
expected to rise due to the aging population.2 Hospitalization
for heart failure particularly results in significant socioeco-
nomic burden due to increased healthcare expenditure.2-5 It has
been estimated that more than half of the total expenditure
related to heart failure results from hospitalizations, while
pharmacotherapy contributed to 18% of the cost.4
Current standard treatment for congestive heart failure
includes pharmacological interventions such as diuretics,
b-blockers, angiotensin-converting enzyme inhibitors, and
angiotensin receptor blockers, while nonpharmacological inter-
ventions includes patient education for self-care and exercise
of device interventions such as implantable cardioverter-
defibrillator, cardiac resynchronization therapy, and left
ventricular–assisted device.6,7 Despite therapeutic advances,
1
Department of Medicine, Faculty of Medicine and Health Science, University
Malaysia Sarawak, Kota Samarahan, Sarawak, Malaysia
2
Department of Medicine, Faculty of Medicine, University Sains Malaysia,
Kelantan, Malaysia
3
Department of Medicine, Faculty of Medicine, University of Malaya, Kuala
Lumpur, Malaysia
Corresponding Author:
Seng-Beng Tan, MRCP, Department of Medicine, Faculty of Medicine,
University of Malaya, Lembah Pantai, 59100 Kuala Lumpur, Malaysia.
Email: pramudita_1@hotmail.com
2 American Journal of Hospice & Palliative Medicine®
the overall 5-year mortality rate remains approximately 50%.
The percentage of patients with heart failure who have end-
stage, refractory heart failure, accounts for 5% to 10% of the
total population.7-10
A novel treatment modality being investigated for the treat-
ment of heart failure is enhanced external counterpulsation
(EECP).11 Enhanced external counterpulsation is a noninvasive,
outpatient therapy consisting of electroencephalogram-gated
sequential leg compression, which produces hemodynamic
effects similar to an intraaortic balloon pump. Preliminary data
showed that EECP improved left ventricular function, func-
tional status, and quality of life in patients experiencing heart
failure and could be a useful adjunct to medical therapy.12,13
However, more data from prospective, randomized, con-
trolled trials are needed to verify the efficacy of EECP as an
adjunctive therapy in managing chronic stable heart failure.11
The increasing prevalence and severity of heart failure to-
gether with poor quality of life among patients with advanced
disease states mandate a search for new, cost-effective
therapies.14
Mindful breathing is an exercise that involves paying atten-
tion to one’s breathing without getting distracted by the envi-
ronment or other inner experiences.15 This maneuver had been
proven to alleviate distress in patients receiving palliative care
and to reduce dyspnea in patients with chronic lung dis-
eases. 16-18 A recent study reported that an 8-week
mindfulness-based intervention could reduce self-reported
symptoms of dyspnea, fatigue, and dizziness compared to con-
ventional treatment alone in out-patients with symptomatic
congestive cardiac failure.19 However, there was no research
which examined the impact of a single session of 20-minute
mindful breathing on patients admitted to hospital due to acute
decompensated congestive cardiac failure. In this study, we
aimed to compare the efficacy of a single session of 20-
minute mindful breathing in reducing dyspnea among patients
with acute decompensated heart failure.
Methods
A parallel-group, non-blinded, randomized controlled study
was conducted at the Cardiology Unit of the University of
Malaya Medical Centre (UMMC), Malaysia from August 1,
2018 to April 30, 2019. Ethics approval was obtained from the
Medical Research Committee of UMMC (MREC no:
2018726430). The study was conducted in accordance with the
Declaration of Helsinki. The inclusion criteria were patients
with acute decompensated heart failure, aged 18 years and
above, with left ventricular ejection fraction (LVEF) of
40% as measured using 3-dimensional transthoracic echocar-
diography and a dyspnea score of 4 or more based on the
dyspnea score from the Edmonton Symptom Assessment Sys-
tem (ESAS). Patients were excluded if they had impaired cog-
nition or conscious level, or psychiatric illnesses that would
prevent them from giving informed consent or from participat-
ing fully in the study. Those with previous experience of
mindfulness practice, a recent history of chest pain, or on non-
invasive mechanical ventilation were also excluded.
Patients who were admitted to the Cardiology ward were
approached and screened for eligibility. Written informed con-
sent was obtained from the eligible patients. Participants were
randomized into either intervention or control group based on
computer-generated random numbers with 1:1 allocation ratio.
The control group would receive standard care by hospital’s
cardiology team while the intervention group would receive a
single session of 20-minute mindful breathing in addition to
standard care. Demographic information and clinical data were
obtained from the hospital Electronic Medical Records system.
Each participant’s premorbid functional status was classified
based on the New York Heart Association (NYHA) classifica-
tion system.20 The underlying aetiologies and pharmacothera-
pies of congestive heart failure were classified based on the
2016 European Society of Cardiology Guideline.6 Dyspnea
was scored using the dyspnea score based on the ESAS. Parti-
cipants from the intervention group who were given a
20-minute mindful breathing session guided by 1 of the 4
investigators, who were medical doctors. They were trained
by the corresponding author, a palliative care consultant who
was also a certified mindfulness trainer. The training included a
brief explanation of basic concepts of mindfulness and its prac-
tice, followed by a 20-minute mindful breathing session guided
by the trainer. Guidance on delivering the intervention with
attention to paralanguage (rate, rhythm, volume, pitch, intona-
tion, and articulation) and body language (eye contact, facial
expression, posture, and bodily movement), followed by super-
vision of the actual delivering of 20-minute intervention by
each investigator were provided. The 20-minute mindful
breathing session was conducted in patients’ preferred lan-
guages (English, Malay, or Mandarin). Participants from the
intervention group were instructed to relax their body, close
their eyes and pay attention to their breathing. If they noticed
any distractions, they were told to redirect their attention back
to their breathing. The instructions to conduct the 20-minute
mindful breathing are shown in Table 1. Participants allocated
to the control group were given standard care alone by the
hospital’s cardiology team. They were told by the investigators
to rest in bed during the study period.
The study outcomes were assessed at minute 0 (T0) and
minute 20 (T20) for both groups by the same investigator. The
measured outcomes were ESAS dyspnea score, respiratory
rate, oxygen saturation, pulse rate, systolic, and diastolic blood
pressure. Vital signs were obtained directly by the investigators
and not from the medical records. Respiratory rates were
counted in 1 minute. The measured outcomes were compared
between participants of both groups to assess the efficacy of
20-minute mindful breathing.
The ESAS is a valid and reliable tool to assess nine common
symptoms experienced by cancer patients.21,22 The nine symp-
toms include pain, tiredness, nausea, depression, anxiety,
drowsiness, appetite, well-being, and dyspnea. The severity for
each symptom upon assessment has a rating from 0 to 10 on a
numerical scale; with 0 indicating absence of the symptom and
Ng et al
Table 1. Instructions for 20-Minute Mindful Breathing.
Step 1 (5 minutes)
Make yourself comfortable
Relax your body
Close your eyes gently
Take two deep breaths slowly
Then, breathe naturally
Notice the flow of air through your nose
Rest your attention gently on your breath
Breathing in, you know you are breathing in
Breathing out, you know you are breathing out
In-out, in-out, in-out
If you are distracted by any sounds, bodily sensations, thoughts or
feelings, gently come back to your breath
Be aware of your in and out-breath for the next few minutes
Step 2 (5 minutes)
Continue to relax your body with your eyes closed
Continue to pay attention to your breath
Follow the entire length of your breath
From the beginning, the middle and the end of your in-breath, to the
beginning, middle and the end of your out-breath
If you are breathing in a long breath, you know you are breathing in a
long breath
If you are breathing in a short breath, you know you are breathing in
a short breath
If you are breathing out a long breath, you know you are breathing
out a long breath
If you are breathing out a short breath, you know you are breathing
out a short breath
Do not force yourself to take a long or short breath
Just breathe naturally
Be aware of the entire length of the breath
In-in-in, out-out-out, in-in-in, out-out-out, in-in-in, out-out-out
If you are distracted by any sounds, bodily sensations, thoughts or
feelings, gently come back to your breath
Follow the entire length of your breath for the next few minutes
10 indicating the worst symptom severity. For this study, the
numerical rating scale for dyspnea in ESAS was used to rate the
severity of dyspnea in participants.
A planned sample size of 68 (34 per arm) patients was cal-
culated and powered to detect the effect size difference between
the 2 study arms of 1.66 standard deviation units, with a 2-tailed
type 1 error rate of 0.05 and 80% power. 15 Because of logistic
reasons, the study was terminated after 30 participants were
enrolled. The number of heart failure patients who fulfilled the
criteria for enrollment was small. Data analyses was performed
using the software package, Statistical Package for the Social
Sciences (SPSS for Windows version 25.0, SPSS Inc).
Results for categorical variables were expressed in percen-
tages. Results for continuous variables were expressed as mean
+ standard deviation or median with interquartile range for
parametric and nonparametric data respectively. Between-
group demographic and clinical characteristics differences
were tested for its significance using the w2 test or Fisher exact
test for categorical variables; and Student t test or Mann-
Whitney U test for continuous variables. Between-group out-
come differences at T0 and T20, as well as its outcome changes
3
Step 3 (5 minutes)
As you follow the entire length of your breath, bring your mind back
to your body
Instead of thinking about the past or future, bring your mind back
to NOW
Bring your mind and body together as one
As you breathe in, feel your whole body moving with your
breathing in
As you breathe out, feel your whole body moving with your
breathing out
Breathing in, you are aware of your whole body as you are
breathing in
Breathing out, you are aware of your whole body as you are
breathing out
Feel the different parts of your body as you breathe in and out
Then, feel the body as a whole, fully united with your mind
Feel the wholeness of yourself with each breath for the next
few minutes
Step 4 (5 minutes)
Once your breathing is harmonious, your body will relax naturally
Feel whether there is any tension in your body
Breathe and relax the tension one by one, from the top to the
bottom
Relax your head, face, neck, arms, forearms, hands, chest, abdomen,
legs, and feet
Then relax your whole body all at once
Breathing in, you calm your body when you are breathing in
Breathing out, you smile
Again, breathing in, you calm your body when you are breathing in
Breathing out, you smile
In-out-calm-smile, in-out-calm-smile, in-out-calm-smile
Feel your breath flowing through your body and calming your body
Feel your breath leaving your body and smile
Continue to relax your whole body for the next few minutes
from T0 to T20, were tested for significance using Student t test
or Mann-Whitney U test depending on data normality. All tests
were 2-tailed with a significance level of 0.05.
Results
A total of 76 patients were screened for eligibility. Thirty-six
patients had ESAS dyspnea score <4, 3 patients had language
barrier, 2 patients refused consent, 2 on noninvasive ventila-
tion, 1 patient was too breathless, 1 in pain, and 1 confused
(Figure 1). None of the screened patients had a previous expe-
rience with mindfulness practice. Thirty patients were ran-
domly assigned to either single session of 20-minute mindful
breathing plus standard care (n ¼ 15) or standard care alone
(n ¼ 15). All recruited patients successfully completed the
study and were included in the analyses.
Patients’ demographic and baseline clinical characteristics
are presented in Table 2. The mean age of the patients was
60 years old. The majority of patients was male (83.3%) and
married (83.3%). There were equal proportion of Chinese
(33.3%) and Indian (33.3%), followed by Malay (30.0%) and
4 American Journal of Hospice & Palliative Medicine®
Patients with acute decompensated heart
failure and ejection fraction ≤40%
assessed for eligibility
(n = 76)
Randomized
(n = 30)
20-minute mindful breathing + standard care
(n = 15)
Analysed
(n = 15)
Figure 1. Consolidated Standards of Reporting Trials diagram.
Sikh (3.3%). Islam was the commonest religion (33.3%), fol-
lowed by Buddhist (26.7%), Hinduism (20%), Christian
(16.7%), and Sikh (3.3%). Most patients spoke English
(56.7%), followed by Malay (30%) and Mandarin (13.3%). The
mean LVEF of the patients was 26.5%. Almost equal number
of patients had NYHA 2 (30.0%), 3 (36.7%), and 4 (33.3%).
Ischemic heart disease (80.0%) was the most common cause of
heart failure. Other underlying causes of heart failure included
nonischemic cardiomyopathy (10%), hypertensive heart dis-
ease (6.7%), and arrhythmia (3.3%). The most commonly pre-
scribed heart failure drugs were b blockers (53.3%), followed
by spironolactone (36.7%), angiotensin converting enzyme
inhibitors (33.3%), and digoxin (6.7%). There was no signifi-
cant difference in the demographic and clinical characteristics
between intervention and control group, except the former had
significantly higher mean LVEF (30.5% + 7.3% vs 22.4% +
7.0%, P ¼0.007) but significantly worse functional status
(NYHA 4%-46.7% vs 20.0%, P ¼ 0.029).
The study outcomes at T0 and T20 are shown in Table 3. At
T0, there was no statistically significant difference between the
2 groups with regard to dyspnea score, respiratory rate, oxygen
saturation, pulse rate, and blood pressures. At T20, there were
statistically nonsignificant trends of lower dyspnea score,
Excluded (n = 46)
ESAS dyspnoea score <4 (n = 36)
Language barrier (n = 3)
Refused consent (n = 2)
On non-invasive mechanical ventilation (n = 2)
Too breathless (n = 1)
In pain (n = 1)
Confused (n = 1)
Standard care
(n = 15)
Analysed
(n = 15)
higher oxygen saturation and lower pulse rate in the interven-
tion group compared to the control group.
Regarding between-group comparisons of changes in para-
meters as shown in Table 4, there was statistically significant
reduction in dyspnea in the mindful breathing group compared
to the control group at minute 20 (U ¼ 49.5, n1 ¼ 15, n2 ¼15,
mean rank1 ¼ 11.30, mean rank2 ¼ 19.70, z ¼ 2.692, r ¼ 0.4,
P ¼ 0.007). However, there was no statistically significant
difference noted between both groups for their changes in other
parameters. Nonsignificant trends were noted in the improve-
ment of oxygen saturation and the decrease in pulse rate. There
was no adverse outcome reported in both groups.
Discussion
This is the first study to show the efficacy of a single session 20-
minute mindful breathing in reducing dyspnea among patients
admitted for acute decompensated heart failure. The guided
mindful breathing practice had reduced dyspnea at minute 20
(median reduction ¼ 2). The minimal clinically important
difference for ESAS individual items is 1 unit.23 Hence, 20-
minute mindful breathing caused a statistically and clinically
significant improvement in dyspnea among inpatients with
Ng et al 5

Table 2. Demographic and Clinical Characteristics of Patients With Acute Decompensated Heart Failure.

Techniques

20-minute
mindful breathing Control
Demographic and clinical characteristics (n ¼ 15) (n ¼ 15) P value

Age, mean + SD (years) 60.7 + 11.2 59.2 + 8.0 0.293a

Gender, n (%)
Male 13 (86.7) 12 (80.0) 0.999b
Female 2 (13.3) 3 (20.0)
Ethnicity, n (%)
Malay 6 (40.0) 3 (20.0) 0.308c
Chinese 3 (20.0) 7 (46.7)
Indian 5 (33.3) 5 (33.3)
Sikh 1 (6.7) 0 (0)
Language, n (%)
English 8 (53.3) 9 (60.0) 0.357d
Malay 6 (40.0) 3 (20.0)
Mandarin 1 (6.7) 3 (20.0)
Religion, n (%)
Islam 6 (40.0) 4 (26.7) 0.525d
Buddhism 4 (26.7) 4 (26.7)
Hinduism 3 (20.0) 3 (20.0)
Christianity 1 (6.7) 4 (26.7)
Sikh 1 (6.7) 0 (0)
Marital status, n (%)
Single 1 (6.7) 2 (13.3) 0.830d
Married 13 (86.6) 12 (80.0)
Divorced 1 (6.7) 1 (6.7)
Ejection fraction, median (IQR) 30.0 (10) 20.0 (11) 0.007d
Mean LVEF, mean + SD 30.5 + 7.3 22.4 + 7.0 0.007d
NYHA classification, n (%)
2 6 (40.0) 3 (20.0) 0.029d
3 2 (13.3) 9 (60.0)
4 7 (46.7) 3 (20.0)
Causes of heart failure, n (%)
Ischemic heart disease 13 (86.6) 11 (73.3) 0.682d
Non-ischemic cardiomyopathy 1 (6.7) 2 (13.3)
Hypertensive heart disease 1 (6.7) 1 (6.7)
Arrhythmia 0 (0) 1 (6.7)
Heart failure treatment, n (%)
On ACE inhibitor 5 (33.3) 5 (33.3) 1.000d
On b blocker 8 (53.3) 8 (53.3) 1.000d
On spironolactone 5 (33.3) 6 (40.0) 0.705d
On digoxin 2 (13.3) 0 (0) 0.143d

Abbreviations: ACE, angiotensin-converting Enzyme; IQR, interquartile range; LVEF, left ventricular ejection fraction; NYHA, New York Heart Association.
a
P values from t test.
b
P values from Fisher exact test.
c
P values from w2 test.
d
P values from Mann-Whitney U test.

acute decompensated heart failure, with a moderate effect size
of r ¼ 0.4. Compared to a previous randomized controlled study
on an 8-week mindfulness-based intervention in alleviating self-
reported symptoms in stable chronic heart failure outpatients,
this study highlighted further the efficacy of such intervention
over brief periods (20 minutes) in patients who presented acutely
for decompensated heart failure requiring hospital admission.19
In acute decompensated heart failure, dyspnea is the most
prominent symptom that prompts the patient to medical care and
to which most acute interventions are directed. It also served as a
prominent endpoint for determining therapeutic efficacy in clin-
ical development programmes for new therapies in acute
decompensated heart failure.24 Given the increased severity of
heart failure along with poor quality of life for those with
advanced disease, there is a need to develop other new treat-
ments that make patients feel better or live longer.14,24 This
guided mindful breathing session is short compared to the pre-
vious study mentioned.19 The mindful breathing session can be
6 American Journal of Hospice & Palliative Medicine®

Table 3. Between-Group Comparisons of Outcome Variables.

Outcomes 20-minute mindful breathing Control t or z P value

ESAS dyspnea score Median (IQR) Median (IQR) z Mann-Whitney U

T0 6.0 (4) 6.0 (2) 0.149 0.882
T20 3.0 (4) 5.0 (2) 1.617 0.106
Respiratory rate Median (IQR) Median (IQR) z Mann-Whitney U
T0 22.0 (6) 24.0 (4) 1.713 0.087
T20 22.0 (4) 24.0 (4) 1.351 0.177
Oxygen saturation Median (IQR) Median (IQR) z Mann-Whitney U
T0 98.0 (5) 98.0 (5) 0.126 0.900
T20 97.0 (4) 85.0 (19) 0.336 0.737
Pulse rate Mean + SD Mean + SD t Student t test
T0 84.6 + 16.8 85.9 + 16.4 0.220 0.827
T20 80.3 + 12.3 84.4 + 17.9 0.726 0.474
Systolic blood pressure Mean + SD Mean + SD t Student t test
T0 121.1 + 15.8 114.3 + 16.8 1.131 0.268
T20 120.0 + 17.3 113.3 + 14.9 1.141 0.264
Diastolic blood pressure Median (IQR) Median (IQR) z Mann-Whitney U
T0 75.0 (15) 72.0 (16) 0.726 0.468
T20 74.0 (20) 71.0 (11) 0.312 0.755
Abbreviations: ESAS, Edmonton Symptom Assessment System; IQR, interquartile range; T0, minute 0; T20, minute 20.

Table 4. Between-Group Comparisons of Changes in Outcome Variables.

Techniques

Outcomes 20-minute mindful breathing Control U t or z P value

ESAS dyspnea score Median (IQR) Mean rank Median (IQR) Mean rank
2.0 (1.0) 11.30 0.0 (1.0) 19.70 49.5 2.692 0.007
Respiratory rate Median (IQR) Mean rank Median (IQR) Mean rank
0.0 (8.0) 16.17 0.0 (4.0) 14.83 102.5 0.431 0.667
Oxygen saturation Mean SD Mean SD
0.27 2.31 0.07 1.67 0.453 0.654
Pulse rate Median (IQR) Mean rank Median (IQR) Mean rank
6.0 (12.0) 13.63 0.0 (9.0) 17.37 84.5 1.165 0.244
Systolic blood pressure Mean SD Mean SD
1.07 11.18 1.07 6.82 0.000 1.000
Diastolic blood pressure Mean SD Mean SD
1.73 7.77 0.60 7.84 0.819 0.420
Abbreviations: ESAS, Edmonton Symptom Assessment System; IQR, interquartile range.

easily guided by any investigator after a brief training session by
the corresponding author. The instructions are simple and easy
to comprehend as shown in Figure 1. Its practice may help
patients to relax and calm down. There is a potential to teach
the exercise to patients so that they can apply it on their own.
This study has several limitations. It was a single-center
study. Although the sample size was calculated based on ade-
quate power analysis, the study was terminated halfway due to
logistic reasons, resulting in a smaller sample size. The study
was not blinded and there was no active control. Although the
ESAS was chosen to measure participants’ dyspnea, there were
only a few validation studies in non-cancer populations.25 The
outcome data could be limited by the unidimensional nature of
the symptom assessment.25 More insight could be gained from
multidimensional measures in future research, including
outcomes such as mood and stress variability. The control
group had a significantly lower EF than the intervention group.
Poor EF could be a confounding factor. The study determined
the immediate effect of a brief intervention and not its sus-
tained effect. Future studies could test the efficacy of multiple
sessions of mindful breathing in producing a sustained effect in
dyspnea reduction.
Conclusion
The current results provided evidence that a single session of
20-minute mindful breathing was effective in reducing dyspnea
for in-patients with acute decompensated heart failure. The
simple exercise of paying whole-hearted attention to the in-
and out-breath without getting distracted offers an additional
Ng et al
rapid, cost-effective, symptomatic treatment for the suffering
heart failure patients.
Acknowledgments
The authors would like to express their heartfelt gratitude to all
patients who have participated in the study.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship,
and/or publication of this article.
ORCID iD
Seng-Beng Tan https://orcid.org/0000-0002-0649-0739
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