Complementary Therapies in Medicine 56 (2021) 102582

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Complementary Therapies in Medicine

journal homepage: www.elsevier.com/locate/ctim

The Buteyko breathing technique in children with asthma: a randomized

controlled pilot study
Jan Vagedes a, b, c, *, Eduard Helmert a, Silja Kuderer a, Katrin Vagedes a, Johannes Wildhaber d,
Frank Andrasik e
a
ARCIM Institute, Filderstadt, Germany
b
Department of Pediatrics, Filderklinik, Filderstadt, Germany
c
Department of Neonatology, Children’s Hospital, University of Tübingen, Tübingen, Germany
d
Department of Pediatrics, Fribourg Hospital HFR, Fribourg, Switzerland
e
Department of Psychology, University of Memphis, Memphis, TN, USA

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Evidence supports the Buteyko breathing technique (BBT) as reducing medication and improving
Breathing retraining control and quality of life in adults with asthma, but having minimal impact on spirometry. For children with
Buteyko breathing technique asthma, evidence addressing the utility of BBT is sparse. We evaluated the effectiveness of BBT in managing
pediatrics
various aspects of asthma in children.
asthma
Methods: Thirty-two children with partly controlled asthma (age 6-15 years, 66% male) were randomized to
either Treatment as Usual (TAU) or TAU combined with Buteyko training (Buteyko group, BG). Children in the
BG received an intensive five-day training followed by three months of home practice. Primary outcome was
bronchodilator reduction. Secondary outcomes were changes in physiological parameters FEV1_AR (at rest),
FEV1_ER (after ergometry), FEV1_BR (after bronchospasmolysis), corticosteroid use, FeNO, SpO2, breath-hold
test and questionnaire data [Asthma Control Questionnaire and Pediatric Asthma Caregiver’s Quality of Life
Questionnaire (PACQLQ)]. All measures were collected at Baseline and a three-month follow-up.
Results: For the primary outcome, no significant between-group difference was found. Regarding the secondary
outcomes, children receiving treatment augmented with BBT revealed significantly greater improvement at the
follow-up than those receiving TAU for FEV1_AR (p = .04, d=-0.50), FEV1_ER (p = .02, d=-0.52), and the
emotional function subscale of the PACQLQ (p < .01, d = 1.03). No between-group differences were found for the
remaining secondary measures of outcome.
Conclusions: Our preliminary findings suggest that the addition of BBT to treatment as usual for children with
asthma enhances outcomes with respect to spirometry and parental emotional function but does not lead to
reductions in medication, at least over the short term.

1. Background increased risk of psychosocial problems resulting from the inability to

Asthma is one of the major medical challenges worldwide and the
most common chronic disease in childhood (1–3). Children with asthma
are not only confronted with potentially life-threatening exacerbations,
but also with school absenteeism impairing educational progress and
further amplifying socioeconomic disparities (4). Moreover, they are at
participate in age-appropriate activities important for the development
of self-esteem and social skills (5,6). Such disease-related impairments
and a reduced quality of life can also adversely impact the families
(7–9).
Current approaches to management of asthma are based primarily on
pharmacotherapy, mainly with inhaled corticosteroids (ICS) and

Abbreviations: ACQ, Asthma Control Questionnaire; AR, at rest; BBT, Buteyko breathing technique; BG, Buteyko group; BH test, breath-hold test; BL, baseline;
BMI, body mass index; BR, bronchodilator; ER, ergometry; ES, effect size; FeNO, fraction of exhaled nitric oxide; FEV1, forced expiratory volume in one second; ICS,
inhaled corticosteroid; PACQLQ, Pediatric Asthma Caregiver’s Quality of Life Questionnaire; PEF, peak expiratory flow; QOL, quality of life; RCT, randomized
controlled trial; SD, standard deviation; SpO2, saturation of peripheral oxygen; TAU, treatment as usual; 3-Mo FUP, three-month follow-up.
* Corresponding author at: ARCIM Institute, Im Haberschlai 7, D-70794 Filderstadt, Germany.
E-mail address: j.vagedes@arcim-institute.de (J. Vagedes).

https://doi.org/10.1016/j.ctim.2020.102582
Received 18 March 2020; Received in revised form 22 September 2020; Accepted 22 September 2020
Available online 23 October 2020
0965-2299/© 2020 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
J. Vagedes et al.
bronchodilators (beta-2 agonists) (10). However, some patients report
an increasing interest in complementary therapies (11). Parents in
particular seek these options due to concerns about possible medication
side effects on their children (12). Breathing retraining is one of the most
prominent complementary approaches and consists of various tech­
niques, such as the Papworth method (13), Yoga (pranayama) (14),
capnometry-assisted respiratory training (CART), or slow breathing and
awareness training (SLOW) (15). Breathing retraining focuses on the
patient’s breathing pattern as dysfunctional breathing, such as chronic
hyperventilation, is known to contribute to hypocapnia and related
physical and mental problems, e.g., asthma and anxiety or panic disor­
ders (2,16).
Another well-known breathing training program—the Buteyko
Breathing Technique (BBT)—was introduced in Russia in the 1950s by
Dr Konstantin Buteyko. Buteyko identified various dysfunctional
breathing habits, such as mouth breathing and upper chest breathing, as
being among the major causes for chronic hyperventilation. Conse­
quentially, he introduced breathing exercises based on breath-holding
maneuvers and breath control to guide patients back to the normal
nasal/diaphragmatic breathing pattern, designed to reduce breathing
volumes and restore metabolic balance (17).
The clinical utility of BBT has been explored in a number of studies in
adult patients with asthma. Overall, these studies have reported bene­
ficial effects on asthma control and quality of life as well as reductions in
medication use, whereas pulmonary function has remained largely un­
changed (14,18–24). In children with asthma, evidence addressing the
value of BBT is limited. Enhancements in lung function and asthma
control following BBT intervention were reported by Elnaggar and
Shendy who conducted an RCT with three intervention groups
comparing BBT, active cycle of breathing technique (ACBT), and
thoracic lymphatic pump technique (TLPT) in 54 children with asthma
(aged 8-14 years) (25). Azab et al. observed similar levels of improve­
ment in pulmonary function and functional capacity (6-minute walk
test) after 3 months of training (3-day initial in-person training com­
bined with daily home practice) when they compared BBT to yoga in an
RCT conducted with 40 individuals (aged 7-12 years) having pediatric
asthma (26). The respiratory outcome in 35 children with asthma (6-12
years) was enhanced upon completion of a short-term BBT intervention
when compared to that resulting from routine nursing care alone (n = 35
controls) (27). McHugh et al. published a case series on BBT in eight
children (28), showing a reduction in beta-2 agonist and ICS use, but no
lung function data were reported. Hepworth et al. recently assessed the
impact of breathing retraining, particularly BBT, on asthma symptoms
and dysfunctional breathing, as assessed with the Asthma Control Test
and the Nijmegen Questionnaire, in 169 children with asthma and found
improved asthma control and dysfunctional breathing in children on all
levels of asthma treatment (3). In the present study, we evaluated
medication use, pulmonary function parameters and parents’ quality of
life in an RCT designed to more fully evaluate potential benefits from
adding BBT to standard care in treating children with asthma.
2. Methods
2.1. Study Design
Participants were randomized to either standard treatment (here­
after referred to as Treatment as Usual, TAU) or to TAU combined with
BBT (hereafter referred to as the Buteyko Group, or BG). Data were
collected from January to November 2014 at the ARCIM Institute and
the Filderklinik in Filderstadt, Germany.
2.2. Study Population
Thirty-two (32) outpatient children with asthma (66% male), from
among 197 considered for participation after examining records at the
Filderklinik and reviewing children who were referred by local
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Complementary Therapies in Medicine 56 (2021) 102582
physicians or responded to local advertisements, were enrolled in our
trial. Inclusion criteria were an age between 6 and 15 years,
physician-diagnosed partly controlled asthma (29,30), assent from the
children, written informed consent from the parents and approval from
the attending physicians. Children participating in another study or
having already experienced BBT were excluded.
2.3. Intervention
2.3.1. Treatment as Usual (TAU)
Children in this condition received routine care, consisting of stan­
dard medication prescribed by the respective attending physicians ac­
cording to the severity of the symptoms.
2.3.2. Buteyko Group (BG)
Children received routine care as described above and additionally
were provided a standard course of BBT, comprised of three compo­
nents: a five-day intensive course of BBT, a booster session one week
later, and a three-month period of training at home.
2.3.3. Five-Day Training of BBT
This aspect consisted of theoretical information and practical
training provided over five consecutive days, with each session lasting
90 minutes, with a parent present. In the first session, children and
parents together were fully informed about the training plan, which
included a detailed description of the exercises. Course units began with
an explanation of normal breathing and abnormal, dysfunctional
breathing such as hyperventilation and breathing pattern disorders (31).
The children were next escorted to a separate room with one of the two
trainers (certified in Buteyko procedures) and instructed in the use of
specific exercises, as described in the training plan, which included
breath-holding and deliberate hypoventilation exercises to retain CO2
and regain breath control (3). Each session began and ended with the
control pause (after a normal, gentle exhalation, breathing is stopped
until the patient feels air hunger) and comprised a succession of reduced
breathing, extended and maximum pauses. The exercises were carried
out at rest in a seated position, which helped the children to become
aware of and potentially correct their own breathing pattern. Reduced
breathing and extended pauses were also practiced during activities,
such as walking, running or performing squats in order to encourage the
children to maintain low-volume nasal/abdominal breathing as long as
possible during activities and sports and to avoid activity-induced un­
controlled heavy breathing. While the children were being trained,
parents received more detailed information from a second trainer who
introduced them to the same exercises to ensure correct supervision of
the children at home. Sessions ended with the children and parents
returning to a common area so the children could demonstrate to their
parents what they had learned and were instructed to practice.
2.3.4. Booster Session and Training at Home
Approximately 1 week later, participants and parents returned to the
clinic to provide feedback on their initial experiences and to ask ques­
tions. The trainers observed each child perform all procedures taught
and provided corrective instructions as needed.
Three-Month Home Practice: The children were instructed to prac­
tice all techniques taught to them, twice per day for 15 minutes.
Adherence to the training was supervised and recorded by the parents.
2.4. Outcomes
All outcome measures were collected prior to the start of the inter­
vention (baseline, BL) and at the three-month follow-up (3-Mo FUP).
2.4.1. Primary Outcome
Change in bronchodilator use (beta-2 agonists) over time was
determined from the medication records the parents were asked to
J. Vagedes et al.
maintain. The amounts were converted into equivalent doses of salbu­
tamol, by considering 100 μg of salbutamol equivalent to 100 μg of
terbutaline and 25 μg of salmeterol (20).
2.4.2. Secondary Outcomes
Change in corticosteroid (ICS) use, various physiological measures,
as well as responses to questionnaires served as secondary measures of
outcome. For ICS usage, dose equivalents were determined as follows:
1000 μg of beclomethasone dipropionate (BDP) were considered
equivalent to 800 μg of budesonide or 500 μg of fluticasone (30).
Spirometry values were measured under three different conditions:
1) at rest (FEV1_AR), then 2) after bicycle ergometer exercise (30 watts,
7 minutes) (“ergometry”, FEV1_ER), followed by 3) after broncho­
spasmolysis (15 minutes after inhalation of 200 μg of salbutamol)
(“bronchodilator”, FEV1_BR) to measure the forced expiratory volume
in one second (FEV1; SpiroScout, LF8, Ganshorn Medizin Electronic
GmbH, Niederlauer, Germany). Further measurements at rest included
fraction of exhaled nitric oxide (FeNO; NIOX VERO®, Circassia AG, Bad
Homburg, Germany), oxygen saturation (SpO2; fingertip pulse oximeter
CMS-50D, Contec Medical Systems Ltd., Qinhuangdao, China), and
breath-hold test (BH test; Buteyko control pause in seconds).
Asthma control was measured with the Asthma Control Question­
naire (ACQ). In children aged 6-10 years, it was administered by a
trained interviewer (32,33). The ACQ is comprised of seven questions,
including the five most important asthma symptoms, bronchodilator use
(all 6 rated over the past week on a scale ranging from 0=well controlled
to 6=extremely poorly controlled), and FEV1 (scale ranging from 0 =
> 95% predicted to 6 = < 50% predicted, provided by clinic staff). We
used a shortened version of the ACQ, comprising questions one to six (5
symptoms plus bronchodilator use). The measurement properties of the
original ACQ and its three shortened versions have been shown to be
very similar, with a high agreement between all four versions (34) and
an internal consistency (Cronbach’s α) greater than 0.70 for all four
versions (35).
Parents’ disease-related quality of life was measured with the Pedi­
atric Asthma Caregiver’s Quality of Life Questionnaire (PACQLQ) (36).
This 13-item questionnaire assesses two separate domains: activity
limitations (n = 4) and emotional function (n = 9). Each item is rated on
a scale from 1 = severe impairment to 7 = no impairment. We report the
average sum scores for each domain. The minimal important difference
for overall caregiver quality of life is 0.50, with similar values for the
emotional function domain (0.64) and the activity limitation domain
(0.67) (36). The internal consistency for the questionnaire as a whole is
high, with a Cronbach’s α of 0.914 (37).
2.5. Sample Size
Given the scarcity of RCTs investigating BBT or similar breathing
exercises in children (2), we estimated our sample size based on findings
from a pilot study (unpublished) with five children assessing asthma
control (ACQ) and medication use before and after BBT training. Thus,
our decision to enroll 32 total participants is perhaps best viewed as a
sample of convenience and our results as those of a pilot study.
2.6. Randomization and Blinding
At the initial assessment (baseline), participants were randomly
assigned to one of the two study conditions. Sealed envelopes containing
the group allocation and a pseudonymized study ID were prepared, with
each participant choosing an envelope in the presence of a research
assistant not involved in the preparation of the envelopes. No further
blinding was performed.
2.7. Statistical analysis
We performed statistical analyses on an intention-to-treat basis,
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Complementary Therapies in Medicine 56 (2021) 102582
using R (38) and RStudio (39). Missing values were imputed using the
multiple imputation by chained equations method (R package: mice (40)).
Two-sided p-values <.05 were considered significant. Baseline measures
are reported descriptively with mean differences, 95% confidence in­
tervals (CI) and Cohen’s d effect sizes (ES) for correlated samples (d) (R
package: effsize (41)). The primary outcome measure, beta-2 agonist use
at 3-Mo FUP, was analyzed using a linear mixed-effects model (R
package: lme4 (42)) allowing for treatment condition (TAU, BG), time
(BL, 3-Mo FUP) and their interaction term as fixed effects and subjects as
a random effect. Post-hoc comparisons were performed in case of sig­
nificant main effects (R package lmerTest (43)) and adjusted for multi­
ple testing using Bonferroni correction. Secondary outcome measures
are reported descriptively with 3-Mo FUP adjusted mean differences (to
account for potential baseline differences), within-group differences, CI
and ES. Data were cross-checked to determine if they conformed to a
normal distribution.
3. Results
3.1. Study population (Fig. 1, Table 1)
Of the 197 children contacted for eligibility assessment, 165 were
excluded because they did not reply (n = 90), did not meet the inclusion
criteria (n = 53), declined to participate due to lack of time (n = 21) or
for other reasons (not specified) (n = 1) (Fig. 1). Thus, 32 children were
enrolled and randomly allocated to TAU (n = 16) or BG (n = 16). Two
participants assigned to BG and one assigned to BG were lost to follow-
up and dropped out of the study. However, all 32 children randomized in
the study were included in the statistical analysis. 66% of all participants
were male, with a mean age of 10.6 years (SD = 2.1, range = 6-15), and
an average BMI of 18.6 kg/m2 (SD = 3.6, range = 13.7-26.8). Baseline
characteristics were similar between both treatment conditions for age,
BMI, medication use, 3 of the 6 physiological measures, and all of the
questionnaire data. All FEV1 values were higher for children assigned to
TAU. None of the participants needed oral corticosteroids. According to
the German national asthma care guideline (44), in the BG five children
received step 1 therapy, three were on step 2, six on step 3, and two on
step 4 therapy. In TAU, four participants were on step 1 therapy, four on
step 2, six on step 3, and two on step 4 therapy. Apart from the three
dropouts, who declined further participation for unknown reasons, no
adverse events (such as hospital admissions or emergency department
visits) were reported.
3.2. Primary and secondary outcomes (Tables 2 and 3, Figs. 2 and 3)
Approximately 12.5% of the physiological, 7.7% of the question­
naire data and 49.2% of information on medication use were missing
and were imputed as described above.
3.2.1. Primary outcome measure: beta-2 agonists
The primary analysis yielded a significant main effect of time [F
(1,30) = 48.96, p < .001], and a marginally significant interaction effect
[F(1,30) = 3.62, p = 0.067]. As the interaction did not reach the signif­
icance level, no post-hoc tests were performed. Although the 2 treatment
conditions did not differ at the 3-Mo FUP [F(1,30) = 1.10, p = 0.30], the
within-group reductions in beta-2 agonist use revealed large effect sizes
(Table 2).
3.2.2. Secondary Outcome Measures
ICS: No significant 3-Mo FUP adjusted mean difference occurred. The
decrease in ICS use in the Buteyko group revealed a medium ES, while
the change for TAU was of a lesser effect size (Table 2).
FEV1: We found significant 3-Mo FUP mean differences with large
ES’s for all FEV1 values, in favor of the BG (Table 2, Fig. 2). The within-
changes revealed an increase in FEV1_ER for the BG, at a small effect
size, and decreases in FEV1_AR and FEV1_BR for TAU, at small to
J. Vagedes et al. Complementary Therapies in Medicine 56 (2021) 102582

Fig. 1. CONSORT Flow Diagram.

Table 1
Baseline characteristics of the study participants
Parameters Total BG TAU Δ CI ES
(n = 32) (n = 16) (n = 16)

Demographics Age, years 10.56(2.14) 10.44(2.25) 10.69(2.09) − 0.25 (-1.82;1.32) 0.12

Sex, male n(%)† 21(65.62) 10(62.50) 11(68.75) - - -
BMI, kg/m2 18.61(3.59) 19.74(4.24) 17.49(2.43) 2.25 (-0.27;4.78) 0.65
Medication β-2 ag. (salb. equiv.), μg/d 174.09(134.36) 209.31(163.12) 138.88(89.76) 70.44 (-25.78;166.65) 0.54
ICS (BDP equiv.), μg/d 242.22(216.38) 202.75(153.95) 281.69(264.08) − 78.94 (-236.61; 78.73) 0.37
Physiological FEV1_AR, % 0.90(0.16) 0.82(0.15) 0.98(0.13) -0.16 (-0.26;-0.06) 1.14
measures FEV1_ER, % 0.85(0.21) 0.75(0.20) 0.96(0.16) -0.21 (-0.34;-0.07) 1.12
FEV1_BR, % 0.96(0.17) 0.88(0.15) 1.05(0.16) -0.16 (-0.28;-0.05) 1.05
FeNO, ppb 47.00(39.58) 51.44(43.41) 42.56(36.22) 8.88 (-20.03;37.78) 0.22
SpO2, % 96.94(1.76) 96.50(2.10) 97.38(1.26) − 0.88 (-2.14;0.39) 0.51
BH test, sec 15.34(4.82) 13.75(2.41) 16.94(6.06) − 3.19 (-6.59;0.22) 0.69
ACQ ACQ score 1.13(0.90) 1.00(0.93) 1.25(0.88) − 0.25 (-0.90;0.41) 0.27
PACQLQ Activity limitations 6.10(1.27) 6.08(1.24) 6.13(1.35) − 0.05 (-0.99;0.88) 0.04
Emotional function 5.63(1.18) 5.71(0.94) 5.54(1.41) 0.16 (-0.71;1.04) 0.14

Data are means (SD) unless otherwise specified with †. BG = Buteyko group, TAU = treatment as usual, Δ =mean between-difference, CI = 95% confidence interval,
ES = Cohen’s d, β-2 ag.=β-2 agonist [μg/d], salb. equiv.=salbutamol equivalent, ICS = inhaled corticosteroid [μg/d], BDP equiv.=beclomethasone dipropionate
equivalent, BMI = body mass index, FEV1=forced expiratory volume in 1 second [%], AR = at rest, ER = after ergometry, BR = after bronchospasmolysis,
FeNO = fraction of exhaled nitric oxide [ppb], SpO2=oxygen saturation [%], BH test = breath-hold test [sec], ACQ = Asthma Control Questionnaire,
PACQLQ = Paediatric Asthma Caregiver’s Quality of Life Questionnaire. Bold indicates confidence intervals that do not contain zero.

medium effect sizes (Table 2, Fig. 2).
FeNO and SpO2: No significant adjusted mean differences or within-
group changes were detected (Table 2).
BH test: The 3-Mo FUP adjusted mean difference was significant,
with a large ES (Table 2), based on the BG results: In the BG, there was a
highly significant increase in the breath-hold test between BL and 3-Mo
FUP, also with a large ES. No significant within-group changes were
detected for TAU (Table 2, Fig. 3).
ACQ: We did not find changes in the ACQ score between or within
either intervention (Table 3).
PACQLQ: We observed a significant 3-Mo adjusted mean difference
for the emotional function domain, with a medium ES, in favor of the BG
(Table 3, Fig. 3). No effect was found for the subscale activity
limitations.
3.3. Sensitivity analysis (Table 4)
In order to evaluate data robustness, the analysis of the physiological

4
J. Vagedes et al. Complementary Therapies in Medicine 56 (2021) 102582

Table 2
Mean values for outcome measures at baseline (BL) and three-month follow-up (3-Mo FUP) and adjusted mean differences
BL 3-Mo FUP Within-group difference (95% CI, Cohen’s d) 3-Mo FUP adjusted mean difference (95% CI, Cohen’s d)

M (SD) M (SD) Δ CI ES Δ CI ES

Medication
BG 209.31(163.12) 31.94(80.41) 177.38 (107.31;247.44) 1. 38
β-2 ag. − 75.81 (-157.67;6.04) 0.67
TAU 138.88(89.76) 37.31(49.22) 101.56 (53.50;149.63) 1.40
BG 202.75(153.95) 106.44(149.22) 96.31 (23.21;169.41) 0.64
ICS 12.62 (-118.66;143.91) 0.07
TAU 281.69(264.08) 172.75(178.04) 108.94 (-5.75;223.62) 0.48
Physiological measures
BG 0.82(0.15) 0.86(0.13) − 0.04 (-0.09;0.01) 0.28
FEV1_AR 0.10 (0.03;0.16) 1.08
TAU 0.98(0.13) 0.92(0.11) 0.06 (0.01;0.11) 0.48
BG 0.75(0.20) 0.81(0.16) -0.06 (-0.11;-0.01) 0.31
FEV1_ER 0.12 (0.04;0.20) 1.10
TAU 0.96(0.16) 0.89(0.16) 0.07 (0.00;0.13) 0.40
BG 0.88(0.15) 0.91(0.12) − 0.03 (-0.08;0.02) 0.21
FEV1_BR 0.12 (0.04;0.19) 1.13
TAU 1.05(0.16) 0.96(0.15) 0.09 (0.03;0.15) 0.57
BG 51.44(43.41) 44.62(31.18) 6.81 (-9.05;22.68) 0.18
FeNO 0.81 (-18.76;20.38) 0.03
TAU 42.56(36.22) 34.94(27.19) 7.62 (-5.18;20.43) 0.24
BG 96.50(2.10) 97.00(1.41) − 0.50 (-1.47;0.47) 0.28
SpO2 1.00 (-0.30;2.30) 0.55
TAU 97.38(1.26) 96.88(1.59) 0.50 (-0.45;1.45) 0.35
BG 13.75(2.41) 20.69(4.11) -6.94 (-9.42;-4.46) 2.06
BH test 6.00 (2.92;9.08) 1.41
TAU 16.94(6.06) 17.88(6.35) − 0.94 (-2.98;1.11) 0.15

β-2 ag.=β-2 agonist (salbutamol equivalent) [μg/d], ICS = inhaled corticosteroid (beclomethasone dipropionate equivalent) [μg/d], FEV1=forced expiratory volume
in 1 second [%], AR = at rest, ER = after ergometry, BR = after bronchospasmolysis, FeNO = fraction of exhaled nitric oxide [ppb], SpO2=oxygen saturation [%], BH
test = breath-hold test [sec]. Bold indicates confidence intervals that do not contain zero.

Table 3
Mean values for questionnaire outcome measures at baseline (BL) and three-month follow-up (3-Mo FUP) and adjusted mean differences
BL 3-Mo FUP Within-group difference (95% CI, Cohen’s d) 3-Mo FUP adjusted mean difference (95% CI, Cohen’s d)

M(SD) M(SD) Δ CI ES Δ CI ES

ACQ
ACQ score BG 1.00(0.93) 0.78(0.74) 0.22 (-0.20;0.63) 0.26
− 0.04 (-0.61;0.53) 0.04
TAU 1.25(0.88) 1.08(0.73) 0.17 (-0.26;0.60) 0.22
PACQLQ
ActLim BG 6.08(1.24) 6.44(0.64) − 0.36 (-1.11;0.39) 0.37
0.33 (-0.57;1.24) 0.27
TAU 6.13(1.35) 6.16(0.80) − 0.03 (-0.60;0.53) 0.03
EmoFct BG 5.71(0.94) 6.23(0.51) − 0.52 (-1.05;0.00) 0.69
0.74 (0.02;1.46) 0.74
TAU 5.54(1.41) 5.33(1.13) 0.22 (-0.32;0.75) 0.17

ACQ = Asthma Control Questionnaire, PACQLQ = Pediatric Asthma Caregiver’s Quality of Life Questionnaire, ActLim = Activity Limitations, EmoFct = Emotional
Function, BG = Buteyko group, TAU = treatment as usual. Bold indicates confidence intervals that do not contain zero.

Fig. 2. Change in Forced Expiratory Volume in 1 second (FEV1) from baseline (BL) to three-month follow-up (3-Mo FUP) (‘-’ median, ‘●’ mean, ‘○’ outlier,
BG = Buteyko group, TAU = treatment as usual, AR = at rest, ER = after ergometry, BR = after bronchospasmolysis, within-group analysis: ‘*’ confidence intervals
that do not contain zero, ‘ns’ confidence intervals that contain zero, adjusted mean difference: ‘†’ confidence intervals that do not contain zero).

outcome parameters was repeated with those participants who had
complete data for ICS (n = 11). Similar trends were observed for the
FEV1 values, FeNO, and BH test. In contrast to the primary analysis, a
significant 3-Mo FUP adjusted mean difference was observed for SpO2
based on an increase in the BG.
4. Discussion
For the primary outcome (beta-2 agonist use), we found no signifi­
cant between-group difference following the intervention. Beta-2
agonist use was reduced in both groups at 3-Mo FUP. Among the sec­
ondary outcomes, no significant difference was observed between the
groups with respect to ICS use. Within the groups, however, ICS use
decreased significantly in the BG while remaining unchanged in TAU. A
reduction in medication use was also reported by other authors evalu­
ating BBT in adult patients with asthma (21,23,24). However, we had a
high amount of missing values for medication. Without missing impu­
tation, the ICS reduction in the BG was not significant. Although we
applied a high-quality missing imputation method, the data basis
possibly remains insufficient to regard the overall reduction in

5
J. Vagedes et al. Complementary Therapies in Medicine 56 (2021) 102582

Fig. 3. Change in breath-hold test and Pediatric Asthma Caregiver’s Quality of Life Questionnaire (PACQLQ) subscale emotional function from baseline (BL) to three-
month follow-up (3-Mo FUP) (‘-’ median, ‘●’ mean, ‘○’ outlier, BG = Buteyko group, TAU = treatment as usual, within-group analysis: ‘*’ confidence intervals that do
not contain zero, ‘ns’ confidence intervals that contain zero, adjusted mean difference: ‘†’ confidence intervals that do not contain zero).

medication was not assessed in this study. Azab et al. (26) found sig­
Table 4
nificant improvements for BBT as well as yoga in most of the measured
Three-month follow-up (3-Mo FUP) adjusted mean differences in respiration
parameters at their 3-month follow-up (pulmonary function and func­
parameters in participants with complete information on inhaled corticosteroids
(n = 11) tional capacity as assessed by a six-minute walk test), with no significant
difference between the groups. No detailed information on pharmaco­
BG TAU 3-Mo FUP adjusted mean
therapy is given in this study. Priyalatha et al. (27) assessed the effect of
difference (95% CI, Cohen’s d)
BBT on the respiratory outcome in children with asthma. BBT was
M(SD) M(SD) CI ES
Δ
conducted twice daily, on five consecutive days, while the control par­
FEV1_AR BL 0.81 0.99 ticipants received routine nursing care. Respiratory outcome (modified
(0.24) (0.15) Becker’s score, SpO2, PEF, and breath holding time), assessed before
0.18 (0.04;0.32) 1.76
3-Mo 0.90 0.90
FUP (0.18) (0.11)
and immediately after intervention, revealed significant improvements
0.76 1.00 for all parameters in the BBT group. The absence of long-term follow-up
FEV1_ER BL
(0.29) (0.20) (as well as the presence of certain methodological limitations) renders
0.21 (0.02;0.40) 1.44
3-Mo 0.88 0.90 these findings tentative (27).
FUP (0.19) (0.13)
While the studies on BBT in adult patients with asthma report that
0.86 1.03
FEV1_BR BL
(0.21) (0.18) pulmonary function has remained largely unchanged, in many children
0.17 (0.04;0.30) 1.77 lung function appears to respond at some level to this training. The
3-Mo 0.93 0.93
FUP (0.17) (0.16) improvements in respiratory parameters we observed were supple­
74.40 31.00 mented by the increase in breath-hold test scores (capacity) for those
FeNO BL
(63.80) (30.35)
− 30.77 (-74.38;12.85) 0.97 children receiving BBT. Young patients have a briefer history of asthma
3-Mo 45.80 33.17
FUP (33.66) (25.47) than most adults, thereby increasing the likelihood of reversing disease-
95.20 97.17 related functional and structural changes in the respiratory system.
SpO2 BL
(2.95) (1.72)
3.50 (1.29;5.71) 2.17 Studies that focus more intently on how and when children in particular
3-Mo 97.20 95.67
can benefit from BBT with respect to lung function seem warranted.
FUP (2.05) (1.75)
13.20 16.50 Evidence suggests that childhood asthma can impose considerable strain
BH test BL on the families and that parental management skills may influence
(2.95) (4.76)
10.10 (3.52;16.68) 2.15
3-Mo 23.80 17.00 disease progression (9). The improvements we found with respect to
FUP (4.27) (7.46) emotional functioning of parents likely arose from them witnessing
BG = Buteyko group, TAU = treatment as usual, BL = baseline, 3-Mo stronger self-regulation capacities in their children, by way of the BBT
FUP = three-month follow-up, β-2 ag.=β-2 agonist (salbutamol equivalent) exercises. Also, improved emotional function of the parents might
[μg/d], ICS = inhaled corticosteroid (beclomethasone dipropionate equivalent) benefit their management skills, which in turn could foster the chil­
[μg/d], FEV1=forced expiratory volume in 1 second [%], BA = baseline, dren’s health status.
ER = after ergometry, BR = after bronchospasmolysis, FeNO = fraction of The present study is not without limitations. Juniper and colleagues
exhaled nitric oxide [ppb], SpO2=oxygen saturation [%], BH test = breath-hold report that an ACQ score of 1.50 is the optimal cut-point to identify
test [sec]. Bold indicates confidence intervals that do not contain zero.
poorly controlled asthma that can benefit from an intervention (45). In
our study, the ACQ score was close to 1.00 in both conditions, which
medication use and the pronounced reduction of beta-2 agonists in the approaches what is considered a well-controlled level for asthma. These
BG as valid and conclusive. For the other secondary outcomes, we found asthma control scores may have limited our ability to detect benefits
improvements in the BG for FEV1, breath-hold test and parents’ from the intervention (due to a ceiling effect). Moreover, we have not
emotional function (PACQLQ). In TAU, the parameters remained un­ raised detailed data on the frequency of asthma exacerbations and
changed or deteriorated. emergency department visits in the year prior to the study. We were
The significant difference between our two groups with respect to unable to perform an exact sample size calculation and consequently
FEV1_AR and ER at three-month follow-up, in favor of the Buteyko relied on a “convenient sample size”; hence, us considering this inves­
group, is in line with the – albeit sparse – evidence base for BBT in tigation along the lines of a pilot study. Recruiting participants by
children with asthma. Elnaggar and Shendy’s (25) RCT comparing BBT, physician referrals and local advertisements was the most feasible
ACBT, and TLPT found significant differences between the groups in method for us to use. However, we cannot completely rule out potential
favor of BBT at their 3-month follow-up (with greater improvement for referral bias in this procedure of enrollment. Given the age range of our
serum Ig E, ventilatory function and asthma perception). Use of asthma study population, it seemed reasonable to rely on parental records of the

6
J. Vagedes et al.
medication used by their children, a method that might carry the risk of
recall bias.
Our participants included children of both sexes and different ages
with mild to moderate asthma. We believe that our results can therefore
be applied to a considerable proportion of the pediatric asthma popu­
lation. However, we did not assess BBT in children with severe or un­
controlled asthma.
We conclude that our results might give preliminary evidence that
BBT could be an effective intervention for children with partly
controlled asthma, with respect to spirometry (FEV1) and breath-hold
parameters. Parental emotional function, an important factor in child­
hood asthma, could also benefit when BBT is administered to their
children. However, given the pilot character of our study and a number
of limitations, the conclusions should be drawn with caution. Whether
the improvements we observed in children with asthma are due to re­
ductions in hyperventilation-induced hypocapnia remains unclear and
points to a need to examine this aspect more fully in future
investigations.
Ethics approval and consent to participate
The study was approved by the ethics committee of the University of
Tübingen, Germany (No. 598/2013BO1). We obtained assent to
participate from the children as well as written informed consent from
the parents.
Availability of data and materials
Deidentified individual participant data that underlie the results
reported in this article will be made available. The data will be made
available beginning three months and ending five years following article
publication to researchers who provide a methodologically sound pro­
posal for use in achieving the goals of the approved proposal. Proposals
should be submitted to j.vagedes@arcim-institute.de.
Funding
No external funding.
Authors’ contributions
JV contributed to the conception and design of the study, collection
of data, analysis and interpretation of the data, and revising the manu­
script. EH and SK contributed to the collection of data, analysis of the
data, and revising the manuscript. KV contributed to the conception and
design of the study, collection of data, interpretation of the data, and
drafting the manuscript. JW and FA contributed to the conception and
design of the study, supervision of data analysis, and critically reviewed
the manuscript for important intellectual content. All authors read and
approved the final manuscript.
Declaration of Competing Interest
The authors report no declarations of interest.
Acknowledgments
We are grateful to Jocelyn and John Wilson, Melbourne, Australia,
for their support with the Buteyko breathing technique. We also thank
the children and parents for their participation in our study as well as Dr
Rainer Ehmann, MD, pneumologist in private practice, Stuttgart, Ger­
many, and Prof Paul Lehrer, PhD, Department of Psychiatry, Rutgers –
Robert Wood Johnson Medical School, Piscataway, NJ, USA, for
important comments on data interpretation.
7
Complementary Therapies in Medicine 56 (2021) 102582
Appendix A. Supplementary data
Supplementary material related to this article can be found, in the
online version, at doi:https://doi.org/10.1016/j.ctim.2020.102582.
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