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Effects of Home-Based Breathing Exercises in Subjects
With COPD
Yufan Lu, Peijun Li, Ning Li, Zhengrong Wang, Jian Li, Xiaodan Liu,
and Weibing Wu
BACKGROUND: We sought to investigate the effects of home-based breathing exercises on pul-
monary function, respiratory muscle strength, exercise capacity, dyspnea, and health-related qual-
ity of life in patients with COPD. METHODS: All randomized, controlled trials involving the use
of home-based breathing exercises as an intervention in patients with COPD were searched on
PubMed,Embase,WebofScience,EBSCO,CNKI,andWangfangDatadatabasesfromJanuary1,
2008, to December 31, 2018. Two researchers independently extracted data and assessed the quality
of the literature that met the inclusion criteria. RESULTS: A total of 13 studies were included, with
a total of 998 subjects. The intervention methods consisted of diaphragmatic breathing, yoga
breathing, breathing gymnastics, and singing. Meta-analysis showed that, compared with the con-
trol group, home-based breathing exercises had significant effects on the percent of predicted FEV
1
(mean difference 3.26, 95% CI 0.52–5.99, P .02), FEV1/FVC (mean difference 2.84, 95% CI
1.04–4.64, P .002), maximum inspiratory pressures (mean difference 20.20, 95% CI 11.78–
28.61, P < .001), maximum expiratory pressures (mean difference 26.35, 95% CI 12.64 to 40.06,
P < .001), 6-min walk distance (mean difference 36.97, 95% CI 25.06–48.89, P < .001), the
modifiedMedicalResearchCouncildyspneascale(meandifference0.80,95%CI1.06to0.55,
P<.001),andtheStGeorgeRespiratoryQuestionnaire(meandifference8.62,95%CI13.09
to 4.16, P < .001). CONCLUSIONS: As an alternative method of home-based pulmonary reha-
bilitation program, breathing exercises can improve pulmonary function, respiratory muscle
strength, exercise capacity, dyspnea, health-related quality of life in patients with COPD. Key words:
chronic obstructive pulmonary disease; breathing exercises; pulmonary function; exercise capacity;
quality of life. [Respir Care 2020;65(3):377–387. © 2020 Daedalus Enterprises]
1
Introduction ing cause of death worldwide. The global prevalence of
2
COPDhasreached20.9%. Its high mortality and prev-
COPD is a progressive inflammatory lung condition alence have made COPD a serious public health prob-
3
that seriously affects human health and is the third lead- lem, with a heavy social and economic burden. COPD
not only affects the lungs, causing dyspnea and reduced
pulmonary function, but it is also accompanied by mul-
MsLu,MsP.Li,MsN.Li,MrWang,MrJ.Li,andMrWuareaffiliated tiple and systemic comorbidities, which leads to respi-
with the Department of Sports Medicine, Shanghai University of Sport, ratory muscle dysfunction that further impairs exercise
4
Shanghai, China. Ms Liu is affiliated with the School of Rehabilitation capacity. Pulmonary rehabilitation, as a comprehensive
Science, Shanghai University of Traditional Chinese Medicine, and the intervention program, can effectively enhance the phys-
Institute of Rehabilitation Medicine, Shanghai Academy of Traditional
Chinese Medicine, Shanghai, China.
This work was funded by the General Administration of Sport of China
(No. 2017B021), the “Qi Kang” young innovative talents project of Correspondence: Xiaodan Liu PhD, School of Rehabilitation Science,
School of Rehabilitation Medicine in Shanghai University of Traditional Shanghai University of Traditional Chinese Medicine, Shanghai 201203,
ChineseMedicine,theScienceandTechnologyCommissionofShanghai China. E-mail: hzhp403@126.com.
Municipality (No. 18DZ1200600), and the Shanghai University of Sport
“High-level International Talent Training Program”. DOI: 10.4187/respcare.07121
RESPIRATORY CARE • MARCH 2020 VOL 65 NO 3 377
HOME-BASED BREATHING EXERCISES IN COPD
5
icalandpsychologicalconditionofpatientswithCOPD. Methods
As a kind of low-intensity aerobic exercise, breathing
exercises reduce hyperinflation by improving the Search Strategy
strength and endurance of respiratory muscles and cor-
recting abnormal chest and abdomen movement pat- This systematic review was registered (PROSPERO
terns. Consequently, pulmonary function, dyspnea, and registration number: CRD42019129458) and is reported
exercise capacity are improved, along with health-re- in accordance with the Preferred Reporting Items for
6
lated quality of life (HRQOL) in patients with COPD. Systematic Reviews and Meta-Analyses (PRISMA)
Breathing exercises are a direct training method for 18
respiratory muscles, and they are highly targeted and statement. To identify relevant manuscripts, the on-
less restricted by the environment. It is an effective line databases of PubMed, Embase, Web of Science,
home-based pulmonary rehabilitation method that can Ebsco, China National Knowledge Infrastructure
bepracticedindependentlybypatientswithCOPD.There (CNKI), and WanFang Data were searched. The follow-
are various types of breathing exercises, including dia- ing search terms were used: (“chronic obstructive pul-
phragmatic breathing, pursed-lips breathing, yoga monary disease” OR “COPD” OR “chronic air flow
obstruction” OR “bronchitis chronic” OR “pulmonary
7
breathing, breathing gymnastics, and singing. Borge emphysema”) AND (“breathing exercises” OR “exer-
8
etal comparedbreathingexerciseswithrespiratorymus- cise of breathing” OR “breathing control exercises” OR
cle training using threshold devices and reported that “diaphragmatic breathing” OR “pursed-lips breathing”
breathing exercises can manage and control breathing OR“yoga” OR “breathing gymnastics” OR “singing”).
during exertion. However, respiratory muscle training Medical Subject Headings (MeSH) terms and free-text
requires a training program based on respiratory muscle keywordswereused.Thesearchstrategieswerewritten
strengthening to improve dyspnea. Another study found according to the retrieval requirements of each data-
that pursed-lips breathing is not only conducive to in- base. Search filters were applied to limit publication
creasing patients’ confidence in their ability to use the time (January 1, 2008, to December 31, 2018), article
technique for long-term management of dyspnea, but it type (randomized controlled trials), species (humans),
9
can also be used effectively at night. In addition, min- and language (English/Chinese) in all database output.
ute ventilation and breathing frequency during exercise In addition, the reference lists of potentially relevant
could be effectively reduced through breathing exer- studies were screened to make the review of the articles
10
cises. Research has shown that yoga breathing can as complete as possible.
effectively improve respiratory muscle strength in sub-
11 12
jects with COPD. Casey et al reported that breathing Inclusion Criteria
exercises can effectively alleviate patient dyspnea due
to its effectiveness in improving respiratory muscle
strength. Some researchers have confirmed that breath- Westructured the criteria for study selection according to
ing exercises can also improve exercise capacity and the principles of PICO (population, intervention, comparison,
HRQOLinpatientswithCOPDandcanberecommended outcomes). Subjects had to be diagnosed with COPD con-
19
as an effective training modality in pulmonary rehabil- firmedbyapulmonologistorspirometry(FEV /FVC0.7 )
1
13
itation. with no history of COPD exacerbation within the previous
However,theeffectiveness of breathing exercises varies 6 weeks. There were no gender and age restrictions. We
depending on design and type. Researchers report that required that at least one type of home-based breathing
diaphragmatic breathing may have different effects com- exercises was used for intervention (ie, diaphragmatic
pared with pursed-lips breathing, in that the former aims to breathing, pursed-lips breathing, yoga breathing, breathing
reduce work of breathing in patients with COPD and the gymnastics, or singing). We required that the home-based
14-16
latter aims to improvegasexchange. Moreover,breath- breathing exercises intervention was compared against a
ing exercises using metronome-based acoustic feedback usual treatment. With regard to outcomes, studies were
did not significantly improved exercise endurance or de- included if they measured lung function parameter (per-
crease the work of breathing for subjects with COPD com- cent of predicted FEV -
1 and FEV1/FVC), respiratory mus
17
pared with exercise training alone. Therefore, it is nec- cle strength (maximum inspiratory pressures [P ] and
Imax
essarytointegratetheresultsofindividualstudiestoclarify maximumexpiratory pressures [P ]), exercise capacity
Emax
the impact of breathing exercises on subjects with COPD. (6-min walk distance [6MWD]), dyspnea (modified Med-
The aim of this meta-analysis was to determine the effects ical Research Council [mMRC] dyspnea scale), and
of breathing exercises on pulmonary function, respiratory HRQOL (St George Respiratory Questionnaire). Finally,
muscle strength, exercise capacity, dyspnea, and HRQOL studies were included only if the study design was a ran-
in subjects with COPD. domized controlled trial.
378 RESPIRATORY CARE • MARCH 2020 VOL 65 NO 3
HOME-BASED BREATHING EXERCISES IN COPD
Table 1. PEDro Criteria and Scores of the Included Randomized Controlled Trials
Random Concealed Baseline Blinding Blinding Blinding Measures for Intention- Between-Group Point Estimate Quality
Study Allocation location Similar (Subject) (Therapist) (Assessor) 85% to-Treat Difference and Variability Score
Analysis Reported Reported (0–10)
Bonilha et al31 YNYNNNYNYY5
Gu et al30 YNYNNNYNYY5
Hu et al24 YNYNNYYYYY7
Kaminsky et al21 YYYYYYYNYY9
26
Li YNYNNNYYYY6
Lin et al27 NNYYYYYNYY7
Lord et al29 YYYNYYYNYY8
Ranjita et al25 YYYNYYYNYY8
Tang et al23 YNYNNNYYYY6
Xu et al28 YNYNYNYYYY7
Yamaguti et al15 YNYNNYYYYY7
Zhang et al32 YNYNNNYNYY5
Zhang et al22 YYYNNNYYYY7
PEDroPhysiotherapy Evidence Database
Exclusion Criteria scored 0). Review quality was classified according to the
PEDro scale score: 9–10 was considered high-quality lit-
Trials were excluded if participants had other organic erature, 6–8 was considered generally high-quality liter-
lesions or were in-patients; if other modes of exercise ature, 4–5 was considered medium-quality literature, and
besides home-based breathing exercises were applied as 4wasconsidered low-quality literature. Two investiga-
the intervention; if the articles were case-control trials, tors conducted quality assessments independently, and dis-
cohorttrials,crossovertrials,cross-sectionalstudies,expert agreements were resolved by seeking third-party opinions.
opinions, literature reviews, or letters; and if articles were
not available in English or in Chinese. Statistical Analysis
Study Collection and Data Collection Data were statistically analyzed using the Cochrane Col-
laboration software (RevMan 5.3). For each outcome, we
Tworeviewers independently screened the title and ab- tested the heterogeneity of results across studies using the
2
stract of each study from the search strategy to rule out chi-square test and the Higgins I test. A fixed-effects model
2
irrelevant studies. According to the abstract review, full wasusedwhenP.10andI 50%,whichwasconsidered
articles were requested for comprehensive review. When low heterogeneity. Otherwise, a random-effects model was
details were missing from the abstracts, full articles were conducted in the meta-analysis and the results were carefully
retrieved and checked for eligibility. Discrepancies were interpreted. Weighted mean differences and 95% CIs were
resolved through discussions with the third investigator. used to pool data in continuous variables. For all results, a
Tworeviewers independently extracted the characteristics 2-sided P value of .05 was considered to indicate a statis-
of the subjects (ie, sample size and participants’ demo- tically significant difference.
graphic characteristics), home-based breathing exercises
interventions (ie, method, frequency, and intensity), and Results
effects using a standardized form.
Literature Search and Results
Quality Assessment
According to the search strategy, a total of 6,733 poten-
Each included study was scored to rate the methodolog- tially relevant studies were identified by searching from each
ical quality of study by the Physiotherapy Evidence Da- database. After the 1,858 duplicates were removed, the titles
20
tabase (PEDro) scale. ThePEDroscalecontains11eval- and abstracts of 4,875 articles were screened, and 4,811 stud-
uationitems,scoredfromtheaspectofexternalauthenticity, ies were excluded based on the exclusion criteria, such as
internal authenticity, and statistical information, with a inappropriate interventions, other interventions, and other
total score of 10 points (Table 1). The 11 criteria of the study designs. Of the remaining 64 studies, 51 were excluded
PEDro scale were rated as “yes” (criteria were met and after full-text review, mainly because of the training forms
scored 1) or rated as “no” (criteria were not met and used in intervention. Finally, 13 studies met the inclusion
RESPIRATORY CARE • MARCH 2020 VOL 65 NO 3 379
HOME-BASED BREATHING EXERCISES IN COPD
Studies identified through used random assignment without reporting on allocation con-
database searching cealment, and 4 studies used computer-generated random
6,733 numbers, applied consistently. One study was randomly as-
signed by coin toss with no report whether the allocation was
Duplicates excluded hidden. Several authors reported difficulty in blinding, con-
1,858 sidering the type of therapy, thus only 2 studies were double-
blind, while 3 were single-blind. One study was performed
Studies screened for intention-to-treat analysis. Research protocols were avail-
4,875 able for all studies, and pre-declared outcomes were reported;
Excluded after title and there were no significant other biases.
abstract screening
4,811 Outcomes
Full text studies assessed Pulmonary Function. Ten studies investigated the ef-
for eligibility fectsofhome-basedbreathingexercisesonpulmonaryfunc-
64 Excluded
51 tion in subjects with COPD. There were 2 main outcome
Not home-based breathing exercises indices, including the percent of predicted FEV andFEV /
as a main intervention: 21 1 1
Not RCTs: 13 FVC. Seven studies evaluated the effect of respiratory
Inadequate outcomes: 11 training on percent of predicted FEV , and a fixed-effects
Full text not available: 3 1
Studies included Cannot extract the data: 2 model was used for meta-analysis due to decreased heter-
2
13 ogeneity (P .48, I 0%). The results showed that
Fig. 1. Flow chart. RCT randomized controlled trial. home-based breathing exercises effectively improved the
percent of predicted FEV in subjects with COPD (mean
1
difference 3.26, 95% CI 0.52–5.99, P .02) (Fig. 2).
criteria and were included in the meta-analysis. The process Seven studies evaluated the effect of respiratory training
of inclusion is shown in Figure 1. on FEV /FVC, and a fixed-effects model was used for
1
meta-analysis due to decreased heterogeneity (P .65,
2
Characteristics of the Selected Studies I -
0%). The overall analysis showed significant im
provement in FEV -
1/FVC after home-based breathing ex
Atotal of 998 subjects participated in the 13 random- ercises (mean difference 2.84, 95% CI 1.04–4.64,
izedcontrolledtrialsincludedinourmeta-analysis.Most P .002) (Fig. 2).
of the included subjects had moderate or severe COPD.
Considering all studies together, the subjects were pre- Expiratory Muscle Strength. The P and P were
Imax Emax
dominantly male. The 13 studies involved 5 interven- measured in 3 studies (Fig. 3). With less heterogeneity
2
tions: diaphragmatic breathing (1 study), pursed-lips (P .96, I 0%), a fixed-effects model was used for
breathing (1 study), yoga breathing (2 studies), breath- meta-analysis. The analysis indicated that there were ef-
ing gymnastics (5 studies of traditional Chinese exer- fectiveincreasesinP (meandifference20.20,95%CI
Imax
cises combined with breathing and 2 of novel combined 11.78–28.61, P .001) and PEmax (mean differ-
breathing exercises), and singing (2 studies). Session ence 26.35, 95% CI 12.64–40.06, P .001).
duration ranged from 10–60 min, with application fre-
quency varying from once per day, 3 times per week to Exercise Capacity. Of the 13 trials, 9 studies assessed
3 times per day, 7 times per week. Program duration in exercise capacity using the 6MWD. When pooled in the
the studies ranged from a minimum of 4 weeks to a meta-analysis, results showed a small heterogeneity
maximum of 12 months. Characteristics of the 13 in- (P .30, I2 16%) and that the home-based breathing
cluded studies are shown in Table 2. exercises led to significant improvements in the 6MWD
(mean difference 36.97, 95% CI 25.06–48.89,
Quality of the Selected Literatures P .001) (Fig. 4).
The detailed results of the quality assessment for the se- Dyspnea. The mMRC score was used to evaluate dys-
21
lected studies are shown in Table 1. One trial wasevaluated pnea. A pooled effect size from data of 5 studies with low
15,22-29 2
as high-quality literature, 9 trials were generally high- heterogeneous (P .22, I 30%) indicated that home-
30-32
quality literature, and 3 trials were of moderate quality. based breathing exercises decreased mMRC scores of sub-
All studies reported that allocation was random. Six studies jectswithCOPD(meandifference0.80,95%CI1.06
mentioned blinding the assessor collecting data. Eight studies to 0.55, P .001) (Fig. 5).
380 RESPIRATORY CARE • MARCH 2020 VOL 65 NO 3
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