What makes difficult asthma difficult? SCH Journal Club Nicki Barker 2012 June 2012 Dysfunctional breathing in children1

Aim To determine whether breathing retraining improves quality of life for children with dysfunctional breathing June 2012 Dysfunctional breathing in children2

Objectives Clarify the problem identified Share an understanding of difficult asthma and dysfunctional breathing Critically appraise a relevant piece of literature Assess the impact of the literature on current practice June 2012 Dysfunctional breathing in children3

Difficult asthma ‘persistent symptoms and/or frequent exacerbations despite treatment at step 4 or step 5’ June 2012 Dysfunctional breathing in children4

Difficult asthma? Compliance issues Incorrect diagnosis Asthma plus a co-morbidity June 2012 Dysfunctional breathing in children5

BTS guidelines 2012 ‘dysfunctional breathing should be considered as part of a difficult asthma assessment’ June 2012 Dysfunctional breathing in children6

BreathWorks Specialist assessment of dysfunctional breathing Children aged 8-16 Referral currently via respiratory clinics Thursday afternoon in physiotherapy O/P’s June 2012 Dysfunctional breathing in children7

Dysfunctional breathing (DB) Dysfunctional breathing HVSVCD Breathing pattern disorder Dysfunctional breathing in children June

DB: A model HVS BPDVCD

DB: A paediatric model HVS BPD VCD

Evidence for breathing ex’s Buteyko breathing technique may be considered to help patients to control the symptoms of asthma Reduces symptoms and bronchodilator use June 2012 Dysfunctional breathing in children11

The Clinical Question PopulationChildren with dysfunctional breathing InterventionBreathing retraining ComparisonNormal care Outcome QOL, symptom scores, changes in asthma medication, objective measures DesignIntervention RCT June 2012 Dysfunctional breathing in children12

Breathing retraining for dysfunctional breathing in asthma: a randomised controlled trial Thomas M, McKinley RK, Freeman E, Foy C, Prodger P, Price D. Thorax Feb 2003; 58(2):110-5 June 2012 Dysfunctional breathing in children13

The Clinical Question PopulationAdult asthma patients with dysfunctional breathing InterventionBreathing retraining ComparisonEquivalent amount of professional attention OutcomeQOL, symptom scores, changes in asthma medication DesignIntervention RCT June 2012 Dysfunctional breathing in children14

Methods Patients aged 17 to 65 n=33 Diagnosis of currently treated asthma Single semi-rural UK GP practice Nijmegen questionnaire score of  23 Randomised to breathing retaining or asthma education June 2012 Dysfunctional breathing in children15

Study flow diagram Thomas M et al. Thorax 2003;58:

Outcome measures Primary –Asthma specific health status (AQLQ) –Nijmegen questionnaire scores Secondary –Changes in asthma medication and medication usage June 2012 Dysfunctional breathing in children17

Using the CASP tool June 2012 Dysfunctional breathing in children18 A/ Are the results of the trial valid? Screening Questions 1 Did the trial address a clearly focused issue? Yes Can't tell No 2 Was the assignment of patients to treatments randomized? Yes Can't tell No 3 Were all of the patients who entered the trial properly accounted for at its conclusion ? Yes Can't tell No

CASP cont. June 2012 Dysfunctional breathing in children19 Detailed Questions 4 Were patients, health workers and study personnel ‘blind’ to treatment? Yes Can't tell No - Virtually impossible with physiotherapy interventions 5 Were the groups similar at the start of the trial? Yes Can't tell No - Control group appeared to have greater inhaled steroid dose 6 Aside from the experimental intervention, were the groups treated equally? Yes Can't tell No - 75mins versus 60mins and in a different format

CASP cont. June B/ What are the results? 7 How large was the treatment effect? - Not clearly stated and no MCID available for Nijmegen Questionnaire 8 How precise was the estimate of the treatment effect? - Confidence interval and limits not stated C/ Will the results help locally? 9 Can the results be applied to the local population? Yes Can't tell No – Questionable choice of measures, adult to paediatric applicability 10 Were all clinically important outcomes considered? Yes No - No objective measures used 11 Are the benefits worth the harms and costs? Yes No - Minimal likelihood of harm. Costs – time of therapist and patient

Key thoughts 50% benefitted at 1 month 25% benefitted at 6 months Small numbers Short duration intervention Intervention not representative of clinical situation Application of findings to children Impact of co-existent asthma June 2012 Dysfunctional breathing in children21

Quality of life as measured by PedsQL MCID = minimal clinically important difference

Symptom score using Nijmegen Questionnaire

Take home messages Consider dysfunctional breathing in cases of difficult asthma Key signs of DB are: Frequent sighing, unsteadiness/irregularity of breathing, upper chest dominated breathing, mouth breathing, difficulty breathing in, throat tightness Refer appropriate cases to BreathWorks Support the research needed to better understand DB in children June 2012 Dysfunctional breathing in children24