The Buteyko Method in Asthma: Opportunities and Opinions
Presentation by Dr James Oliver to the
British Thoracic
Society Summer Meeting 2005
Introduction
The Buteyko Method is a system
of breathing exercises and other behavioural modifications first developed
in the 1950’s by Dr Konstantin Buteyko a Ukrainian physician and academic.
Following significant use within Russia and other countries of the former
Soviet Union it transferred to Western counties, notably Australia and
New Zealand, approximately 20 years ago.
The central theme of the Buteyko
Method is that certain aspects of hyperventilation serve to exacerbate
a number of common conditions, including asthma. The primary goal of
the training prescribed by the technique is towards reducing or eliminating
the tendency to hyperventilate at the onset of symptoms. This
requires students to develop considerable self control, and hence is
very dependent on the commitment of the student to put in the required
daily practice. Even strong advocates for the Buteyko Method would
be the first to recognise that this need for hard work will no doubt
restrict the popularity of the method; especially among those with little
spare time or who want an easy solution. However, provided that
the technique does manage to prove its worth, then by making it more
widely available at least patients will have the choice.
In most countries Buteyko is
classed as a complementary therapy; this is no bad thing as the use
of Buteyko fits very comfortably as an adjunct to continuing conventional
asthma care. However, the negative, stereotypical image of the
term ‘complementary’ in some sectors of conventional medicine, (i.e.
implying unscientific or irrational ideas dependent on bizarre physiological
precepts), is inappropriate in the case of Buteyko, since it is very
much based on the conventional Western scientific model. As with
any other branch of science, observations (e.g. anecdotal reports of
the success of the Buteyko techniques) lead to the formation of standard
scientific hypotheses, which are in turn amenable to testing using standard
scientific methods.
A key element of today’s
presentation is that by taking such hypotheses seriously it may be possible
to identify relatively simple measures which could improve the quality
of life for many asthmatics, without the need for a significant investment
of time and capital.
Evidence of Effectiveness
and Theoretical Background
There have now been 6 recorded
randomised, controlled trials of the Buteyko Method conducted outside
of Russia (1-6). A recent review by Bruton and Lewith (7) provides
a detailed analysis of the findings for interested readers.
As far as interpretation of
the evidence is concerned the crucial issue is the true meaning of the
significant reductions in the use of beta-agonists, and (in two cases)
inhaled steroids, in the absence of any increase in exacerbations, reduction
in quality of life or deterioration in lung function. There are cogent
views on both sides of the argument. However, part of the confusion
seems to lie in a certain ambiguity as to the actual hypothesis being
tested on each occasion. A notable exception is the trial by Cooper
et al (3) who tried to separate the effects of multiple simultaneous
changes in therapy by conducting a separate steroid reduction phase.
This is clearly an approach that warrants attention in the planning
of future trials, along with efforts to find alternative and less controversial
outcome measures.
The most common theory put
forward to explain the Buteyko method is one based on the potential
benefits of reversing the effects of the hypocapnia caused by hyperventilation.
Again Dr Bruton and her colleague Dr Holgate at Southampton University
have produced a fine review of the existing evidence behind this theory
(8). While it has to be said that there is some slight evidence
in favour of this model it is far from conclusive. For my own
part I would also include the following as potential candidates for
investigation:
1). The potential contribution
of the excitatory non-adrenergic, non-cholinergic (eNANC) system to
the generation of asthma symptoms.
Present evidence suggests that
small, non-myelinated, C-fibre sensory nerves which are present beneath
the respiratory epithelium of human airways are capable of releasing
various neuropeptides such as substance P, neurokinin A and calcitonin
gene related peptide (CGRP) (9). The combined action of these agents
is believed to cause bronchoconstriction, vasodilation, increased mucus
production and activation of immune cells such as eosinophils, neutrophils
and mast cells. This process has come to be known as ‘neurogenic inflammation’.
The degree to which such nerve
induced inflammation contributes to the development of asthma symptoms
is currently unknown. However, given the potential for adverse consequences
in asthma, efforts to reduce stimulation of these sensory nerves by
avoidance of coughing and use of shallow quiet breathing might be seen
as beneficial.
2). The potential benefits
of intermittent hypoxia training (IHT).
Another technique to have received significant attention over many years in the former Soviet Union is the therapeutic use of intermittent hypoxia (10). Nowadays this mostly involves the use of machines comparable to oxygen concentrators but driven in reverse.
Subjects breathe oxygen depleted
air (range 11-16% O2) for repeated short periods over the space of approximately
one hour a day, according to specific protocols. The treatment is repeated
daily for two-three weeks.
Inevitably this training induces
an adaptation reaction in the subject, which is claimed to have a number
of beneficial effects in a variety of medical conditions, including
asthma. In the latter a remission of symptoms is said to occur
in 70% of subjects which lasts for 3-4 months following the course of
treatment. The mechanism is said to be partly due to an anti-inflammatory
effect brought about by increases in cellular anti-oxidant defence systems.
There have not been any trials
of this technique outside of Russia as far as is known. However, anecdotal
evidence from the few therapists using these machines in western countries
tends to support the Russian claims.
Overall, there is a striking
similarity between the protocols for the use of intermittent hypoxia
and the Buteyko breathing exercises. The voluntary hypoventilation and
breath-holding in Buteyko clearly produces an element of hypoxia as
well as a retention of CO2. However, whether this is a part of the mechanism
behind the technique remains to be established.
Other potential mechanisms
such as an effect of the breathing exercises on the non-linear dynamics
of the respiratory centre are also possible; however the complex nature
of this subject puts it beyond the scope of this handout.
The Core Components of the
Buteyko Exercises
In practice the Buteyko Method
is a complex package of interventions that includes not only breathing
exercises but also advice regarding diet and physical exercise. However,
in terms of the breathing exercises there are broadly 4 main components.
The instruction to breathe
through the nose all the time is very much a golden rule in Buteyko
and considerable effort is expended in establishing a nasal breathing
habit if it is not already present. The frequent association between
rhinitis and asthma means that for many patients nose breathing represents
a challenge at first. However, the method contains specific exercises
consisting of breath-holding and head and neck movements which cause
temporary decongestion of the nasal mucosa and allow subjects to breath
more easily through the nose.
Much more difficult is correction
of the mouth breathing habit which is generally unconscious and is reinforced
by changes in the musculature around the jaw over time. This means that
initially the mouth can only be kept closed with deliberate effort.
Constant reminders are usually required to keep the mouth closed both
from physical reminders such as stickers and the patient’s relatives
or work colleagues.
At night the advice is to tape
the lips gently closed using Micropore paper tape to ensure that breathing
continues through the nose overnight during sleep. For many people
this raises issues of safety regarding the possibility of respiratory
obstruction or aspiration. However, a recent survey of Buteyko practitioners
world wide (unpublished data) found that of approximately 21,000 asthmatic
patients advised to tape their mouths at night there were only four
recorded instances of adverse effects. These were 2 panics attacks,
an allergy to the Micropore tape and a minor injury to the lip from
pulling off a small piece of skin.
Subjects are given guidelines
on how and when to tape along with rules such as not to tape after ingesting
alcohol, hypnotics or at any time when vomiting seems likely (e.g. during
gastric infections).
One has to remember that experience
gained from investigations of sleep apnoea shows that the incidence
of respiratory obstruction during sleep is relatively common yet rarely
causes any more harm in the short term than a disturbed sleep pattern.
Subjects learning the Buteyko
Method are advised not to cough unless absolutely required to clear
retained secretions. The relevance of this may relate to the effect
of the eNANC nervous system as mentioned above.
It is interesting to note as
an aside the reports of the success of behavioural techniques to help
patients with eczema learn not to scratch (11). Obviously there may
be a similar rationale behind both of these approaches.
The Buteyko approach to the
management of asthma symptoms is very much to try to abort the attack
at the start rather than wait until symptoms have become established.
Therefore students are advised to begin to hypoventilate as soon as
they feel the first signs of chest tightness or wheeze. With this
approach symptoms will usually settle within a few minutes. All patients
are advised that they must still always carry a reliever inhaler in
case they do not manage to control the attack.
Hypoventilation at the start
of an asthma attack is not easy and therefore subjects need considerable
self control in order to be able to achieve this effectively.
Therefore regular daily practice is required to build up their experience
and effectively desensitize them to the feeling of breathlessness. This
is just as much a psychological process as a physiological one.
The exercises involve:
a). Short periods of voluntary hypoventilation (approximately 3-5 minutes)
b). Breath holding exercises (depending on the subject anything up to 60 seconds)
c). Muscular relaxation
The exercises are formed into
groups or sets and are repeated 3-5 times a day. The total practice
time required is about an hour a day, although this can be reduced after
4-6 weeks. In the long run regular daily exercise sets may not
be necessary as subjects can build the techniques into their usual daily
activity.
Contrary to popular expectations
the Buteyko Method is not ‘anti-medication’. In particular there
is no resistance to the use of steroids when these are required for
the treatment of exacerbations or to maintain adequate control of asthma
symptoms.
Medication advice regarding
reliever medications is entirely consistent with current BTS/SIGN guidelines
(i.e. use only when required to control symptoms of asthma). No advice
is given regarding the stepping up or down of preventer medications;
these decisions are all referred back to the patient’s own doctor.
One of the major advantages
of the Buteyko Method is that it is entirely complementary to conventional
medical care for asthma. Therefore patients can simply use the techniques
as an adjunct to their existing medical management in order to assist
in the control of their symptoms.
Potential Topics for Future
Asthma Research
One of the advantages of studying
the Buteyko Method is that it provides a fresh perspective on the current
medical management of asthma.
Although there have clearly
been considerable changes in the management of asthma over the last
20 years this has mostly revolved around a shift in emphasis when it
comes to applying existing treatments (e.g. the increasing use of inhaled
steroids, or the more widespread use of spacer devices). The number
of genuine innovations has been lower than might have been anticipated
given the considerable investment of time and money towards asthma research.
One genuine innovation within
this period has been the introduction of the anti-leukotrienes. They
are now widely used and form part of the step-wise approach to asthma
management advocated by the in the BTS/SIGN guidelines. In particular
their use is mentioned as an option in adult patients with chronic asthma
who are inadequately controlled on inhaled corticosteroids.
A recent Cochrane review (12)
of the effect of adding in anti-leukotrienes at licensed doses in patients
who are already taking inhaled steroids revealed the following:
a). Significant improvement in morning peak flow with weighted mean difference of 7.65 L/Min (CI 3.55-11.75)
b). Significant reduction in use of beta-agonists with weighted mean difference of -1 puff/week (CI -0.5 to -2 puffs week)
c). Trends to improvement in
symptoms score and quality of life but these did not reach the level
of statistical significance.
The point here is that although
significant differences are shown the overall improvement can at best
be described as ‘modest’. For example the common practice
of rounding a patient’s peak flow reading up or down to the nearest
10 L/min threatens to hide any visible improvement in airway function
at the levels quoted.
Now clearly the reality is
that some patients respond better than others; in those that respond
well there will obviously be more significant and clinically meaningful
benefits. However, my point is not to criticise the use of anti-leukotrienes
but to illustrate the overall magnitude of therapeutic effects that
we are currently considering to be worthwhile. The question is
whether, if we are looking for effects on this scale, there are other
interventions we could make which could have beneficial effects at a
similar level. In other words we are not looking for cures but just
other things that could produce modest improvements.
An example that comes from
looking at the Buteyko Method is the golden rule of breathing through
the nose. This is an area that has received very little attention
in terms of conventional asthma research. Common experience shows
us that oro-nasal breathing is common among patients with asthma, particularly
when they are symptomatic. What research there is on the subject tends
to support this (13, 14). Given the common association between asthma
and rhinitis this is hardly surprising. (It should be noted that
although the use of nasal steroids to combat rhinitis has only shown
minor non-significant effects to improve asthma control (19) this form
of therapy does nothing to correct the mouth breathing habit, which
is often deeply embedded).
Research attempting to quantify
the potential benefits of nose breathing in asthma is also very sparse.
However, what there is appears to indicate a positive effect (15, 16).
Although many practitioners
within the health service will already be advising patients with asthma
to try to breathe through their nose, there is little evidence of a
concerted effort to make this standard practice. For example Asthma
UK does not produce any advice leaflets for patients on the benefits
of nose breathing; there are no modules on training patients to nose
breathe at the National Respiratory Training Centre; and the advice
to nose breathe is not mentioned in the BTS/SIGN Guidelines.
It is clear that there is very
little evidence at present to justify a major change in policy. However,
there is circumstantial evidence that it is at least worth while conducting
further trials to gain such evidence as might be required. For
example the fact that we possess such an efficient nasal system to meet
the demands of filtration, warming and humidification must indicate
that in evolutionary terms better nasal function must give rise to some
fitness or selection advantage for the individual. In addition the fact
that throughout the billions of separate evolutionary steps that have
separated every single species of mammal, reptile and bird the nose
has been retained, indicates that its use is hardly likely to be optional.
The issue of encouraging nose
breathing in asthma is a simple one, but one that may bring significant
improvements in asthma control; possibly on a par with the effect of
the anti-leukotrienes. Given the relative ease with which research could
be carried out in this area it seems sensible to make it a goal within
the near future. Unfortunately manpower and resources issues within
the existing Buteyko movement make it very unlikely that such evidence
could be amassed quickly. Therefore there is a need for assistance from
those conventional practitioners who may be interested in such questions
and wish to help take them further.
Another issue that could be
addressed in a similar way is the potential benefit from the Buteyko
instruction to hypoventilate at the first sign of asthma symptoms.
The fact that it has been amply demonstrated that hyperventilation induces
bronchospasm in the majority of asthmatics (17) and that patients with
asthma commonly hyperventilate in response to symptoms (18) indicates
that there are at least some grounds for investigating a possible connection.
Again it is not to be expected that such a manoeuvre by itself, (i.e.
without the other components of the Buteyko Method) will abolish symptoms
altogether; however it may be possible to demonstrate that it either
reduces the severity, or leads to more rapid resolution, of bronchospasm
induced by a set stimulus.
Current Opinions of Buteyko
Practitioners within the NHS
Should therapists working for
the NHS be teaching the Buteyko Method?
There are two broad issues
that need to be addressed here. Firstly there is the issue of
safety as it is clearly not desirable for those within the health service
to be engaged in activities which do more harm than good. Secondly
there is the question of cost effectiveness and whether any intervention
can be proven to bring about meaningful improvements in patient care.
In terms of safety harder evidence
comes from the four published trials of the Buteyko method (1-4) where
there was no recorded excess of adverse events in those treated with
the techniques. However, clearly the total number of patients
treated in these trials was relatively small. Softer evidence comes
from the extensive use of the Buteyko Method in Russia over the course
of 50 years with no reports of significant long term health damage.
The results of my own survey of the 73 patients I have treated with
the Buteyko method tends to support a benign effect on symptoms and
a positive attitude towards the technique (See Fig 1 + Fig 2).
However, I am fully aware of the very many problems is drawing any conclusions
from this type of exercise where there are multiple confounding factors.
How would you rate your
asthma symptoms now compared to before you learned the Buteyko method?
Figure 1.
Would you recommend the
Buteyko method to other people with asthma?
Figure 2.
There are certain common conditions
that carry a theoretical risk of harm from the Buteyko exercises and
these are listed in table 1. In cases where caution is required practitioners
will employ only milder techniques over a longer period (i.e. no extended
breath holds).
| Contraindications | Cautions |
|
|
Although documented evidence
on the safety of Buteyko may be relatively small it has to be remembered
that the entire action of the Buteyko techniques is dependent on the
cooperation and motivation of the patient. The effort required to engage
in the exercises has to be supported by some benefit as far as the patient
is concerned otherwise their use of the techniques will rapidly diminish.
Therefore potential adverse effects may well be self limiting.
However much research is done
there can never be an absolute guarantee of safety for every patient,
just as with any other therapy. Clearly there needs to be supervision
and a reporting system for potential adverse effects in the same way
as for pharmaceuticals but, given the nature of the interventions prescribed
within the Buteyko method, the risk of serious harm appears low at present.
Opinions of Physiotherapists
currently using the Buteyko Techniques
Ever since the founding of
the Buteyko Breathing Association in the UK in 1999 it has been a stated
aim of the organisation to promote the availability of the Buteyko Method
within the NHS.
In 2002 a colleague Janet Brindley
and I started to run training courses for health professionals to learn
the Buteyko techniques. These were aimed very much at therapists from
within the NHS, with fees kept at a level consistent with the possibility
of full reimbursement from NHS departments.
In June 2005 I conducted a
postal survey of 22 UK physiotherapists who had been through the training
and who had been using the Buteyko techniques in practice for more than
12 months.
The results from the 18 replies
received are given in fig 3.
Of course there are inevitable
problems in extrapolating the results of such a small survey across
the physiotherapy workforce in general, particularly when these individuals
were self selected and may represent a small subgroup of ‘believers’.
However, it was felt that the results might be of interest to other
physiotherapists who may be contemplating learning more about the Buteyko
techniques.
Summary
The Buteyko Method has drawn
significant attention from the public and media over the last 10 years.
The results of 6 randomised controlled trials into the technique are
currently not accepted as proof that the method has any significant
therapeutic value, although they are not inconsistent with a useful
effect being present. Clearly further investigations with more attention
to the specific hypotheses being tested and alternative outcome measures
are required.
Even if the Buteyko method
is proven to be effective, in practical terms it is always going to
be of most value to a subset of patients with asthma who are prepared
to invest the significant time and effort required to master the breathing
exercises. Therefore the overall future impact on the prescribing
costs for asthma medications within the NHS is not known.
One of the main advantages
of the Buteyko Method is that it provides a new perspective from which
to observe our current management of asthma. It highlights a few potential
interventions, such as retraining asthmatics to breathe through their
noses, or deliberately hypoventilating at the start of an attack which
may be fruitful areas for research in the future.
If you would like to contact
me for further details please feel free to do so.
e-mail james@kerdevez.demon.co.uk
tel. (01326) 241632
Figure 3. Responses of 18 UK physiotherapists trained in Buteyko techniques
References
1. Bowler SD et al ‘Buteyko breathing techniques in asthma: a blinded randomised controlled trial’ Med J Aust 1998 169:575-578
2. Opat AJ et al ‘A clinical trial of the Buteyko Breathing Technique in Asthma as taught by a video’ J Asthma 2000 37:557-564
3 Cooper S et al ‘Effect of two breathing exercises (Buteyko and pranayama) in asthma: a randomised controlled trial’ Thorax 2003 58:674-679
4. McHugh P et al ‘Buteyko Breathing Technique for asthma: an effective intervention’ N Z Med J 2003 116 : U710
5 McGowan J ‘Health Education: does the Buteyko Institute Method make a difference?’ Thorax 2003 58:iii28 [abstract S92]
6. Abramson M et al A randomised controlled trial of the Buteyko method for asthma Int J Immunorehab 2004; 6(2):244
7. Bruton A Lewith GT ‘The Buteyko breathing technique for asthma: A review’
Complementary Therapies in Medicine 2005 13(1):41-46
8. Bruton A. Holgate ST. ‘Hypocapnia and Asthma: A mechanism for Breathing Retraining’ Chest 2005;127:1808-1811
9. Kraneveld AD et al ‘Excitatory non-adrenergic-non-cholinergic neuropeptides: key players in asthma’ European Journal of Pharmacology 2000 405:113-129
10. Bernardi L ‘Interval Hypoxic Training’ in Hypoxia: From Genes to the Bedside
RC Roach et al (Ed) Kluwer Academic/Plenum Publishers New York, 2001.
11. Armstrong-Brown S ‘The Eczema Solution’ Vermilion Press 2002
12. Ducharme F et al ‘Addition of anti-leukotriene agents to inhaled corticosteroids for chronic asthma (Review)’ The Cochrane Database of Systematic Reviews 2004 Issue 1
13. Kairaitis K ‘Route of Breathing in Patients with Asthma’
Chest 1999; 116:1646-1652
14. Venetikidou A. ‘Incidence of malocclusion in asthmatic children’
J. Clin. Ped. Dent. 17(2):89-94 1993
15. Mangla PK. Menon MP ‘Effect of nasal and oral breathing on exercise-induced asthma’ Clinical Allergy 1981; 11(5):433-9
16. Petruson B. Theman K. ‘Reduced nocturnal asthma by improved nasal breathing’ Acta Oto-Laryngologica 1996; 116(3):490-2
17. Hurwitz K et al ‘Interpretation of Eucapnic Voluntary Hyperventilation in the Diagnosis of Asthma’ Chest 1995; 108:1240-45
18. Kesten S et al ‘Respiratory
Rate during Acute Asthma’ Chest 1990; 97(1):58-62