The Effectiveness of Breathing Exercises on Improving Asthma Control and Quality of

Life in Asthma Patients: A Systematic Review

Hasanudin1, Alfian Nur Rosyid2, Yuni Damayanti1, Yosin Herloheti Pella1, Arina Dery

Puspitasari3, Tintin Sukartini1

1
Faculty of Nursing, Universitas Airlangga, Surabaya, Indonesia.
2
Departement of Pulmonary and Respiratory Medicine, Faculty of Medicine, Universitas

Airlangga, and Universitas Airlangga Hospital, Surabaya, Indonesia.

3
Faculty of Pharmacy, Universitas Airlangga and Universitas Airlangga Hospital, Surabaya,

Indonesia.

Abstrak:

Background: Asthma is a heterogeneous disease characterized by chronic inflammation of

the airways, with a history of respiratory symptoms such as wheezing, dyspnea, shortness of

breath, coughing, and variable airflow limitation. Objective: To examine the effectiveness of

breathing exercises in improving asthma control and asthma patients' quality of life.

Methods: A systematic literature search was performed using four databases through

CINAHL, PubMed, SAGE, and Scopus for the last 5 years. A combination of keywords

including "breathing exercises," "breathing techniques," "yoga," "asthma control," "quality of

life." Only randomised controlled trials that examined the effects of breathing exercises in

improving asthma control and quality of life were included in the review. The Joanna Briggs

Institute (JBI) critical appraisal checklist for randomized controlled trials was used to assess

the selected articles' bias and methodological quality. Results: A total of 307 articles were

retrieved, and eleven publications were included for full-text analysis. Interventions include

those involving the use of Pranayama yoga, Buteyko breathing technique, progressive muscle

relaxation biofeedback, and breathing relaxation, Speech-guided breathing retraining,

Papworth breathing exercises, and combined some breathing exercises. These interventions
 are types of breathing exercises that significantly affected asthma control and quality of life

for asthma patients. Conclusion: Breathing exercises are widely used in clinical practice as

part of the management of asthma patients. Breathing exercises have been shown to improve

asthma control and quality of life for asthma patients.

Keywords: Breathing exercises, breathing technique, yoga, asthma control, and quality of

life.

Corresponding author: Tintin Sukartini, Faculty of Nursing, Universitas Airlangga, Surabaya,

Indonesia. Mulyorejo Campus C Universitas Airlangga, Surabaya, Indonesia. Email: tintin-

[email protected]. Telephone: +6282119366000,

1. Introduction

The Global Initiative for Asthma (what year?) defines asthma as a heterogeneous disease

characterized by chronic inflammation of the airways, with a history of respiratory

symptoms, such as wheezing, dyspnea, shortness of breath, coughing, and variable airflow

limitations 1.

Asthma is a problem for the whole world; an estimated 358 million people are affected

by this disease. Based on standard methods for assessing asthma symptoms, global asthma

prevalence ranges from 1 to 22% of the population in various countries. The majority of

asthma symptoms in children have decreased over the past few years. The prevalence of

symptoms has declined in Western Europe but increased in areas where prevalence was

previously low. The majority of asthma symptoms in Africa, Latin America, Eastern Europe,

and Asia continue to grow. The World Health Organization Global Burden of Disease Study

estimates that in 2015, 26.2 million people were living and experiencing disabilities

(DALYs), representing 1.1% of the total global disease burden. It is estimated that asthma

causes 495,000 deaths worldwide each year, with case fatality rates varying widely 1.
 Asthma is caused by a variety of allergic and non-allergic stimuli, such as infectious,

emotional, and hormonal factors, food, gastroesophageal reflux, hypersensitivity reactions to

drugs and chemicals. Allergen exposure is the main triggering factor for the recurrence of

asthma in patients who have allergy-related IgE problems; exposure to these allergens

includes dander in pets. Pollen and dust allergies. Besides, the respiratory system's viral

infections, especially those caused by rhinoviruses (RV), often trigger acute asthma

exacerbations in allergic and non-allergic humans 2.

Asthma patients use more breathing support muscles as a result of reduced chronic

inflammation and expiratory airflow. This causes the patient to experience a lack of air so

that breathing is limited, fast, and shallow. These changes reduce the efficiency of breathing

and the ability to breathe. A breathing pattern that does not function appropriately in asthma

patients can worsen symptoms. Management of asthma patients is to provide

pharmacological and non-pharmacological therapy. One of the non-pharmacological

therapies that can be applied to prevent asthma recurrence is breathing exercises such as

fast/slow breathing techniques, deep breathing, diaphragmatic breathing, breath-holding

exercises, nasal breathing, and breathing exercises using the pranayama technique. This

breathing technique aims to help maintain breathing more accurately and effectively and can

control asthma symptoms and improve quality of life in asthma patients 3.

This systematic review aimed to determine the effectiveness of breathing exercises in

improving asthma control and quality of life in asthma patients. This systematic review also

aims to provide recommendations regarding various breathing exercises that can be applied to

asthma patients based on current evidence.

2. Material/ Methods

A review protocol was prepared to guide the process of preparing the articles to develop

the systematic review. The protocol covers the rationale and objectives of the systematic
 review, eligibility criteria for studies to be included, sources of information, search strategies

to be used, study selection and data collection processes, data items and results to be

searched, methods for assessing the risk of bias for individual studies:, and data synthesis.

Systematic reviews are reported following the preferred reporting item guidelines for

systematic review and meta-analysis (PRISMA).

2.1 Search Strategy

A systematic review search was conducted using four electronic databases: CINAHL,

PubMed, SAGE, and Scopus. The search period was carried out in October 2020. The

developed combination of keywords and MeSH terms was then adapted to other databases.

The keywords and subject titles used in the search for articles were ("breathing exercises OR

yoga AND asthma control AND quality of life OR Health-Related Quality Of Life OR

Life Quality) published full-text articles in the last five (2016 - 2020) in English. Use

Boolean Logic (and, or).

2.2 Inclusion and Exclusion Criteria

Tabel 1. Picot Framework

PICOT Inclusion Criteria

framework

Population Asthma patients

Intervention The interventions included breathing exercises either used as a single

intervention or as part of a combined intervention.

Compactors Patients who do not get breathing exercises

Outcomes Improved asthma control and quality of life

Time 2016-2020

Study Design Randomized control trial

Language English
 Exclusion Articles that do not discuss breathing exercises in asthmatic patients,

Criteria: articles without full text and abstracts without intervention details,

timeless than 2016, and studies conducted in languages other than

English, and non-RCT designs were excluded.

2.3 Study Selection

According to the PRISMA guidelines, potential articles were first retrieved from the

electronic database. After the removal of duplicates, the article titles and abstracts were

screened for eligibility. The full text of each selected article that met the inclusion criteria

was taken for further examination. A secondary search was performed of the studies'

reference lists to identify additional records. Finally, relevant lessons that met all of the

inclusion criteria were included in the systematic review. The search and screening processes

were performed by three independent reviewers.

2.4 Risk of Bias

The Joanna Briggs Institute (JBI) critical appraisal checklist was used to assess the

methodological quality of the included randomized controlled trials. Bias was assessed by 13

items 4. Three independent reviewers assessed the risk of bias for each included study. Any

disagreements were resolved by discussion.

2.5 Data extraction

A structured form is used to extract information from the included articles, starting

from the author, year, country, design, age of the respondent, sample size, intervention,

outcome, and the conclusion of the article used to evaluate the intervention's effect.
3. Results

3.1 Study Selection

A total of 307 articles were identified. After duplication removal, titles and abstracts were

obtained 302 articles to be reviewed for eligibility. Then 153 articles were issued based on

the last 5 years since 2016-2020. The method used had to be a randomized trial (RCT), and

the language used was English so that 149 articles were obtained. After further exclusion of

149 articles, 46 articles were obtained for further review. Finally, 11 articles were included in

the systematic review following the application of the inclusion and exclusion criteria.

Identification Study Identifield through Additional Studies Identified

database Searching CINAHL, Through other Sources
PubMed, SAGE dan Scopus (n=0)
(n = 307)

Screening Studies after duplicate removed

(n=302)

Studies Screened Studies excluded

(n=149) (n=153)
Elibility

Full-text articles assessed Studies excluded

for eliability (n=35)
(n=46)

Included
Studies included in the
qualitative synthesis
(n=11)

Figure. 1 Flow chart of study selection

3.2 Risk of Bias

Table 2. Risk assessment of bias using the JBI critical appraisal checklist for randomized

controlled trials.

Penulis dan Tahun Critical Appraisal Checklist Result %

1 2 3 4 5 6 7 8 9 10 11 12 13

Erdoğan Yüce & √ √ √ √ √ √ √ √ √ √ √ √ √ 13 100

Taşcı., (2020)

Evaristo et al., (2020) √ √ √ √ √ √ √ √ √ √ √ √ √ 13 100

Vagedes et al., (2020) √ √ - √ √ √ √ √ √ √ - √ √ 11 84

Malarvizhi. M et al., √ √ √ √ √ √ √ √ √ √ √ √ √ 13 100

(2019)

Georga et al., (2019) √ √ √ - √ - - √ √ √ - √ √ 9 69

Arden-Close et al., √ √ - - √ - √ √ √ √ - √ √ 9 69

(2019)

Bahçecioğlu Turan & √ √ √ √ - - √ √ √ √ √ √ √ 11 84

Tan, (2019)

Agnihotri et al., √ √ √ √ √ √ √ √ √ √ √ √ √ 13 100

(2018)

Bruton et al., (2018) √ √ √ √ √ √ √ √ √ √ √ √ √ 13 100

Von Bonin et al., √ √ √ - - - √ √ √ √ - √ √ 12 92

(2018)

Thomas et al., (2017) √ √ √ - √ √ √ √ √ √ √ √ √ 12 92

Based on table 2, there are 11 articles assessed for risk of bias using the JBI critical

appraisal checklist for randomized controlled trials and the results are a score of 100% (n=5
 articles) 3,5,6,7,8 The score of 92% (n = 2 articles) 9,10
. A score of 84% (n=2) 11,12
and a score of

69% (n=2) 13,14.

3.3 Characteristics of The Study

3.3.1 Participants and setting

The included articles were published in 2016 - 2020, of the 11 selected articles all

came from outside Indonesia, namely from the United Kingdom (n=3 articles) 8,10,14. Turkey

(n=2 articles) 3,12, Germany (n=2 articles)11,9, India (n=2 articles)6,7, Brazil (n=1 articles)5, and

Greece (n=1 articles)13. The total number of respondents of this review were 2,608. The total

population involved ranged from 32 to 655 participants. Participants involved were limited

by several criteria such as age, diagnosed with asthma under GINA, did not participate in a

breathing exercise program for the past six months, did not have any other chronic illnesses,

did not have any physical or cognitive deficiencies and a diagnosis of psychiatric illness that

could hinder understanding training provided, not illiterate, Has been prescribed at least one

asthma drug in the previous year, does not have severe airflow limitation (FEV1 <60%), does

not smoke and gives written consent to attend training.

3.3.2 Characteristics of the Intervention

Breathing exercises given to asthma patients vary from breathing exercises performed

as a single intervention as well as a combined intervention. Breathing exercises given to

asthma patients include Yoga Pranayama (n=5)3,5,6,7,12, Buteyko breathing technique (n=1)11,

Progressive muscle relaxation and breathing relaxation (n=1) 13, Speech-guided breathing

retraining (n=1)9, Papworth Breathing Exercise (n=1)10, Combined several breathing

exercises (n=2) 8,14.

Other breathing exercises given to asthma patients are breathing exercises given face-

to-face (n=5) 11, 5,6, 7,9, Breathing exercises given face to face and giving CD (n=1) 13, breathing

exercises are given face-to-face and giving CDs and training handbooks (n=1) 12. Breathing
 exercises are given face-to-face and DVDs (n=1) 10. Breathing exercises were given face-to-
8,14
face and provided with DVDs and printed booklets (n=2) . Breathing exercises that are

given face-to-face and video on cellphones3.

8,9,10,14
Breathing exercises can be provided by a psychotherapist (n=4) Coach certified

(n=6) 3,11,5,6,7,13 the researcher himself (n=1)12.

6, 7,13,14
Variation in duration of breathing exercises 30 minutes (n=4) . 40 minutes (n=3),
5,8,10
. 45 minutes (n = 1)3, 70 minutes (n=1),12. 90 minutes (n=1)11, unspecified (n=1)9.

Breathing exercises were carried out for 1 month (n=1) 3. 1 month 2 weeks (n=1)12, 2

months (n=1)13, 3 months (n=3)11,5,9, 6 months (n=2)6, 7, 12 months (n=3) 8,10,14.

Breathing exercises were carried out based on the age of the respondent, Yoga

Pranayama: age 11-60 years 7 , age ≥ 18 years 3, ages 21-60 years6, 30-65 years old5, and 36-

45 years old12. Buteyko breathing techniques: ages 6-15 years11. Progressive muscle

relaxation and respiratory relaxation: age ≥ 18 years 13. Speech-guided breathing retraining:

age ≥ 12 years9. Papworth Breathing Exercises: age ≥ 46 years 10, Combined several breathing

exercises: age: ≥ 18 years and 16–70 years 8,14.

3.4 Effect of breathing exercises and breathing techniques on asthmatic patients

3.4.1 Yoga pranayama

The yoga pranayama breathing technique has been shown to improve asthma

control and quality of life in asthmatic patients, but did not show a significant difference

in the pulmonary function test values 3. Aerobic exercise and breathing exercise yoga

pranayama cause a similar effect in controlling asthma, psychological stress, and

inflammation of the airways 5. The yoga pranayama group showed a trend in improving

better quality of life scores than the control group 6. In intragroup comparisons of pre-test

and post-test mean scores of respiratory function, asthma control and quality of life

between the experimental and control groups found statistically significant differences.
 The mean post-test score was found to be increased in the group who received pranayama

yoga practice, while the control group was found to be decreased 12. A significant

improvement was found in all subdomains of the Quality of Life questionnaire at month

three and month six in the yoga pranayama experimental group compared to the control

group 7.

3.4.2 Buteyko breathing technique

Children who received standard asthma treatment coupled with the Buteyko

breathing technique revealed much more significant improvement than those that received

only treatment interventions according to the severity of their asthma symptoms from

their physicians. There was an increase in the emotional function subscale as well as an

increase in quality of life in the experimental group that received Buteyko breathing

technique exercises 11.

3.4.3 Progressive muscle relaxation and breathing relaxation

Patients in the progressive muscle relaxation group accompanied by relaxing

breathing biofeedback showed less significant results for stress reduction, but showed

substantial results related to the quality of life (regarding symptoms, daily

activities/limitations, emotional function) and asthma control and increased frequency of

physical exercise which is higher compared to patients in the usual care group 13.

3.4.4 Speech-guided breathing retraining

There was a statistically significant difference between the anthroposophic

therapeutic speech (ATS) group and the control group regarding the quality of life scores,

domain scores for symptoms, activity limits, emotional functioning, and asthma control

scores. No significant differences were observed in the parameters of spirometry, inhaled

glucocorticoids, peak flow and days without exacerbation of asthma per week. No severe

side effects occurred during the anthroposophic therapeutic speech (ATS) session 9
 3.4.5 Combined several breathing exercises

Respiratory retraining programs, including diaphragmatic breathing, nasal

breathing, slow breathing, controlled breath holds, and simple relaxation exercises that

were guided by the therapist in exercising, had a significant improvement in the quality of

life scores than the group receiving only regular care 8. The statistically significant results

showed that adults with asthma who received combined breathing exercises, namely:

stomach breathing, nose breathing, slow breathing, controlled breath-holding, face-to-face

relaxation training by physiotherapists experienced a significant increase in quality of life

scores and decreased anxiety compared with asthma patients receiving regular care 14.

3.5 Components of an effective breathing exercise

3.5.1 Method of Intervention: Breathing exercises that are given face-to-face vs.

Breathing exercises that are offered face to face and DVDs.

Breathing exercises given face-to-face and given by certified psychotherapists and

trainers have shown significant results regarding the improvement of asthma control and
11,5,6,7,9
also the quality of life of asthma patients . The disadvantage of this method is that

asthma patients cannot do breathing exercises independently at home because some of

them may forget the techniques and movements that have been learned with therapists

and coaches. Breathing exercises that were given face-to-face and DVDs showed

significant results regarding the improvement of asthma control and quality of life for

asthma patients and were proven to be more effective for asthma patients, and this is

because asthma patients can do breathing exercises independently at home after they

practice with therapists and trainers through the DVDs that have been given 3,8,10,12,13,14.
3.5.2 Exercise duration: Breathing exercises performed for one month vs two months vs

three months vs 12 months.

Breathing exercises carried out for one month can improve quality of life, control

asthma and improve lung function 3. Breathing exercises improve quality of life-related to

symptoms, daily activities/limitations, and emotional function, improve asthma control,

and better frequency of physical exercise 13. Breathing exercises improve quality of life

and asthma control 12.

The Buteyko Breathing exercises carried out for three months can reduce

bronchodilator use, improve asthma control and quality of life, and reduce the use of
11
corticosteroids . The main result of periodic Speech-guided breathing retraining for

three months is an improvement in the quality of life, an increase in asthma control 9.

The Pranayama yoga breathing exercises that are carried out for six months can
6, 7
improve the quality of life of patients . Pranayama yoga practice can improve the

quality of life and exercise capacity5.

Breathing exercises performed for 12 months and observed every three months, six

months and 12 months can improve quality of life in asthma patients, including control of

asthma symptoms, psychological state, hyperventilation symptoms, assessment of airway

10
physiology and inflammation and health resources and use and cost . Breathing

exercises can improve the quality of life of asthma patients, asthma control, and health

care costs8. Breathing exercises can improve the quality of life of asthma patients, control

asthma symptoms, increase daily activities and increase control of emotional function 14.
 Table 3. Study Characteristics and Findings
No Author and Year Country Method Age Sample Intervention Outcome Conclusion
1. Erdoğan Yüce Turkey Randomized ≥ 18 years 102 Pranayama breathing Asthma Control The Pranayama breathing
and Taşcı, 2020 3 control trial Patient technique was applied Test, Asthma technique improved
asthma to the experimental Quality of Life, asthma control and
group for 20 minutes pulmonary quality of life in patients
once per day for one function. with asthma, but did not
month, in addition to show a significant
standard treatment. difference in pulmonary
function test (PFT)
values.
2. Evaristo et al., Brazil Randomize 30-65 years 54 Patient Pranayama yoga Asthma clinical Outpatients with
20205 d control asthma practice is practised control, quality of moderate to severe
trial for 40 minutes per life, asthma asthma who attended
session, twice a week symptom-free days, aerobic training or
for three months. airway breathing exercise
inflammation, programs showed similar
exercise capacity, results in asthma control,
psychological quality of life, asthma
distres, daily-life symptoms, psychological
physical activity, distress, physical
and pulmonary activity, and airway
function inflammation.
3. Vagedes et al., Germany Randomized 6-15 years 32 The children received Primary outcome The results showed that
2020 11 controlled children routine care and were Bronchodilator the Buteyko Breathing
pilot study with given additional reduction. Technique could be an
partly Buteyko Breathing Secondary effective intervention for
controlled Technique therapy, outcomes were children with partially
asthma which consists of changes in controlled asthma, with
three components: an physiological respect to spirometry
intensive 5-day parameters (FEV1) and breath-
Buteyko Breathing FEV1_AR (at rest), holding parameters.
Technique course, a FEV1_ER (after
 booster session one ergometry),
week later, and a threeFEV1_BR (after
month home training bronchospasmolysi
period. s), corticosteroid
use, FeNO, SpO2,
breath-hold test
and questionnaire
data Asthma
Control
Questionnaire and
Pediatric Asthma
Caregiver's
Quality of Life
4. Malarvizhi et al., India Randomized 21- 60 years 250 adult Yoga group subjects Asthma Quality of The results of this study
2019 6 contol trial patients received 30 minutes of Life indicate that simple yoga
with mild yoga training for a practice such as
to week under the pranayama is an effective
moderate guidance of a trained therapy for improving the
asthma yoga teacher and were quality of life in
advised to practice at asthmatic patients and
home once a day for can be practised as an
six months. adjunct therapy to regular
conventional care for
better outcome outcomes.
5. Georga et al., Greece Randomized ≥ 18 years 42 Patient Biofeedback-assisted Perceived Stress This study supports that
2019 13 control and asthma relaxation breathing Scale,, the Asthma stress management
trial SM group techniques for 15 Control Test, the techniques such as
(n=23) minutes and Mini Asthma progressive muscle
and a biofeedback-assisted Quality of Life relaxation and relaxing
usual care relaxation breathing breathing with
(UC) for 15 minutes, were biofeedback assistance
control performed twice daily have a beneficial role in
group for 8 weeks (for a asthma patients, namely
(n=19). maximum of 112 improving asthma
 sessions). control and also the
quality of life in asthma
patients.
6. Arden-Close et UK Randomized ≥ 18 years 393 Abdominal breathing Anxiety, Asthma Adults with asthma who
al., 2019 14 control Pasien exercises, nose Quality of Life received face-to-face
Trial Adults breathing, slow breathing training by a
with breathing, controlled physiotherapist
asthma breathing exercises, experienced improved
(DVD and relaxation training that quality of life and
booklet, n is carried out for 12. decreased anxiety.
= 261; months and is
F2FB, n = followed up every 3
132). months 6 months and
12 months
7. Bahçecioğlu Turkey Randomized 36-45 years 112 Yoga exercises were Respiratory The results showed that
Turan and Tan, Controlled Patients applied to the asthma function and the application of yoga
2019 12 Study Asthma group for 70 minutes Asthma Control had a positive impact on
twice a week for 12 Test and Asthma the respiratory function
sessions, in addition to Quality of Life of patients and the
standard treatment. control of asthma relapse
symptoms and their
quality of life was found
to improve.
8. Agnihotri et al., India Randomized 11- 60 years 255 Participants in the Quality Of Life This study shows that
2017 7 Control Patient yoga group received yoga interventions
study yoga interventions (Asanas, Pranayama and
(Asanas, Pranayama, meditation) are effective
and meditation) for 30 therapies in improving
minutes per day, 5 quality of life and can be
times a week for 6 practised as an adjunct
months at the therapy to standard
Department of medical care for better
Pulmonary Medicine. outcomes.
9. Bruton et al., UK Randomized 16–70 years 655 Breathing exercises Asthma Quality of Respiratory retraining
 2018 8 Control patients are carried out for 40 Life, Asthma programs improve the
trial minutes, for 12 Control, Hospital quality of life of patients
months. than Anxiety and with uncontrolled asthma
evaluated at 3 months, Depression even though they have
6 months, and 12 little impact on lung
months by function or airway
physiotherapy. inflammation. Such a
program can be delivered
conveniently and cost-
effectively as a
standalone digital
audiovisual program,
thereby reducing health
care costs as well.
10. von Bonin et al., Germany Randomized ≥ 12 years 63 Patient The training program Asthma Quality of Speech-guided breathing
2018 9 control trial with for each patient Life, Asthma retraining significantly
asthma consists of 10 Control Test improves asthma control
frequently applied and quality of life for
ATS exercises, which asthmatic patients.
include a combination
of the spoken sound of
the syllable (eg
"Wwwwww-T" /
"OM") and rhyme,
Each participant is
viewed one-to-one by
a certified therapist
who the same for all
training sessions and
required to train at
least three times a
week
11. Thomas et al., UK Randomized ≥ 46 years 650 adults Physiotherapy-based Asthma Quality of Breathing exercises can
2017 10 control trial with breathing training is Life. Secondary improve asthma control
asthma delivered over three outcomes included and quality of life and
sessions. Papworth asthma control, reduce health care costs
breathing exercises psychological in adults with asthma
were carried out for state, whose condition remains
12 months and hyperventilation uncontrolled despite
evaluated every 3 symptoms standard pharmacological
months, 6 months, and therapy. Breathing
12 months. exercises work well for
patients and can be
effectively administered
as a standalone
intervention.
4. Discussion

This is a systematic review of randomized controlled trials to assess the effectiveness

of breathing exercises on improving asthma control and quality of life for asthma patients.

This review identified eleven studies conducted in six countries to examine the effect of

breathing exercise, either as a single intervention or in combination with other interventions,

on improving their asthma control and quality of life.

In this review breathing exercises given to asthma patients include yoga pranayama,

buteyko breathing technique, progressive muscle relaxation and breathing relaxation,

speech-guided breathing retraining, papworth breathing exercise and combined several

breathing exercises that can effectively improve asthma control and quality of life of asthma

patients.

Breathing exercise is a non-pharmacological therapy that is used to support treatment

for asthma patients. The goal of this therapy is to control asthma symptoms, improve quality

of life, reduce hyperventilation symptoms, and improve lung function. A variety of breathing

exercises that can be applied to asthmatic patients include the papworth method, the Buteyko

breathing technique, Yoga breathing, Diaphragmatic breathing, Modification of breathing

patterns, Nasal breathing, Holding breath exercises, and Abdominal breathing or other

similar interventions that manipulate breathing patterns. Breathing exercises usually focus on

tidal volume and minutes and relaxation 15. Breathing exercises that can be done by asthmatic

patients have many techniques, but we need to know that from these various techniques, if

done routinely by patients and guided by a therapist, there will be many benefits, including

improved asthma control and quality of life.

Breathing exercises are effective if they are provided by a certified therapist or trainer

and can be done face-to-face or via video. Giving a DVD is very important so that the patient
can repeat the breathing exercises at home. Asthma patients with uncontrolled respiratory

symptoms may benefit from breathing exercises. Up to 30% of asthma patients report that

they use breathing techniques to control the recurrence of asthma symptoms. This therapy

should be given by a respiratory therapist whose implementation can be done directly or

8,16
guided through digital support . The importance of a therapist or trainer is that when a

patient experiences a recurrence of symptoms while doing breathing exercises such as

shortness of breath, rapid pulse, weakness, and cold sweat, the therapist will stop the

exercise for the safety of the patient.

Variation in duration of breathing exercises: 30 minutes, 40 minutes, 45 minutes, 70

minutes and 90 minutes. Breathing exercises do not yet have standard protocols regarding

duration and frequency, but we need to know that breathing exercises that are done either for

30 minutes or 90 minutes in one exercise session are all effective in improving asthma

control and also their quality of life.

Breathing exercises have several durations: one month, 1 month 2 weeks, 2 months, 3

months, 6 months and 12 months. Breathing exercises do not yet have a standard protocol

regarding time and frequency because there are still differences in some articles. Research

results from Agnihotri et al., (2017), showed differences in breathing exercises performed

for 3 months and 6 months. Comparison between groups at 3 and 6 months after the yoga

intervention was that there were significant differences in the activity limitation domain and

emotional function scores at month 3 and significant differences were found in the total

quality of life with all subdomains at 6 months. There were better improvements in symptom

scores, activity limitation scores, emotional function scores, responses to environmental

stimuli and the quality of life scores. The longer and more routine asthma patients do

breathing exercises, the better the benefits will be to their lungs, this is because the patient
 begins to be able to control symptoms of recurrence, strengthen respiratory muscles,

maintain controlled asthma so that the quality of life can improve 7.

Breathing exercises can be performed in children and adults, from 6 years of age to 70

years of age, and are on average done at 18 years of age. In a systematic review of the effect

of inspiratory muscle training and breathing exercises in children with asthma from Castilho

et al., (2020), Breathing exercises are a strategy of asthma management, which has been

recommended as an adjunct treatment for uncontrolled asthma in children. This exercise

aims to maintain good breathing patterns and pulmonary ventilation and to reduce lung

hyperinflation, bronchospasm and dyspnoea sensations17.

Research Results from Thomas et al., (2017), demonstrated that Papworth's breathing

exercises could improve asthma control and quality of life and reduce health care costs in

adults with asthma whose condition remains uncontrolled despite standard pharmacological

therapy. The Papworth breathing exercises do well with patients and can be given effect as a

standalone intervention. Breathing exercises can be given to children and adults with asthma

as long as they are under the supervision of a therapist during breathing exercises 10.

5. Clinical Implications

Scientific studies have shown that intervention in the form of breathing exercises is

effective in improving asthma control and improving the quality of life of asthma patients.

The results of this study are indeed very useful in the field of nursing science because they

can help nurses in providing nursing interventions for asthma patients. Breathing exercises

that are done face-to-face and giving DVDs can be an effective strategy in increasing the

intensity of breathing exercises in asthmatic patients, which in this systematic review

provides information that the longer the patient does breathing exercises, it can improve lung

function. Further studies are needed in the application of audio-visual-based breathing

 exercise interventions guided by a certified therapist or professional trainer through specific

applications so that asthma patients can do it at home.

6. Summary

Asthma is a heterogeneous disease characterized by chronic inflammation of the

airways, with a history of respiratory symptoms, such as wheezing, dyspnea, shortness of

breath, coughing, and variable limitation of airflow. Breathing exercises are one of the non-

pharmacological therapies used to support the treatment of asthma patients, the goal of this

therapy is to control asthma symptoms, improve quality of life, reduce hyperventilation

symptoms, and lung function. Breathing exercises can be done by both children and adults.

The duration of the most effective breathing exercises is done routinely with the guidance of

a certified trainer or therapist then carried out for 12 months and evaluated every 3 months, 6

months, and 1 year. Methods of effective breathing exercises can be done by meeting in

person with a therapist and giving DVDs so that patients can do breathing exercises at home.

This systematic review proves that breathing exercises have been shown to be effective in

improving asthma control and improving the quality of life for asthma patients.
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