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What makes difficult asthma difficult?. Nicki Barker 2012. SCH Journal Club . Aim. To determine whether breathing retraining improves quality of life for children with dysfunctional breathing. Objectives. Clarify the problem identified - PowerPoint PPT Presentation
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What makes difficult asthma difficult?SCH Journal Club
Nicki Barker2012
June 2012
Dysfunctional breathing in children 1
Aim
To determine whether breathing retraining improves quality of life for children with dysfunctional breathing
June 2012
Dysfunctional breathing in children 2
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 children 3
Difficult asthma
‘persistent symptoms and/or frequent exacerbations despite treatment
at step 4 or step 5’
June 2012
Dysfunctional breathing in children 4
Difficult asthma?
• Compliance issues
• Incorrect diagnosis
• Asthma plus a co-morbidity
June 2012
Dysfunctional breathing in children 5
BTS guidelines 2012
‘dysfunctional breathing should be considered as part of a difficult
asthma assessment’
June 2012
Dysfunctional breathing in children 6
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 children 7
Dysfunctional breathing (DB)
Dysfunctional breathing
HVS VCD Breathing pattern disorder
Dysfunctional breathing in children
June 2012
8
DB: A model
HVS
BPDVCD
DB: A paediatric model
HVS
BPDVCD
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 children 11
The Clinical Question
Population Children with dysfunctional breathing
Intervention Breathing retraining
Comparison Normal care
Outcome QOL, symptom scores, changes in asthma medication,
objective measures
Design Intervention RCT
June 2012
Dysfunctional breathing in children 12
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 children 13
The Clinical Question
Population Adult asthma patients with dysfunctional breathing
Intervention Breathing retraining
Comparison Equivalent amount of professional attention
Outcome QOL, symptom scores, changes in asthma medication
Design Intervention RCT
June 2012
Dysfunctional breathing in children 14
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 children 15
Study flow diagram
Thomas M et al. Thorax 2003;58:110-115
Outcome measures• Primary
– Asthma specific health status (AQLQ)– Nijmegen questionnaire scores
• Secondary– Changes in asthma medication and medication usage
June 2012
Dysfunctional breathing in children 17
Using the CASP tool
June 2012
Dysfunctional breathing in children 18
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 children 19
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 2012
20
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 children 21
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 children 24