Physiotherapy interventions can play a role in managing dyspnoea according to a number of recent ‘breakthrough’ studies, the ERS International Congress was told.
Dr Daniel Langer, a physiotherapist from the University of Leuven, Belgium, said breathing retraining was a non-drug therapy that has been shown to be of benefit to patients with incompletely controlled asthma.
“But the problem is that due to cost and restrictions it is difficult to deliver this intervention to all those who might benefit from it,” he said.
Dr Langer told the meeting that a large UK study of adults with symptomatic asthma had compared face-to-face breathing retraining sessions with a physiotherapist versus a self-guided breathing retraining intervention or usual medical care.
The self-guided intervention involved a combination of DVD training and a booklet, which had previously been piloted in patients.
The study showed both face-to-face training and the self-guided interventions resulted in significant improvements in total quality of life (AQLQ score) at 12 months from baseline.
“The largest improvements were reported in the symptoms score – the breathlessness domain of the questionnaire.”
The quality of life improvements were of a similar magnitude to those observed with common pharmacological step-up therapies.
However there was no significant difference between groups in secondary outcomes such as airway obstruction or inflammatory markers, suggesting the intervention did not affect the underlying disease process.
Importantly, a cost-effectiveness analysis favoured either intervention versus usual medical care with the cost of intervention offset by reductions in health service use.
“As expected the DVD intervention achieved equivalent outcomes to the face-to-face physiotherapy intervention at a lower cost.”
However there was mixed evidence for the use of inspiratory muscle training (IMT) in COPD patients.
Dr Langer said pronounced inspiratory muscle weakness was present in about 40% of patients with COPD and independent of FEV1.
“The problem in these patients and the rationale for training is these patients experience perceived breathlessness, mainly on exertion, related to the imbalance between load on the respiratory muscles and capacity of the respiratory muscles.”
A recent meta-analysis showed inspiratory muscle training as a stand-alone intervention could improve inspiratory muscle function, functional exercise capacity and symptoms of dyspnoea.
“But of course in clinical practice, we often would like to use it as part of a more comprehensive pulmonary rehabilitation program and you would hope that this would reduce the symptoms during exercise and allow them to gradually exercise at higher intensity.”
However the meta-analysis found there was no additional benefit when inspiratory muscle training was added to pulmonary rehabilitation.
He said three other trials published this year have also found no additional signal when the intervention was added to pulmonary rehabilitation.
“Based on these results, there has been an ongoing discussion about the value of IMT, including some outspoken editorials, concluding that we should stop using IMT in the rehabilitation of patients with COPD.”
Dr Langer said he disagreed with the conclusions given the heterogeneity in study designs and outcome measures.
“I would rather say that these studies highlight the complexity of conducting studies where the control group already receives an effective baseline treatment.”
Future studies should focus on the selection of candidates for adjunctive treatments, particularly patients who may be non-responsive to pulmonary rehabilitation alone.