Clinical Question

Do breathing exercises lead to improvements in dyspnea, exercise capacity, and health-related quality of life in patients with chronic obstructive pulmonary disease (COPD)?

Evidence-Based Answer

Patients with COPD who are treated with breathing exercises vs. standard care showed an improvement in exercise capacity, with inconsistent changes in dyspnea and health-related quality of life. Adding breathing exercises to a pulmonary rehabilitation program did not show any increased benefit. Breathing exercises may be helpful for those without access to a pulmonary rehabilitation program. (Strength of Recommendation: B, based on inconsistent or limited-quality patient-oriented evidence.)

Practice Pointers

Pulmonary rehabilitation is recommended for all patients with COPD to improve physical function and quality of life. This multidisciplinary approach, which includes exercise training, education, nutritional intervention, and psychosocial support, improves dyspnea and functional capacity, and lowers the rates of hospital admission and mortality.^1,2 Breathing exercises are commonly used as part of such programs, but data supporting their use alone are limited.

Breathing exercises are intended to reverse the typical COPD pattern of increased accessory muscle and rib cage use. This Cochrane review, which included 16 randomized controlled trials, evaluated breathing exercise techniques such as pursed lip breathing, diaphragmatic breathing, and pranayama yoga.

Pursed lip breathing improved outcomes of a six-minute walk test by 50.1 m (95% confidence interval [CI], 37.2 to 63.0) after eight weeks of an intervention involving 15 minutes of breathing exercises three times daily. However, there was no significant improvement in dyspnea using the University of California–San Diego Shortness of Breath Questionnaire after four weeks or 12 weeks when pursed lip breathing was taught using pulse oximetry for feedback with daily home practice. In a study comparing health-related quality of life for pursed lip breathing vs. placebo, pursed lip breathing showed a significant improvement in the dyspnea domain following eight to 12 weeks of training (mean difference = –12.9 units; 95% CI, –22.3 to –3.6), but no significant improvement in any other domain, including mood, social function, and well being.

Diaphragmatic breathing encourages patients to use their abdominal wall when breathing to reduce chest wall motion.¹ This technique increased dyspnea in one study, whereas it significantly improved dyspnea after four weeks of training in another study. There was also an increase in functional capacity of 34.7 m (95% CI, 4.1 to 65.3) as measured by a six-minute walk test, and improvement in quality of life as measured by the St. George's Respiratory Questionnaire (mean difference = –10.5 points; 95% CI, –17.7 to –3.3). One study found no significant difference in peak oxygen consumption, 12-minute walk distance, peak work, or endurance work with diaphragmatic breathing.

Results of yoga training on dyspnea and quality of life for patients with COPD are mixed. A meta-analysis of two studies noted a significant improvement in the six-minute walk test of 44.5 m after 12 weeks of yoga training, but one of the studies found no improvement in distress levels after the six-minute walk test. The same studies had conflicting conclusions about quality of life; one showed improvement, whereas the other did not.

Some of the included studies examined a combination of techniques. One study found that combining pursed lip breathing, diaphragmatic breathing, and nutritional supplementation improved total quality of life compared with usual care. Another study found that combining pursed lip breathing, diaphragmatic breathing, and walking improved symptom-related quality of life on the St. George's Respiratory Questionnaire. Yet, there was no significant difference in functional capacity as measured by the six-minute walk test (mean difference = 0.6 m; 95% CI, –23.4 to 24.2).

The Institute for Clinical Systems Improvement suggests using pulmonary rehabilitation programs to improve symptoms in those with moderate to severe COPD.³ Breathing exercises can be easily taught in the clinic; online resources are also available (e.g., http://www.webmd.com/lung/copd/copd-breathlessness-9/exercise). Although breathing exercises may be useful as an adjunct treatment for patients with COPD, family physicians should keep in mind that these exercises cannot replace full pulmonary rehabilitation for improvements in dyspnea or quality of life.