Positive Health Online

Advocates of the Buteyko breathing method claim that people suffering from asthma and other respiratory problems can gain significant relief from their symptoms just by changing the way they breathe. Despite a wealth of anecdotal reports of benefit from around the world and positive results in all four of the clinical trials of the method published so far,[1],[2],[3],[4] the technique itself remains relatively obscure. This is perhaps surprising, given that out of the five million asthma sufferers in the UK, there are estimated to be more than half a million whose symptoms are still inadequately controlled despite best use of conventional medication.[5] In this article I shall be outlining some of the background behind the Buteyko technique and asking why it is that conventional medicine has so far paid it so little attention?

The Complete Buteyko Toolkit

The History of the Method

The use of breathing exercises in the treatment of respiratory conditions clearly dates back thousands of years to the origins of Eastern disciplines such as Yoga and Chi Kung. However, the development of the technique that has come to be known as the Buteyko Method first began in the 1950s in the laboratory of Professor Konstantin Buteyko, a Ukrainian physician and academic.

Professor Buteyko once stated that his technique could be summarized in just two words – 'breathe less'. He based this statement on the hypothesis that people with asthma can unknowingly make their own condition worse through an unconscious habit of hyperventilation, (i.e. breathing more than is required to meet the needs of gas exchange). Such hyperventilation is a well-recognized feature of asthma in conventional medicine,[6] but it is usually regarded merely as a symptom of the illness and not generally thought to be a significant problem. In some ways this is odd, since there is clear evidence from the medical literature that hyperventilation by itself can cause a deterioration in lung function in asthmatics.[7]

The crucial step taken by Professor Buteyko was to reason that, if over breathing caused a worsening of asthma symptoms, then teaching patients to counteract this by deliberately under breathing should bring about an improvement in their condition. Buteyko's own work in his laboratory soon convinced him that this was in fact the case. However, it took until 1981 before his methods gained official approval from the Russian Health Ministry, following clinical trials conducted in a Moscow children's hospital.

Partly as a result of the Russian policy of glasnost in the mid-1980s, word of Professor Buteyko's technique soon began to spread outside the former Soviet Union. In particular, it spread to Australia and New Zealand where a small cohort of practitioners began to make an impression. As a result, a clinical trial of the Buteyko Method in asthma was conducted in Brisbane in 1994.[1] The results showed that after three months the subjects taught the breathing exercises had reduced their consumption of reliever inhalers by over 90%, with a simultaneous trend towards improved quality of life and a reduction in the need for steroid preventer medications.

Since the original Brisbane trial, a further five more trials have been conducted, three of which have been published in mainstream medical journals. All of the trials showed similar evidence of benefit to that in Brisbane. Importantly, none of the trials showed any evidence of increased hospital admissions or significant side effects after treatment.

Critics of the trials argue that in most cases the size of the study groups used was too small, and the outcome measures too subjective, to draw any firm conclusions about the true value of the method at this stage. However, the fact that none of the clinical trials to date has come up with a negative result is clearly of note, and makes it much less likely that the improvements seen with Buteyko are simply due to chance. In theory, one would have thought that this would increase the likelihood of Buteyko being recognized by the conventional medical community. However, as we shall see, when it comes to conventional medicine the presence of scientific evidence is only one of several criteria that need to be fulfilled.

Buteyko in Practice

The process of learning the Buteyko Method can be divided into five key steps (see Box 1 below).

The actual breathing exercises themselves are typically arranged into routines or 'sets', each lasting about 20 minutes. At the outset subjects are asked to perform at least three sets of exercises a day. Obviously this represents a significant time commitment. However this underlines the fact that, although Buteyko is an effective and safe treatment, it is not an easy option and requires a good deal of commitment. Fortunately, after the first month the amount of practice can usually be reduced quite significantly, as trainees learn to combine active breath control with other routine, day-to-day activities.

Buteyko classes can either be conducted on a one-to-one basis or take place in small groups. On average, it takes about five hours of tuition for patients to learn the actual techniques although, as pointed out above, this must be backed up by plenty of homework.

One of the most controversial aspects of the Buteyko Method is the use of paper surgical tape to hold the lips together at night to ensure that nose breathing continues during sleep. This can raise some anxieties, but is not compulsory. However, provided the rules are followed correctly, there is no risk of suffocation or choking and the benefit in terms of improved sleep and reduced symptoms at night can be dramatic.

Although the vast majority of people with asthma can benefit from learning the Buteyko Method there are some medical conditions where use of the full range of breathing exercises would be contraindicated or used only with caution. These include conditions such as sickle cell anaemia, arterial aneurysms and insulin dependent diabetes. A full list of these conditions is clearly beyond the scope of this article but obviously forms a vital part of the training to become a Buteyko practitioner.

The Struggle for Recognition

So why is it that a safe, straight forward and clinically effective physical therapy such as Buteyko should remain so little recognized, particularly by conventional medicine, after almost 50 years? Indeed, why is this true of many complementary therapies?

To be fair of course, in the case of Buteyko, some of the explanation does involve the politics of the Iron Curtain that effectively prevented the free movement of ideas and practitioners outside of the former Soviet Union for many years.

In addition, some of a more cynical persuasion might argue that, since the method has understandably received little support from the pharmaceutical industry, this only serves to underline how much the research agenda in medicine and the evolution of new techniques is influenced by drug companies.

However, these reasons aside I think there are some important observations that can be made, which in turn have relevance to other complementary therapies besides Buteyko. These are:

1. A Supporting Theory. Evidence of benefit from clinical trials is only one part of the equation when it comes to getting doctors to back new treatments. One of the other important factors is that there must be a convincing explanation as to how and why the treatment works. Moreover, it must be explicable in terms of the conventional medical paradigm. For Buteyko, there are certainly a number of hypotheses that are potential candidates to explain how the treatment works (see Box below). However, although these are currently supported by circumstantial evidence, as yet none have reached the point of being proven.

How Buteyko Might Work

Professor Buteyko believed that his method worked by promoting an increase in carbon dioxide levels within the body. However, in addition to this there are a number of other possible mechanisms. For example:

• Recurrent exposure to mild oxygen deficiency causes effects similar to high altitude acclimatisation. Oxygen transport is improved and inflammatory reactions are inhibited.[8]
• Repeated exposure to feelings of breathlessness while relaxed leads to desensitization and reduced anxiety during attacks.
• Techniques to prevent coughing help to avoid stimulation of sensory nerves in the airways that have been implicated in causing asthma symptoms.[9]
• Voluntary changes in respiratory rhythm have been shown to alter the function of the nervous system and reduce the sensation of breathlessness.[10]

2. Evidence of Disease Modification. Even though the relief of symptoms is clearly a worthwhile outcome for the patient, doctors like to see that the underlying disease process has also been improved. This is a stumbling block for Buteyko at present, since none of the trials have been able to demonstrate an improvement in lung function following Buteyko treatment. Unfortunately this is potentially misleading, because the design of all the trials so far has allowed participants to reduce their medication after learning Buteyko. Normally, if a patient simply reduced their medication one would expect their lung function to deteriorate. The fact that in the trials of Buteyko the participants' lung function remained the same is therefore a possible sign that the treatment could have influenced their lung function in a positive way.

3. Ease of Prescribing. At present Buteyko is not an easy treatment for doctors to recommend to their patients since the number of Buteyko practitioners is extremely limited. For example, in total there are probably less than 500 Buteyko practitioners at present worldwide, and the vast majority of these are part time – combining Buteyko teaching with the practice of other conventional or complementary therapies. Although there are a very few areas in the UK where Buteyko is currently available on the NHS, most practitioners are working privately. In general, the going rate for a private course in Buteyko varies from £150-£300.

4. That Word 'Complementary'. Although attitudes among doctors are changing slowly, there remain many that view all therapies described as complementary with deep suspicion. On the one hand one could argue that Buteyko is not a complementary therapy at all, since Professor Buteyko was a conventionally trained doctor and his method is an official part of Russian health care. However, I believe there are good reasons for describing Buteyko as complementary since it does work extremely well alongside the conventional management of conditions such as asthma. For this reason it should be quite possible for Buteyko practitioners to build strong alliances with local GPs/nurses for the benefit of their mutual patients.

5. Simplicity can be a Handicap. With every year conventional medicine becomes evermore technologically advanced. Subconsciously, we come to assume that complex problems require complex solutions. Furthermore there is a tendency to believe that medical research is an incremental progress and that therefore all the simple solutions will have been tried already at some point. This attitude was very well illustrated by the comments of a Junior Doctor responding to a talk I gave on the Buteyko Method. He declared, "Everything you have said makes perfect sense, but there must be a catch somewhere, otherwise we would be using it already."

In reality of course it is quite obvious that modern medicine is failing to take into account some quite basic interventions that are of potential benefit in conditions such as asthma. Take for example the idea that it is better to breathe through your nose rather than your mouth. Here is something over which there is almost certainly complete agreement among respiratory specialists, due to the well known functions of the nose to filter, warm and humidify the incoming air before it reaches the delicate lining of the lungs. (To this list can now be added a fourth function of the nose which is to produce a gas called nitric oxide. This has been found to increase the efficiency of gas exchange within the lungs.)[11]

With all this agreement among the experts you would have thought that, like in Buteyko, the instruction to nose breathe would be standard medical practice, especially as many asthmatics have a tendency to mouth breathe most of the time.[12] Yet this is not the case. Even the current National Guidelines on Asthma make no mention of this advice. Of course, simply getting patients with asthma to breathe through their noses again is not going to relieve their asthma entirely but, given that it is such a simple, low cost intervention, one has to ask why it is not current standard practice.

Perhaps, when put like this, the medics will begin to see that there really may be a place for physical treatments such as Buteyko after all. Remember, as we said at the beginning, there are over 500,000 asthma patients in the UK who need something more than just conventional medication in order to control their symptoms. I would argue that the Buteyko Method is one of the best hopes these people have at present, and consequently it deserves far greater attention and recognition than that which it currently receives.

References

1. Bowler SD et al. Buteyko breathing techniques in asthma: a blinded randomised controlled trial Med. J Aust. 169: 575-578. 1998.
2. Opat AJ et al. A clinical trial of the Buteyko Breathing Technique in Asthma as taught by a video. J Asthma. 37: 557-564. 2000.
3. Cooper S et al. Effect of two breathing exercises (Buteyko and pranayama) in asthma: a randomised controlled trial. Thorax. 58: 674-679. 2003.
4. McHugh P et al. Buteyko Breathing Technique for asthma: an effective intervention. N Z Med J. 116: U710. 2003.
5. National Asthma Campaign Out in the Open: A true picture of asthma in the United Kingdom today. The Asthma Journal special supplement. Vol 6 issue 3. 2001.
6. Osborne CA et al. Hyperventilation and asymptomatic chronic asthma. Thorax. 55: 1016-1022. 2000.
7. Hurwitz K et al. Interpretation of Eucapnic Voluntary Hyperventilation in the Diagnosis of Asthma. Chest. 108: 1240-45 1995.
8. Serebrovskaya TV. Intermittent Hypoxia Research in the Former Soviet Union and the Commonwealth of Independent States: History and Review of the Concept and Selected Applications. High Altitude Medicine & Biology. 3(2): 205-221. 2002.
9. Kraneveld AD et al. Excitatory non-adrenergic-non-cholinergic neuropeptides: key players in asthma. European Journal of Pharmacology. 405: 113-129. 2000.
10. Bernardi L et al. Slow breathing reduces chemoreflex response to hypoxia and hypercapnia and increases baroreflex sensitivity. Journal of Hypertension. 19(12): 2221-9. 2001.
11. Lundberg JON et al. Inhalation of nasally derived nitric oxide modulates pulmonary function in humans'. Acta Physiol Scand. 158: 343-347. 1996.
12. Kairaitis K. Route of Breathing in Patients with Asthma. Chest. 116: 1646-1652. 1999.

Further information

For information regarding the Buteyko Method please contact the Buteyko Breathing Association either through their website www.buteykobreathing.org or by requesting an information pack using their 24-hour answer phone system on Tel: 01277 366906.

A five-day intensive Buteyko Practitioner training course is currently available and open to qualified health professionals and complementary therapists. A good working knowledge of respiratory anatomy and physiology is required. For further information Tel: 01277 366906; www.teachingbuteyko.co.uk