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What makes difficult asthma difficult?

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

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What makes difficult asthma difficult?

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  1. What makes difficult asthma difficult? Nicki Barker 2012 SCH Journal Club Dysfunctional breathing in children

  2. Aim To determine whether breathing retraining improves quality of life for children with dysfunctional breathing Dysfunctional breathing in children

  3. 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 Dysfunctional breathing in children

  4. Difficult asthma ‘persistent symptoms and/or frequent exacerbations despite treatment at step 4 or step 5’ Dysfunctional breathing in children

  5. Difficult asthma? Compliance issues Incorrect diagnosis Asthma plus a co-morbidity Dysfunctional breathing in children

  6. BTS guidelines 2012 ‘dysfunctional breathing should be considered as part of a difficult asthma assessment’ Dysfunctional breathing in children

  7. BreathWorks • Specialist assessment of dysfunctional breathing • Children aged 8-16 • Referral currently via respiratory clinics • Thursday afternoon in physiotherapy O/P’s Dysfunctional breathing in children

  8. Dysfunctional breathing (DB) Dysfunctional breathing in children

  9. DB: A model

  10. DB: A paediatric model

  11. 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 Dysfunctional breathing in children

  12. The Clinical Question Dysfunctional breathing in children

  13. 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 Dysfunctional breathing in children

  14. The Clinical Question Dysfunctional breathing in children

  15. 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 Dysfunctional breathing in children

  16. Study flow diagram Thomas M et al. Thorax 2003;58:110-115

  17. Outcome measures • Primary • Asthma specific health status (AQLQ) • Nijmegen questionnaire scores • Secondary • Changes in asthma medication and medication usage Dysfunctional breathing in children

  18. Using the CASP tool 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 Dysfunctional breathing in children

  19. CASP cont. 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 - Controlgroup 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 Dysfunctional breathing in children

  20. CASP cont. 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

  21. 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 Dysfunctional breathing in children

  22. Quality of life as measured by PedsQL MCID = minimal clinically important difference

  23. Symptom score using Nijmegen Questionnaire

  24. 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 Dysfunctional breathing in children

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