Breathing exercises for children with asthma (Protocol) Macêdo TMF, Freitas DA, Chaves GSS, Holloway EA, Mendonça KMPP

This is a reprint of a Cochrane protocol, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2014, Issue 3 http://www.thecochranelibrary.com

Breathing exercises for children with asthma (Protocol) Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

TABLE OF CONTENTS HEADER . . . . . . . . . . ABSTRACT . . . . . . . . . BACKGROUND . . . . . . . OBJECTIVES . . . . . . . . METHODS . . . . . . . . . ACKNOWLEDGEMENTS . . . REFERENCES . . . . . . . . APPENDICES . . . . . . . . CONTRIBUTIONS OF AUTHORS DECLARATIONS OF INTEREST .

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Breathing exercises for children with asthma (Protocol) Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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[Intervention Protocol]

Breathing exercises for children with asthma Thalita MF Macêdo1 , Diana A Freitas1 , Gabriela SS Chaves1 , Elizabeth A Holloway2 , Karla MPP Mendonça3 1 Department

UK.

3 PhD

of Physical Therapy, Federal University of Rio Grande do Norte, Natal, Brazil. 2 c/o Cochrane Airways Group, London, Program in Physical Therapy, Federal University of Rio Grande do Norte, Natal, Brazil

Contact address: Karla MPP Mendonça, PhD Program in Physical Therapy, Federal University of Rio Grande do Norte, Avenida Senador Salgado Filho, 300, Bairro Lagoa Nova, Natal, Rio Grande do Norte, 59078-970, Brazil. [email protected]. Editorial group: Cochrane Airways Group. Publication status and date: New, published in Issue 3, 2014. Citation: Macêdo TMF, Freitas DA, Chaves GSS, Holloway EA, Mendonça KMPP. Breathing exercises for children with asthma. Cochrane Database of Systematic Reviews 2014, Issue 3. Art. No.: CD011017. DOI: 10.1002/14651858.CD011017. Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the effects of breathing exercises in children with asthma.

BACKGROUND

Description of the condition Asthma is a chronic inflammatory disorder of the lungs that can lead to structural and functional changes resulting from bronchial hyperresponsiveness and airflow obstruction (Allen 2012; Brightling 2012; Holgate 2009; Taylor 2008; Zhang 2010). Symptoms of asthma include recurrent episodes of wheeze, cough, breathlessness and chest tightness, together with episodes of marked worsening of symptoms known as exacerbations (Bateman 2008; Brightling 2012; Zhang 2010). The diagnosis of asthma is based on the individual’s medical history, physical examination findings and lung function and laboratory test results (Sveum 2010). Asthma is a serious public health problem and a major cause of disability and health resource utilisation among those affected (Bateman 2008; Eisner 2012; To 2012). Around 300 million individuals of all ages worldwide are affected by asthma (Bateman 2008; Bousquet 2010; Brightling 2012). Asthma is the most common chronic disease in childhood (Solé 2006). Increased morbid-

ity, mortality and economic costs are associated with patients with severe or difficult to treat asthma, particularly in industrialised countries (Eisner 2012; Zhang 2010). In addition, psychological symptoms may interfere with the severity of respiratory symptoms and may influence patients’ quality of life (Juniper 2004; Rimington 2001). Such consequences affect not only the patient but the whole family universe (Nogueira 2009), especially when it comes to children. Asthma is sometimes associated with symptomatic hyperventilation, which decreases carbon dioxide (CO2 ) levels, causing hypocapnia (Bruton 2005a; Laffey 2002; Thomas 2001). Hypocapnia resulting from hyperventilation may perpetuate the bronchospasm, culminating in a cycle of progressive hypocapnia and increasing bronchospasm (Laffey 2002). Thus, hypocapnia may contribute to increased airway resistance in patients with asthma (Laffey 2002; van den Elshout 1991). This fact has led to increasing interest in strategies that can be used to reduce hyperventilation.

Breathing exercises for children with asthma (Protocol) Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Description of the intervention The main objective of asthma treatment is to achieve and maintain its clinical control (GINA 2012). Although no cure for asthma is known, its symptoms are controllable in most patients (Taylor 2008). Asthma treatment can be pharmacological or non-pharmacological or a combination of these approaches; it includes strategies of symptom control (information on environmental triggers and asthma education) to reduce symptoms and improve quality of life related to health (Burgess 2011; Rimington 2001; Welsh 2011). Pharmacological treatment of asthma consists of maintaining control of the disease with the least medication, thereby minimising risks of adverse effects (Sveum 2010). Non-pharmacological treatments have been used widely by researchers and professionals in the search for complementary therapies for the treatment of asthma; their use is reported in approximately 42% of patients in some populations (Blanc 2001). Some patients are interested in non-pharmacological therapies because they may feel or hope that they will lead to improvement in overall health (Bishop 2008), and because they are keen to try to reduce the need for pharmacological treatment (Brien 2011). Complementary medicine includes breathing exercises, homeopathy, acupuncture, aromatherapy, reflexology, massage, inspiratory muscle training and the Alexander technique (Blanc 2001; Bruton 2005b; Cooper 2003; Dennis 2012; Grammatopoulou 2011; Holloway 2007; Lima 2008; McCarney 2003; McHugh 2003). Breathing exercises have been used routinely by physiotherapists and other professionals to control the hyperventilation symptoms of asthma (Bruton 2005b) and can be provided in the form of the Papworth method, the Buteyko breathing technique, yoga or any similar intervention that manipulates the breathing pattern (Ram 2003). Even though breathing exercises are commonly used, there is not a consensus regarding the effectiveness of breathing exercises. It was previously reported that groups with the same baseline characteristics may show different responses to different breathing exercise techniques (Prem 2013). Also, the duration of the intervention may interfere with the response to treatment, as was suggested previously (Grammatopoulou 2011). A previous systematic review on breathing exercises for asthma included studies performed in participants with mild to severe asthma (Ernst 2000). However, meta-analysis was not provided to assess the impact of breathing exercises at different levels of asthma severity.

reduce anxiety associated with asthma symptoms (Singh 1990). Therefore, breathing exercises in patients with asthma may provide psychological benefits by increasing patients’ sense of control over their condition (Ram 2003).

Why it is important to do this review The worldwide high prevalence of asthma became a public health problem because of the high healthcare costs resulting from hospitalisation and medication (Giavina-Bianchi 2010). Asthma promotes changes in the whole family context, not only because of the costs associated with health care, but also because of the impact of this condition on daily living, including patients’ quality of life (Ferreira 2010). Asthma control is promoted by the correct use of medication and may be associated with other therapies, such as breathing exercises. Such techniques have been widely used as adjunct therapy in the treatment of asthmatic patients, generating considerable interest among researchers to develop studies that aim to provide evidence of this intervention. Recently, we published a Cochrane systematic review regarding the use of breathing exercises in adults with asthma (Freitas 2013). This review included studies that differed significantly in terms of intervention characteristics, such as types of breathing exercises, numbers of participants, numbers and duration of sessions, reported outcomes and statistical presentation of data. Such differences limited meta-analysis and attainment of conclusive results. On the other hand, this review indicated that breathing exercises are a safe and well-tolerated intervention for people with asthma. Similarly, no conclusive evidence was provided in two previous systematic reviews (Ernst 2000; Ram 2003), even though outcomes reported from individual trials showed that breathing exercises may have a role in the treatment and management of asthma. It is important to synthesise the evidence obtained on such techniques, taking into account their effects in the paediatric population. To our knowledge, no systematic review on this topic has been published previously. Thus, within this review, we aim to summarise and assess evidence from randomised controlled trials regarding the effects of breathing exercises in children with asthma.

OBJECTIVES To assess the effects of breathing exercises in children with asthma.

How the intervention might work Breathing exercise techniques focus on the use of an appropriate breathing pattern to reduce hyperventilation and hyperinflation, thereby increasing CO2 levels, which may reduce bronchospasm, normalise the breathing pattern and reduce breathlessness (Bruton 2005b; Burgess 2011). Such techniques may also be used to help

METHODS

Criteria for considering studies for this review

Breathing exercises for children with asthma (Protocol) Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Types of studies

We will include children (younger than 18 years of age) with a diagnosis of asthma. We will exclude participants with other associated respiratory disease.

meeting abstracts (see Appendix 1 for further details). We will search all records in the CAGR using the search strategy provided in Appendix 2. We will also conduct a search of ClinicalTrials.gov (www.ClinicalTrials.gov) and the World Health Organization (WHO) trials portal (www.who.int/ictrp/en/). We will search all databases from their inception to the present, and we will impose no restriction on language of publication.

Types of interventions

Searching other resources

We will include trials comparing breathing exercises versus asthma education or alternatively versus no active control group (e.g. waiting list control).

We will check reference lists of all primary studies and review articles for additional references. We will search relevant manufacturers’ websites for trial information. We will search for errata or retractions from included studies published in full text on PubMed (www.ncbi.nlm.nih.gov/pubmed) and will report within the review the date this was done.

We will include randomised controlled trials (RCTs). Types of participants

Types of outcome measures

Primary outcomes

1. Quality of life (measured by any respiratory disease-specific or generic instrument). 2. Asthma symptoms (measured by any respiratory diseasespecific or generic instrument). 3. Serious adverse events (any undesired outcomes due to the intervention).

Secondary outcomes

1. Reduction in medication usage (e.g. inhaled or oral steroids or rescue bronchodilator). 2. Number of acute exacerbations (mean number and number of participants experiencing one or more exacerbations). 3. Physiological measures-lung function (especially low flow rates) and functional capacity. 4. Days off school. 5. Adverse events. Reporting in the trial one of more of the outcomes listed here is not an inclusion criterion for the review.

Data collection and analysis

Selection of studies Two review authors (TMFM and DAF) will independently screen titles and abstracts for inclusion of all potential studies identified as a result of the search and will code them as ’retrieve’ (eligible or potentially eligible/unclear) or ’do not retrieve’. We will retrieve the full-text study report/publication, and two review authors (TMFM and DAF) will independently screen the full text, identify studies for inclusion and identify and record reasons for exclusion of ineligible studies. We will resolve disagreement through discussion, or, if required, we will consult a third review author (KMPPM). We will identify and exclude duplicates and will collate multiple reports of the same study, so that each study rather than each report is the unit of interest in the review. We will record the selection process in sufficient detail to complete a PRISMA flow diagram and a ’Characteristics of excluded studies’ table.

Data extraction and management

Search methods for identification of studies

Electronic searches We will identify trials from the Cochrane Airways Group Specialised Register (CAGR), which is maintained by the Trials Search Co-ordinator for the Group. The Register contains trial reports identified through systematic searches of bibliographic databases including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, AMED and PsycINFO, and by handsearching of respiratory journals and

To record study characteristics and outcome data, we will use a data collection form that has been piloted on at least one study in the review. One review author (TMFM or DAF) will extract the following study characteristics from included studies. 1. Methods: study design, total duration of study, method of randomisation, method of allocation concealment, outcome assessor blinding, number of study centres and locations, study setting, withdrawals and dropouts and dates of the study. 2. Participants: N, mean age, age range, gender, severity of condition, diagnostic criteria, baseline lung function, smoking history, inclusion criteria and exclusion criteria.

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3. Interventions: types of breathing exercises, methods (including numbers and duration of sessions and methods used in control group comparisons). 4. Outcomes: primary and secondary outcomes specified and collected, and time points reported. 5. Notes: funding for trial and notable conflicts of interest of trial authors. Two review authors (TMFM and DAF) will independently extract outcome data from included studies. We will note in the ’Characteristics of included studies’ table whether outcome data were reported in a usable way. We will resolve disagreements by consensus or by involving a third review author (KMPPM). One review author (TMFM) will transfer data into the Review Manager (RevMan 2012) file. We will double-check that data have been entered correctly by comparing the data presented in the systematic review against the study reports. A second review author (DAF) will spot-check study characteristics against the trial report to confirm accuracy.

Measures of treatment effect

Assessment of risk of bias in included studies

Cross-over trials

Two review authors (TMFM and DAF) will independently assess risk of bias for each study using the criteria outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011a). We will resolve disagreements by discussion or by involving another review author (KMPPM). We will assess the risk of bias according to the following domains. 1. Random sequence generation. 2. Allocation concealment. 3. Blinding of participants and personnel. 4. Blinding of outcome assessment. 5. Incomplete outcome data. 6. Selective outcome reporting. 7. Other bias. We will grade each potential source of bias as high, low or unclear and will provide a quote from the study report, together with justification for our judgement, in the ’Risk of bias’ table. We will summarise the risk of bias judgements across different studies for each of the domains listed. We will consider blinding separately for different key outcomes when necessary (e.g. for an unblinded outcome assessment, risk of bias for all-cause mortality may be very different than for a patient-reported pain scale). When information on risk of bias relates to unpublished data or correspondence with a trialist, we will note this in the ’Risk of bias’ table. When considering treatment effects, we will take into account the risk of bias for studies that contribute to that outcome.

We will not include cross-over studies, as the design is not appropriate for this intervention.

Assesment of bias in conducting the systematic review We will conduct the review according to this published protocol and will report deviations from it in the ’Differences between protocol and review’ section of the systematic review.

We will analyse dichotomous data as odds ratios, and continuous data as mean differences or standardised mean differences with 95% confidence intervals (CIs). We will enter data presented on a scale with a consistent direction of effect. We will undertake meta-analyses only when this is meaningful (i.e. if treatments, participants and the underlying clinical question are similar enough for pooling to make sense). We will narratively describe skewed data reported as medians and interquartile ranges. When multiple trial arms are reported in a single trial, we will include only the relevant arms. If two comparisons (e.g. breathing exercise A vs control and breathing exercise B vs control) are combined in the same meta-analysis, we will halve the control group to avoid double-counting. Unit of analysis issues

Cluster-randomised trials

We will include data from cluster-randomised trials if the information is available. For cluster-randomised trials, we will adjust results when the unit of analysis in the trial is presented as the total number of individual participants instead of as the number of clusters. We will adjust the results using mean cluster size and the intracluster correlation co-efficient (ICC) (Higgins 2011b). For meta-analysis, we will combine data from individually randomised trials using the generic inverse-variance method, as described in Chapter 16.3 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011b). Dealing with missing data We will contact investigators or study sponsors when possible to verify key study characteristics and to obtain missing numerical outcome data (e.g. when a study is identified as an abstract only). When this is not possible, and the missing data are thought to introduce serious bias, we will perform a sensitivity analysis to explore the impact of including such studies in the overall assessment of results. Assessment of heterogeneity The review authors will assess heterogeneity in trial results by inspecting the forest plots to detect non-overlapping CIs and by applying the Chi2 test (with P value 0.10 indicating statistical significance). We will use the I² statistic to measure heterogeneity among

Breathing exercises for children with asthma (Protocol) Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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trials in each analysis. If we identify substantial heterogeneity (> 50%) we will report this and will explore possible causes by prespecified subgroup analysis (Higgins 2011c). Assessment of reporting biases If we are able to pool more than 10 trials, we will create and examine a funnel plot to explore possible small-study and publication biases (Higgins 2011d).

1. Degree of asthma severity. 2. Duration of treatment. 3. Types of breathing exercises. We will use the following outcomes in subgroup analyses. 1. Quality of life. 2. Reduction in medication usage. We will use the formal test for subgroup interactions in Review Manager (RevMan 2012).

Sensitivity analysis Data synthesis The review authors will use RevMan 5.1 to combine outcomes when possible (RevMan 2012). The review authors will use a fixedeffect model unless substantial heterogeneity (I2 > 50%) is observed, in which case they will use a random-effects model.

We plan to carry out the following sensitivity analyses. 1. Trial quality (studies with overall high risk of bias versus overall low risk of bias).

Reaching conclusions Summary of findings table We will create a ’Summary of findings’ table using the following outcomes: quality of life, asthma symptoms, serious adverse events, reduction in medication usage, number of acute exacerbations, physiological measures and days off school. We will use the five GRADE considerations (study limitations, consistency of effect, imprecision, indirectness and publication bias) to assess the quality of a body of evidence as it relates to the studies contributing data to the meta-analyses for prespecified outcomes. We will apply methods and recommendations described in Section 8.5 and Chapter 12 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011e) using GRADEpro software. We will justify all decisions to downgrade or upgrade the quality of studies by using footnotes, and we will make comments when necessary to aid readers’ understanding of the review. Subgroup analysis and investigation of heterogeneity We plan to carry out the following subgroup analyses.

We will base our conclusions only on findings from the quantitative or narrative synthesis of included studies in this review. We will avoid making recommendations for practise, and our implications for research will suggest priorities for future studies and will outline remaining uncertainties in this area.

ACKNOWLEDGEMENTS The authors would like to thank Emma Welsh (the Managing Editor of the Cochrane Airways Group) for assistance provided in beginning this review, Elizabeth Stovold (the Trials Search Coordinator/Information Specialist of the Cochrane Airways Group) for the search strategy used in the review and Emma Jackson (Editorial Assistant of the Cochrane Airways Group) for assistance provided. Anne Holland was the Editor for this review and commented critically on the review.

REFERENCES

Additional references Allen 2012 Allen JC, Seidel P, Schlosser T, Ramsay EE, Ge Q, Ammit AJ. Cyclin D1 in ASM cells from asthmatics is insensitive to corticosteroid inhibition. Journal of Allergy 2012 Feb 19 [Epub ahead of print]. [DOI: 10.1155/2012/307838] Bateman 2008 Bateman ED, Hurd SS, Barnes PJ, Bousquet J, Drazen JM, FitzGerald M. Global strategy for asthma management and prevention: GINA executive summary. European Respiratory Journal 2008;31(1):143–78.

Bishop 2008 Bishop FL, Yardley L, Lewith GT. Treat or treatment: a qualitative study analyzing patients’ use of complementary and alternative medicine. American Journal of Public Health 2008;98(9):1700–5. Blanc 2001 Blanc PD, Trupin L, Earnest G, Katz PP, Yelin EH, Eisner MD. Alternative therapies among adults with a reported diagnosis of asthma or rhinosinusitis: data from a population-based survey. Chest 2001;120(5):1461–7. Bousquet 2010 Bousquet J, Mantzouranis E, Cruz AA, Aït-Khaled N,

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Baena-Cagnani CE, Bleecker ER, et al.Uniform definition of asthma severity, control, and exacerbations: document presented for the World Health Organization Consultation on Severe Asthma. Journal of Allergy and Clinical Immunology 2010;126(5):926–38. Brien 2011 Brien SB, Bishop FL, Riggs K, Stevenson D, Freire V, Lewith G. Integrated medicine in the management of chronic illness: a qualitative study. British Journal of General Practice 2011;61(583):e89–96. Brightling 2012 Brightling CE, Gupta S, Gonem S, Siddiqui S. Lung damage and airway remodelling in severe asthma. Clinical and Experimental Allergy 2012;42(5):638–49. Bruton 2005a Bruton A, Holgate ST. Hypocapnia and asthma: a mechanism for breathing retraining?. Chest 2005;127(5): 1808–11. Bruton 2005b Bruton A, Lewith GT. The Buteyko breathing technique for asthma: a review. Complementary Therapies in Medicine 2005;13(1):41–6. Burgess 2011 Burgess J, Ekanayake B, Lowe A, Dunt D, Thien F, Dharmage SC. Systematic review of the effectiveness of breathing retraining in asthma management. Expert Review of Respiratory Medicine 2011;5(6):789–807. Cooper 2003 Cooper S, Oborne J, Newton S, Harrison V, Thompson Coon J, Lewis S, et al.Effect of two breathing exercises (Buteyko and pranayama) in asthma: a randomised controlled trial. Thorax 2003;58(8):674–9. Dennis 2012 Dennis JA, Cates CJ. Alexander technique for chronic asthma. Cochrane Database of Systematic Reviews 2012, Issue 9. [DOI: 10.1002/14651858.CD000995.pub2] Eisner 2012 Eisner MD, Yegin A, Trzaskoma B. Severity of asthma score predicts clinical outcomes in patients with moderate to severe persistent asthma. Chest 2012;141(1):58–65. Ernst 2000 Ernst E. Breathing techniques - adjunctive treatment modalities for asthma? A systematic review. The European Respiratory Journal 2000;15(5):969-72.

Giavina-Bianchi 2010 Giavina-Bianchi P, Aun MV, Bisaccioni C, Agondi R, Kalil J. Difficult-to-control asthma management through the use of a specific protocol. Clinics 2010;65(9):905–18. GINA 2012 Global Initiative for Asthma. Global strategy for asthma management and prevention 2012. http:// www.ginasthma.com (accessed 10 October 2013). Grammatopoulou 2011 Grammatopoulou EP, Skordilis EK, Stavrou N, Myrianthefs P, Karteroliotis K, Baltopoulos G, et al.The effect of physiotherapy-based breathing retraining on asthma control. Journal of Asthma 2011;48(6):593–601. Higgins 2011a Higgins JPT, Altman DG, Sterne JAC. Chapter 8: Assessing risk of bias in included studies. Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. www.cochranehandbook.org: The Cochrane Collaboration, 2011. Higgins 2011b Higgins JPT, Deeks JJ, Altman DG. Chapter 16: Special topics in statistics. Cochrane Handbook for Systematic Reviews of Interventions. 5.1.0 edition. The Cochrane Collaboration, 2011. Higgins 2011c Deeks JJ, Higgins JPT, Altman DG. Chapter 9: Analysing data and undertaking meta-analyses. Cochrane Handbook for Systematic Reviews of Interventions. 5.1.0 edition. The Cochrane Collaboration, 2011. Higgins 2011d Sterne JAC, Egger M, Moher D. Chapter 10: Addressing reporting biases. Cochrane Handbook for Systematic Reviews of Intervention. 5.1.0 edition. The Cochrane Collaboration, 2011. Higgins 2011e Schünemann HJ, Oxman AD, Vist GE, Higgins JPT, Deeks JJ, Glasziou P, et al.Chapter 12: Interpreting results and drawing conclusions. Cochrane Handbook for Systematic Reviews of Intervention. 5.1.0 edition. The Cochrane Collaboration, 2011. Holgate 2009 Holgate ST, Arshad HS, Roberts GC, Howarth PH, Thurner P, Davies DE. A new look at the pathogenesis of asthma. Clinical Science 2009;118(7):439–50.

Ferreira 2010 Ferreira LN, Brito U, Ferreira PL. Quality of life in asthma patients. Revista Portuguesa de Pneumologia 2010;16(1): 23–55.

Holloway 2007 Holloway EA, West RJ. Integrated breathing and relaxation training (the Papworth method) for adults with asthma in primary care: a randomised controlled trial. Thorax 2007; 62(12):1039-42.

Freitas 2013 Freitas DA, Holloway EA, Bruno SS, Chaves GSS, Fregonezi GAF, Mendonça KMPP. Breathing exercises for adults with asthma. Cochrane Database of Systematic Reviews 2013, Issue 10. [DOI: 10.1002/14651858.CD001277.pub3]

Juniper 2004 Juniper EF, Wisniewski ME, Cox FM, Emmett AH, Nielsen KE, O’Byrne PM. Relationship between quality of life and clinical status in asthma: a factor analysis. European Respiratory Journal 2004;23(2):287–91.

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Laffey 2002 Laffey JG, Kavanagh BP. Hypocapnia. New England Journal of Medicine 2002;347(1):43–53. Lima 2008 Lima EVNCL, Lima WL, Nobre A, Santos AM, Brito LMO, Costa MRSE. Inspiratory muscle training and respiratory exercises in children with asthma [Treinamento muscular inspiratório e exercícios respiratórios em crianças asmáticas]. Jornal Brasileiro de Pneumologia 2008;34(8): 552–8. McCarney 2003 McCarney RW, Brinkhaus B, Lasserson TJ, Linde K. Acupuncture for chronic asthma. Cochrane Database of Systematic Reviews 2003, Issue 3. [DOI: 10.1002/ 14651858.CD000008.pub2] McHugh 2003 McHugh P, Aitcheson F, Duncan B, Houghton F. Buteyko breathing technique for asthma: an effective intervention. New Zealand Medical Journal 2003;116(1187):U710. Nogueira 2009 Nogueira KT, Silva JRL, Lopes CS. Quality of life of asthmatic adolescents: assessment of asthma severity, comorbidity, and life style. Jornal de Pediatria 2009;85(6): 523–30. Prem 2013 Prem V, Sahoo RC, Adhikari P. Comparison of the effects of Buteyko and pranayama breathing techniques on quality of life in patients with asthma: a randomized controlled trial. Clinical Rehabilitation 2013;27(2):133-41. Ram 2003 Ram FS, Holloway EA, Jones PW. Breathing retraining for asthma. Respiratory Medicine 2003;97(5):501–7. RevMan 2012 Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2012. Review Manager (RevMan). 5.2. Rimington 2001 Rimington LD, Davies DH, Lowe D, Pearson MG. Relationship between anxiety, depression, and morbidity in adult asthma patients. Thorax 2001;56(4):266–71. Singh 1990 Singh V, Wisniewski A, Britton J, Tattersfield A. Effect of yoga breathing exercises (pranayama) on airway reactivity in subjects with asthma. Lancet 1990;335(8702):1381–3.

Solé 2006 Solé D, Wandalsen GF, Camelo-Nunes IC, Naspitz CK. Prevalence of symptoms of asthma, rhinitis, and atopic eczema among Brazilian children and adolescents identified by the International Study of Asthma and Allergies in Childhood (ISAAC) - Phase 3. Jornal de Pediatria 2006;82 (5):341–6. Sveum 2010 Sveum R, Bergstrom J, Brottman G, Hanson M, Heiman M, Johns K, et al.Institute for Clinical Systems Improvement. Diagnosis and management of asthma, 2010. https:// www.icsi.org/_asset/rsjvnd/Asthma.pdf Vol. (accessed 10 October 2013). Taylor 2008 Taylor DR, Bateman ED, Boulet LP, Boushey HA, Busse WW, Casale TB, et al.A new perspective on concepts of asthma severity and control. European Respiratory Journal 2008;32(3):545–54. Thomas 2001 Thomas M, McKinley RK, Freeman E, Foy C. Prevalence of dysfunctional breathing in patients treated for asthma in primary care: cross sectional survey. BMJ 2001;322(7294): 1098–100. To 2012 To T, Stanojevic S, Moores G, Gershon AS, Bateman ED, Cruz AA, et al.Global asthma prevalence in adults: findings from the cross-sectional world health survey. BMC Public Health 2012;12:204. van den Elshout 1991 van den Elshout FJ, van Herwaarden CL, Folgering HT. Effects of hypercapnia and hypocapnia on respiratory resistance in normal and asthmatic subjects. Thorax 1991; 46(1):28–32. Welsh 2011 Welsh EJ, Hasan M, Li P. Home-based educational interventions for children with asthma. Cochrane Database of Systematic Reviews 2011, Issue 10. [DOI: 10.1002/ 14651858.CD008469.pub2] Zhang 2010 Zhang X, Köhl J. A complex role for complement in allergic asthma. Expert Review of Clinical Immunology 2010;6(2): 269–77. ∗ Indicates the major publication for the study

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APPENDICES

Appendix 1. Sources and search methods for the Cochrane Airways Group Specialised Register (CAGR)

Electronic searches: core databases

Database

Frequency of search

CENTRAL

Monthly

MEDLINE (Ovid)

Weekly

EMBASE (Ovid)

Weekly

PsycINFO (Ovid)

Monthly

CINAHL (EBSCO)

Monthly

AMED (EBSCO)

Monthly

Handsearches: core respiratory conference abstracts

Conference

Years searched

American Academy of Allergy, Asthma and Immunology (AAAAI) 2001 onwards American Thoracic Society (ATS)

2001 onwards

Asia Pacific Society of Respirology (APSR)

2004 onwards

British Thoracic Society Winter Meeting (BTS)

2000 onwards

Chest Meeting

2003 onwards

European Respiratory Society (ERS)

1992, 1994, 2000 onwards

International Primary Care Respiratory Group Congress (IPCRG) 2002 onwards Thoracic Society of Australia and New Zealand (TSANZ)

1999 onwards

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MEDLINE search strategy used to identify trials for the CAGR

Asthma search 1. exp Asthma/ 2. asthma$.mp. 3. (antiasthma$ or anti-asthma$).mp. 4. Respiratory Sounds/ 5. wheez$.mp. 6. Bronchial Spasm/ 7. bronchospas$.mp. 8. (bronch$ adj3 spasm$).mp. 9. bronchoconstrict$.mp. 10. exp Bronchoconstriction/ 11. (bronch$ adj3 constrict$).mp. 12. Bronchial Hyperreactivity/ 13. Respiratory Hypersensitivity/ 14. ((bronchial$ or respiratory or airway$ or lung$) adj3 (hypersensitiv$ or hyperreactiv$ or allerg$ or insufficiency)).mp. 15. ((dust or mite$) adj3 (allerg$ or hypersensitiv$)).mp. 16. or/1-15

Filter to identify RCTs 1. exp “clinical trial [publication type]”/ 2. (randomised or randomised).ab,ti. 3. placebo.ab,ti. 4. dt.fs. 5. randomly.ab,ti. 6. trial.ab,ti. 7. groups.ab,ti. 8. or/1-7 9. Animals/ 10. Humans/ 11. 9 not (9 and 10) 12. 8 not 11 The MEDLINE strategy and the RCT filter are adapted to identify trials in other electronic databases.

Appendix 2. Search strategy to identify relevant trials from the CAGR #1 AST:MISC1 #2 MeSH DESCRIPTOR Asthma Explode All #3 asthma*:ti,ab #4 #1 or #2 or #3 #5 MeSH DESCRIPTOR Breathing Exercises #6 (breath*) NEAR5 (technique* or exercise* or re-train* or train* or re-educat* or educat* or physiotherap* or “physical therapy” or “respiratory therapy”) #7 buteyko or “qigong yangsheng” or pranayama* OR yoga* #8 “breathing control” #9 #5 or #6 or #7 or #8 #10 #4 and #9 #11 child* or paediat* or pediat* or adolesc* or infan* or toddler* or bab* or young* or preschool* or “pre school*” or pre-school* or newborn* or “new born*” or new-born* or neo-nat* or neonat* #12 MeSH DESCRIPTOR Child Explode All Breathing exercises for children with asthma (Protocol) Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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#13 MeSH DESCRIPTOR Pediatrics Explode All #14 MeSH DESCRIPTOR Infant Explode All #15 MeSH DESCRIPTOR Adolescent Explode All #16 #11 or #12 or #13 or #14 or #15 #17 #10 and #16 [Note: in search line #1, MISC1 refers to the field in the record where the reference has been coded for condition, in this case, asthma]

CONTRIBUTIONS OF AUTHORS Thalita Macêdo: developed and advised on the protocol; completed the first draft of the protocol; made an intellectual contribution to the protocol; approved the final version of the protocol before submission. Diana Freitas: developed and advised on the protocol; completed the first draft of the protocol; made an intellectual contribution to the protocol; approved the final version of the protocol before submission. Gabriela Chaves: completed the first draft of the protocol; made an intellectual contribution to the protocol; approved the final version of the protocol before submission. Elizabeth Holloway: contributed clinical expertise; approved the final version of the protocol before submission. Karla Mendonça: developed and co-ordinated the protocol; completed part of the first draft of the protocol; made an intellectual contribution to the protocol; approved the final version of the protocol before submission.

DECLARATIONS OF INTEREST None known.

Breathing exercises for children with asthma (Protocol) Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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