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Complementary Therapies in Medicine (2005) 13, 41—46
The Buteyko breathing technique for asthma:
Areview
a,! b
A. Bruton , G.T. Lewith
a School of Health Professions and Rehabilitation Sciences, University of Southampton, Highfield,
Southampton SO17 1BJ, UK
b Complementary Medicine Research Unit, University of Southampton, Highfield,
Southampton SO17 1BJ, UK
Summary Breathing exercises and breathing retraining are often used in the man-
agement of asthma. One specific form of breathing therapy, known as the Buteyko
breathingtechnique(BBT)hasreceivedconsiderableattention,butthereisapaucity
of rigorous research evidence to support its recommendation for asthma patients.
Thereareonlyfourpublishedclinicaltrialsandtwoconferenceabstractsevaluating
BBT. Although all have reported improvements in one or more outcome measures,
results have not been consistent.
This article provides the background to the BBT, reviews the available evidence
for its use and examines the physiological hypothesis claimed to underpin it. In
commonwithothertherapies,BBTisnotastandardisedtreatmentmodality.TheBBT
‘package’iscomplex,asitalsoincludesadviceandeducationaboutmedicationuse,
nutrition and exercise, and general relaxation. This makes it difficult, and possibly
inappropriate,toattempttoteaseoutasinglemechanism.Buteyko’stheoryrelating
to carbon dioxide levels and airway calibre is an attractive one, and has some basis
in evidence from experimental studies. However, it is not known whether altering
breathingpatternscanraisecarbondioxidelevelssignificantly,andthereiscurrently
insufficient evidence to confirm that this is the mechanism behind any effect that
BBT may exert. Further research is necessary to establish unequivocally whether
BBT is effective, and if so, how it may work.
©2005Elsevier Ltd. All rights reserved.
Introduction healthcare costs are as a result of hospitalization,
the second greatest cost is for medication (£850
2
The burden of asthma is increasing causing se- million p.a. in the UK). Breathing exercises have
vere socioeconomic strain.1 Although the greatest beenincorporatedintovarioustherapiesforasthma
and hyperventilation. The nature of the breathing
* Corresponding author. Tel.: +44 23 8059 5283; exercise varies with the nature of the therapy, the
3
fax: +44 23 8059 5303. therapists and the cultural background. However,
E-mail address: ab7@soton.ac.uk (A. Bruton). two systematic reviews of breathing exercises for
0965-2299/$ — see front matter © 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ctim.2005.01.003
42 A. Bruton, G.T. Lewith
asthma have identified little published suitable for a validated screening tool that has been shown to
inclusion.4,5 There is, therefore, insufficient evi- have 95% effectiveness in distinguishing hyperven-
dence to support the recommendation of breath- tilators from “normals”.13 It consists of 16 items
ing exercises in asthma.6 Opinions differ as to the of sensations associated with hyperventilation.
proportion of UK asthma sufferers who currently Buteyko suggested that hyperventilation leads to a
use such therapy. The National Asthma Campaign reduction in blood and alveolar CO2 levels to which
foundthat30%ofrespondentswereusingbreathing the airways respond by constricting to prevent
7 8 14
exercises. However, Partridge et al.’s study eval- further loss of CO . Conventional medication, in
2
uatingastratifiedcrosssectionoftheasthmapopu- the form of bronchodilators, is said to exacerbate
lation found only 6% using such therapy. The House the loss of CO2 and compound the symptoms when
of Lords Select Committee’s enquiry into comple- the bronchodilator wears off. By teaching people
mentary and alternative medicine (CAM)9 revealed to underbreathe it is hypothesized that they will be
that around 5 million people had consulted a CAM able to raise their CO2 levels and thus encourage
practitioner in 1999, despite a lack of robust re- bronchodilatation without medication.
search evidence. Buteyko’s techniques were developed in the
Physiotherapists and others have routinely used 1950s but until recently they received little atten-
breathing exercises to treat patients with hyper- tion outside Russia. BBT is currently being taught in
ventilation symptoms.Theaimistodevelopamore Europe,Australia,NewZealand,andtheUSA.There
efficient pattern of respiration by ‘normalising’ is some scientific support for the underlying physio-
the breathing pattern, thereby reducing breath- logicaltheoryintherecentworkbyOsborneetal.10
lessness. The relationship between asthma and who found that stable mild asthmatic patients had
hyperventilation is complex and it can be difficult significantly lower resting CO2 levels than healthy
to distinguish true asthma from asthma-like symp- matchedcontrols.Thereisalsosomeevidencesug-
toms induced by overbreathing.10 Nevertheless, gesting that CO2 acts directly on the airway smooth
whatever the underlying mechanism for hyperven- muscle to cause bronchodilatation15 while low CO
16,17 2
tilation, there is evidence to suggest that it can causes bronchoconstriction. However, this CO
11 2
lead to significant increases in airway resistance. hypothesis does not fit with other respiratory disor-
Recently a technique with similar aims to physio- ders in which a low CO does not seem to be asso-
2
therapy, the Buteyko breathing technique (BBT), ciated with bronchoconstriction.
has received considerable attention. The purpose As with many complementary medical interven-
of this article is to provide some background to tions, it may be that the specific effect of the
BBT, review the available evidence for its effec- therapy is far less powerful than the non-specific
tiveness, and examine the physiological hypothesis effect of the therapeutic relationship and patient
behind it. empowerment.18 This certainly requires further in-
vestigation.
Background
Buteyko technique
The late Professor Konstantin Buteyko was a
Russian physiologist (1923—2003) who gave his The major component of the Buteyko ‘package’
name to a novel treatment approach that is cur- is breathing therapy. The breathing component
rently being applied to patients with asthma in a aims to reduce hyperventilation through periods
number of countries. The approach varies in some of controlled reduction in breathing, known as
details in different countries and with different ‘slow breathing’ and ‘reduced breathing’, com-
practitioners, but essentially consists of a package bined with periods of breath holding, known as
of breathing therapy, relaxation techniques and ‘control pauses’ and ‘extended pauses’. These
exercises combined with advice and education techniques are very similar to those routinely used
about medication use, nutrition and general by respiratory physiotherapists for patients with
health. Professor Buteyko theorised that ‘hidden’ hyperventilation symptoms. In Buteyko, they are
hyperventilation is the basic cause of asthma. This sometimesaccompaniedbyphysicalactivitiestoin-
theoryisgivensomesupportbyThomasetal.12who crease the build-up of CO2. The emphasis is on self-
surveyed 210 asthma patients using the Nijmegen monitoring using the pulse rate and the ‘pauses’ as
questionnaire and found that a third of females objective measures of outcome. Classical Buteyko
and a fifth of males surveyed had scores suggestive theorywouldsuggestthatthereisadirectrelation-
of dysfunctional breathing. This questionnaire is ship between the length of the ‘control pause’ and
The Buteyko breathing technique for asthma: A review 43
CO levels. No evidence has been published outside clinical research it is therefore essential to pro-
2
Russiathatwouldsupportthishypothesis.Thereare vide an adequate description of the methodology
twomainproblemswiththehypothesis:oneisthat employed, with clear explanations of the Buteyko
the nature of the ‘control pause’ is that it is de- training provided. The trials published so far have
pendent on subjective sensations of ‘air hunger’ or involvedinterventionsdeliveredbyrepresentatives
‘lack of air’, which may not be consistent over time from different Buteyko organisations, with insuffi-
within or between individuals. The second prob- cient detail to be certain of the exact content of
lem is that the hypothesis assumes that the drive the intervention.
to breathe is only related to CO levels. Since it
2
can be demonstrated experimentally that provid-
ing supplemental oxygen can increase breath hold- The evidence so far
ing time,19 it is likely that hypoxia is also relevant.
20
However, Nishino et al. have found an inverse re- There are two questions to be posed about BBT: (1)
lationship between the period of ‘no respiratory Does it work? (2) If it does work, how does it work?
sensation’ during breath holding and the slope of Despitemanyadvocates,claimsmadethatBBTpro-
the CO response curve. vides a ‘drug-free’ solution for asthma sufferers
2
BBTalsoincludesadviceandtrainingontheben- haveyettobesubstantiated.Becauseguidelinesfor
efits of nasal breathing over oral breathing. The asthma management emphasize the importance of
nose not only warms, filters and humidifies the in- regular controller therapy with anti-inflammatory
spired air, but also produces nitric oxide—–a potent asthma drugs, any alternatives require rigorous as-
bronchodilator. One proposed model for asthma21 sessment. However, a review of the literature via
is that exposure to an allergen causes some bron- PubMed(1966—2004),Embase(1966—2004),Cinahl
chospasm which gives rise to the sensation of dys- TM
(1982—2004)andWebofScience (1992—2004)re-
pnoea and chest ‘tightness’. The natural response vealed only four randomised controlled trials (RCT)
is for the patient to try to breathe more deeply involving Buteyko published in full and two in ab-
through the mouth, thereby inhaling more allergen stract form (see Table 1). A rigorous systematic re-
and both cooling and drying the airways—–thus pro- view was therefore not felt to be appropriate and
voking further bronchospasm and a greater drive to the six trials are described below.
breathe. Resisting this urge to overbreathe is the The first RCT involved a study of 39 asthma
core of the Buteyko training. There is evidence to patients randomised to receive BBT or control
suggest that people with asthma use oral breathing (asthma education and relaxation) over 7 days.23
more than healthy controls22 and Buteyko patients At 3 months post-intervention minute ventila-
are encouraged to breathe through the nose during tion and ! -agonist use were significantly less
2
the day and to try ‘taping’ the mouth at night using in the intervention group (p=0.002). However,
MicroporeTM, to encourage nasal breathing. Various methodological flaws (e.g. uncontrolled telephone
‘nose clearing’ exercises are also taught. Although contact between the Buteyko practitioner and
mouth taping has given rise to some controversy, the intervention group, lack of validated outcome
there is no evidence that this can be in any way measures) question the significance of these find-
harmful. 24
ings. A second study by Opat et al. involved 36
Another common component of BBT is advice on subjects with mild-moderate asthma, randomised
medication use. This usually involves encouraging to receive Buteyko training by video versus a relax-
patients to minimise their use of ! agonists and ation video. The intervention group again showed
2
is in line with Buteyko philosophy that ‘reliever’ significant reductions in medication use compared
inhalers exacerbate the loss of CO2. Unfortunately with the control group, as well as improvements in
such advice may invalidate medication usage as an quality of life. As already noted, medication usage
outcome measure for clinical research. is part of the advice/education package offered by
Buteyko practitioners, and so may not be the most
appropriate outcome measure. Nevertheless, re-
Standardisation of BBT training ductioninmedicationusewasalsofoundbyCooper
18 25 26
et al., McHugh et al., and McGowan. Cooper
In clinical practice, the delivery of BBTisnotastan- et al. reported an RCT in which 90 patients with
dard form of treatment. It will differ between one asthma were randomised to receive BBT, a device
practitioner and another, and will also be individ- which mimics pranayama (a yoga breathing tech-
ualised for each patient. Such variability is com- nique), or a dummy pranayama device. Bronchial
montomanyformsoftherapeuticpractice,includ- responsiveness and symptoms were compared over
ing ‘mainstream’ therapies like physiotherapy. In 6 months in a parallel group study. The results
44 A. Bruton, G.T. Lewith
Table 1 Randomised controlled trials involving Buteyko breathing.
First author Study Study design Outcome measures Significant Results
(date) participants
Bowler 23 39 adults in 1. BBT vs. Medication use; PEF; FEV1; MV; ↓Medication use
(1998) 2 groups 2. Education+relaxation ETCO2; QoL ↓MV
+breathing exercises
Opat 24 36 adults in 1. BBT video vs. Medication use; symptom ↓Medication use
(2000) 2 groups 2. Placebo video scores; PEF; QoL ↑QoL
Cooper 18 90 adults in 1. BBT vs. Symptom scores; BHR; ↓Symptoms
(2003) 3 groups 2. Yoga device vs. medication use; FEV1; QoL; ↓Medication use
3. Placebo device exacerbations
McHugh 25 38 adults in 1. BBT vs. Symptom scores; medication ↓Medication use
(2003) 2 groups 2. Education+relaxation use; FEV1
McGowan 600 adults 1. BBT vs. QoL; activity; symptom scores; ↓Symptoms
(2003)26 in 3 groups 2. Asthma education vs. medication use ↓Medication use
3. Medication control
Abramson 95 adults in 1. BBT+placebo video vs. Medication use; symptom ↑ETCO2 (4 vs. 3)
(2004)28 4 groups 2. Asthma scores; QoL; FEV1; ETCO2;
response to CO
education+Buteyko 2
video vs.
3. Asthma
education+placebo
video vs.
4. BBT+Buteyko video
BBT: Buteyko breathing technique; BHR: bronchial hyperresponsiveness; ETCO2: end tidal carbon dioxide; FEV1: forced expiratory
volume in 1s; MV: minute ventilation; PEF: peak expiratory flow; QoL: quality of life.
werethattheButeykogroupshowedimprovements Buteyko (placebo video plus placebo educator).
in symptoms and reduced bronchodilator usage Their findings are interesting but the complexity
when compared to both of the other groups, but of their design makes interpretation difficult. A
no change in either bronchial responsiveness or much larger trial involving 600 adults has been
lung function. In the McHugh et al. RCT, 38 people published in abstract form by McGowan.26 Reduc-
with asthma were randomised to receive BBT or a tions in both medication use and symptoms are
control intervention consisting of asthma educa- reported, with these changes persisting over the
tion and poorly described relaxation techniques. 12 months. However, the abstract provides insuffi-
Relaxation may not be the ideal control, as a cient detail to judge the rigour of the methodology
systematic review by Huntley et al.27 found some employed. At present, therefore, there is insuf-
evidence that relaxation therapy may improve lung ficient evidence to support a specific effect from
function in asthma. However, no changes in lung BBT.
function (percentage predicted FEV ) were found
1
in either group in the McHugh trial. In a controlled
trial currently only published in abstract form, Buteyko mechanism
Abramson et al.28 have also reported no changes
in lung function in the 95 adults studied. However, There is even less evidence about its mechanism
they did find a significant increase in end tidal CO2 of action. Conventional Buteyko theory states that
in one group and some non-significant reduction in hyperventilation causes the excessive removal of
response to CO2 in another. They employed a fac- CO , resulting in a change in homeostasis which
torial design involving four groups, one receiving 2
is partially neutralised by various compensating
‘full’ Buteyko (Buteyko practitioner plus Buteyko mechanisms. The hyperventilation theory is based
video), two receiving ‘partial’ Buteyko (Buteyko upon respiratory physiology, acid—base balance
practitioner plus placebo video, or Buteyko video and biochemistry.29 Inappropriate hyperventilation
plus placebo educator) and one receiving no leads to reduced levels of CO and hence a raised
2
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