Article Review: Effect of two breathing exercises (Buteyko and pranayama) in asthma: a randomised controlled trial.

Published: Thorax 2003;58:674-679.
By: S Cooper, J Oborne, S Newton, V Harrison, J Thompson Coon, S Lewis, A Tattersfield.
I recommended to first read the original article (freely available online).

This article reports on a blinded randomized controlled trial comparing how (1) Buteyko Breathing, (2) a breathing device called Pink City Lung Exerciser (PCLE) and (3) a disabled and ineffective placebo PCLE breathing device benefit asthma patients. The trial took place over 6 months with 89 asthma patients of which 69 completed the trial. The trial found positive results for Buteyko Breathing in terms of asthma symptoms and reduced medication use and no significant results at all for both the real and placebo PCLE breathing devices.

Trial results in brief:

  • 1) Buteyko lowers asthma symptoms. The average asthma symptom score went down by 3 (on a scale of 0 to 5).
  • 2) Buteyko reduces beta2-agonist medication use. Beta2-agonist medication usage went down by 2 puffs per day on average.
  • 3) Buteyko improved 1 dimension (out of 8) in the SF-36 quality of life questionnaire (role limitation due to physical problems).
  • 4) Buteyko showed a trend towards lower steroid medication use: 8 out of 20 people doing Buteyko were able to reduce their steroid medication usage by more than 75%. The average reduction in steroid medication use (over 20 people) was 41%.
  • 5) No change in breathing capacity tests (FEV1 / FVC) and bronchial responsiveness (PD20) was observed.

General remarks

As an experienced Buteyko instructor reading this article, I have several remarkson this trial:

1: A weak version of Buteyko

Reading through the paragraph describing the way Buteyko was taught, I first notice that mention is made of an adaptation of the Russian technique which was first introduced in Australia but is now used worldwide. This refers to the split in Buteyko teaching methods that occured in Australia soon after the introduction of Buteyko Breathing there. The Buteyko version that was used in this trial is a rather weak & simplified version of Buteyko, which is less effective than the original and more advanced Buteyko techniques. In effect, the trial tests a low-potency beginners' version of Buteyko Breathing.

2: Only 2 Buteyko sessions per day?

I was surprised to learn that in this Buteyko course students are asked to practice Buteyko just 2 times per day while normally 3 to 5 sessions per day are recommended. This is a too low dosage to start off with and weakens the effectiveness of Buteyko.

3: Buteyko discourages the use of beta2-agonist medication?

The article mentions that during the Buteyko course, all participants were strongly discouraged to use beta2-agonist medication. I disagree with this. Buteyko instructors should not discourage the use of medications - this should be left up to each persons' medical doctors to decide. Once good progress is made with Buteyko, the needed medication dosage will lessen by itself due to lessening of symptoms. Buteyko instructors should not be pro-active with this by encouraging to reduce medication before symptoms go down.

4: About the Pink City Lung Exerciser (PCLE)

By the way the Pink City Lung Exerciser is described, it seems to me to be a device similar to the more well-known Frolov device. The Frolov device is Russian in origin and is based on Professor Buteyko's theories on CO2 but sadly isn't a very effective device in terms of benefits and Professor Buteyko didn't recommend its use. The authors mention that they intended this device to mimic Pranayama yogic breathing techniques but that is unfair to Pranayama since Pranayama uses no such breathing devices. Using the name pranayama in the title of the article is misleading: Pranayama is a 3000 year old tradition and these Russian Frolov devices have been around for only about 30 to 40 years.

5: Why is minute breathing volume not measured?

In this trial the minute breathing volume of asthma patients wasn't measured. This is strange, especially since a previous study on Buteyko (1998) quoted in this article showed that Buteyko significantly lowers minute breathing volume. Since minute breathing volume is so fundamental to Buteyko Breathing theory, why wasn't it measured in this trial?

6: Why is the Control Pause not measured?

The Control Pause is an extremely important breathing test in Buteyko Breathing, that we use as an indication of health and progress with Buteyko Breathing. Since the article contains no info whatsoever on the Control Pause nor the minute breathing volume of the asthma patients, we are limited in the conclusions we can take from this article regarding the effectiveness of the Buteyko that was taught.

7: Authors fail to declare multiple conflicts of interest

When looking up the authors, it immediately becomes clear they have multiple conflicts of interest:
1) The authors are doctors working in the division of Respiratory Medicine of the City Hospital in Nottingham, UK. Working at the hospital, they would generate income for the hospital and themselves by prescribing asthma medications to asthma patients. Buteyko Breathing is a natural, medication-free alternative to asthma medication and reduces the need for asthma medications by asthma patients. The authors of the article thus have a personal financial interest in the field they are researching and a financial incentive to skew the study or interpret its results in a way detrimental to Buteyko Breathing. This conflict of interest is not declared in the article.
2) The authors published many studies on asthma medications and conventional asthma treatments. They are professional researchers who make a living in the field of asthma medication research. Surely some of their previous and later studies were sponsored or financed by large pharmaceutical companies with a vested interest in promoting the increased use of asthma medications. Publishing a positive article on Buteyko can negatively impact the sales of asthma medications and would thus be detrimental to the interests of the pharmaceutical companies with which the authors have an ongoing financial relationship and dependency.
In short, these authors have strong multiple financial conflicts of interest. The fact that these conflicts of interest are not declared makes it even more serious and I conclude these authors are not neutral agents in the field they are researching but are likely to be biased against Buteyko.

8: Biased Conclusion: Buteyko doesn't affect lung function

One of the conclusions of this article is that Buteyko Breathing doesn't affect lung function. But they are able to come to this conclusion only because they did not measure minute breathing volume. A previous study (1998) had already shown that Buteyko lowers minute breathing volume. Minute volume (MV) is the essense of lung function as it indicates hows how hard the lungs are working: How many liters of air the lungs are breathing per minute. Now for some reason the authors of this article believe that minute breathing volume does not indicate lung function... Which is quite a rediculous belief and is an indication the authors of this article are biased: According to them only their own preferred breathing measurements (FEV1, FVC, PD20) represent lung function and the minute breathing volume does not. It doesn't make sense. This biased opinion was mentioned not once but several times in the article.

9: Long discussion section in the article

The article includes a detailed discussion section where they point out several drawbacks of their article setup, which is good. The authors do note that the Pink City Lung Exerciser isn't the same as Pranayama as it leaves out the mental aspect of Pranayama and they point out several reasons by which Buteyko may have been at a disadvantage in their own trial but do not mention that they themselves have multiple conflicts of interest.

10: Buteyko has long teaching sessions?

In the discussion part of the article it is mentioned that the Buteyko training sessions are very long. I just want to point out here that the Advanced Buteyko Institute uses the Advanced Buteyko app as an integral part of the Buteyko course. I personally have been using apps in my Buteyko teaching for 5 years now and have been able to make the training sessions much shorter than before while students are very appreciative of the facilitating role the app plays in their Buteyko training process, especially during the individual (1-on-1) Buteyko courses using long-distance teaching via Skype. I am sure our students would not say that the training sessions are long - and I would personally say they are quite short and to the point, focused on practical matters. In group courses, the teaching sessions will always be longer than during individual coaching. Of course, the app did not exist in 2003 but big improvements have been made since then when doing the Buteyko courses available via the Advanced Buteyko Institute.

11: The Buteyko instructors were limited in their ability to provide support.

The authors decided they wanted to limit the contact that Buteyko instructors have with the asthma patients, because in a previous study it was noted that the asthma patients received extra support sessions while the patients in the control group (not doing Buteyko) did not receive those. Rather than limit the Buteyko instructors in their job of teaching Buteyko, the authors should have provided extra support sessions for the control and Pranayama groups.

12: Strange biased last paragraph of the article.

After concluding that Buteyko reduces asthma symptoms and lessens the need for asthma medications, the authors in the last paragraph of the article state that Buteyko produces 'some benefit' and 'may be worth trying'. Really? What other results are they looking for? It seems the authors don't really believe the results of their own trial which shows that Buteyko works and does what it promises. Unbiased authors (without conflicts of interest) would have been perfectly justified to say that Buteyko reduces asthma symptoms and should be recommended to all asthma patients as a natural and medication-free effective treatment option which can be supplemented with asthma medications as required. I attribute this very biased statement in the last paragraph to the authors' financial conflicts of interest and overall bias against Buteyko.

13: No mention of percentage reduction of asthma symptoms.

The article mentions that Buteyko led to a reduction of asthma symptoms by '3' but it doesn't give the precise percentage. The median score of asthma symptoms at the start of the trial is shown in table 1 as a '4' so with a reduction of 3 that would be an approximate decrease in asthma symptoms of 75% (best estimate). This 75% decrease in asthma symptoms is never mentioned in the article. 75% seems impressive to me, so why is this percentage not just plainly mentioned in the article? Is this another example of the authors' bias and financial conflict of interest? The article also fails to mention how many people experienced a complete reversal of all their asthma symptoms which must surely have happened to at least a few people in the trial, if the average reduction is 75%.

14: No reporting of the percentage decrease in beta2-agonist medication usage.

The authors use 2 different numbers to report on beta2-agonist medication use. For beta2-agonist medication use at the start of the trial they report the average dosage in micrograms per day. For the subsequent decrease in medication usage after 6 months for Buteyko they use the number of puffs per day. This makes it impossible for readers of the article to calculate the percentage decrease in beta2-agonist usage. This is quite absurd... They report that there is a decrease but won't tell us how much the actual percentage decrease is? Again this just doesn't make sense as the percentage decrease is the easiest way to convey the effectiveness of Buteyko. It's possible that this is again a sign of the authors' bias and conflicts of interest.

Final Score: Article Rating

I give this article an overall rating of 5 out of 10.

Main positive points:

  • (1) This article uses the gold standard of trials (blinded randomised controlled trial).
  • (2) The asthma patients were taught Buteyko by an actual Buteyko instructor.
  • (3) Large discussion section in the article where they point out some ways in which their own study may have disadvantaged Buteyko and/or Pranayama.

Main negative points:

  • (1) The authors did not declare their multiple financial conflicts of interest against Buteyko.
  • (2) The authors give biased interpretations of the results of the trial. For example regarding minute breathing volume (not being part of lung function??) and the final sentence which offers a biased practical recommendation for patients.
  • (3) The authors wrongly considered the Pink City Lung Exerciser device a substitute for Pranayama yogic breathing exercises taught by a yoga instructor.
  • (4) The authors didn't measure the minute breathing volume nor Control Pause of the asthma patients. This is extremely relevant information in any study on Buteyko.
  • (5) The version of Buteyko tested can be considered beginners' level and quite low-potency.
  • (5) The Buteyko instructor was prevented from applying their normal teaching routine. The limited support sessions likely had a negative affect on the effectiveness of Buteyko.
  • (6) It seems as if an effort was made to hide the exact percentage reduction of asthma symptoms and medication use. The 75% reduction of asthma symptoms is not mentioned but can still be calculated by discerning readers. For beta2-agonist medication it cannot be calculated by readers at all.

Review by drs. Eduard Reuvers, 2017