ORIGINAL ARTICLE |
https://doi.org/10.5005/jp-journals-11010-1149 |
Redefining Respiratory Care with Digital Interventions in Children with Bronchial Asthma: Exploring the Efficacy of Game-based Breathing Training and the Buteyko Method
1–4Department of Physiotherapy, Dr MGR Educational and Research Institute, Chennai, Tamil Nadu, India
Corresponding Author: Carlin Jersha Rachel, Department of Physiotherapy, Dr MGR Educational and Research Institute, Chennai, Tamil Nadu, India, Phone: +91 9176345400, e-mail: carlinjersharachel.physio@drmgrdu.ac.in
Received: 26 July 2024; Accepted: 05 January 2025; Published on: 17 February 2025
ABSTRACT
Aim and background: This study aimed to evaluate smartphone game application with the Buteyko breathing technique to improve pulmonary function in asthma patients. Airway constriction and inflammation are the hallmarks of asthma. It is the most prevalent chronic illness in both adults and children. Although there are many recent studies showing the effectiveness of various methods, the Buteyko method and game therapy applications may reduce medication needs and symptoms.
Methods: This was a quasi-experimental study of pre- and posttrial type carried out with 30 children diagnosed with asthma. Based on the inclusion and exclusion criteria, they were chosen using a simple random sampling method and split into two groups. Subjects of group A received the Buteyko breathing technique, and subjects of group B received the Buteyko breathing technique along with an interventional digital breathing technique, for 15 minutes, 5 sessions per week for 4 weeks. The pre- and posttest were analyzed using the Asthma Control Test and the Becker Asthma Score.
Results: On comparison, a significant difference in means at p ≤ 0.05 was observed in group B when comparing the Academic Competence Test (ACT) and Behavioral Assessment Scale (BAS) scores of groups A and B between pre- and posttests.
Conclusion: The Buteyko breathing technique along with the Digital Interventional Breathing Technique is more effective in improving pulmonary function in asthma patients compared to the Buteyko breathing technique. The findings of this study pave the way for depicting the role of games in the treatment protocol, by improving the interaction of the patient and thereby improving pulmonary function.
Clinical significance: The evaluation of digital solutions for asthma, including artificial intelligence (AI)-assisted breathing techniques and the Buteyko method, holds significant clinical relevance. These innovative approaches offer potential advancements in personalized asthma management by improving breathing efficiency and reducing reliance on medication. Digital interventional breathing techniques can provide real-time feedback and tailored exercises, while the Buteyko method emphasizes controlled breathing to reduce symptoms. Together, these technologies promise to enhance patient outcomes, increase adherence to treatment protocols, and ultimately improve the quality of life for individuals with asthma.
Keywords: Asthma, Breathing games, Buteyko breathing, Digital interventional breathing technique, Pulmonary function
How to cite this article: Rachel CJ, Raman K, Blessy T, et al. Redefining Respiratory Care with Digital Interventions in Children with Bronchial Asthma: Exploring the Efficacy of Game-based Breathing Training and the Buteyko Method. Indian J Respir Care 2024;13(4):243–247.
Source of support: Nil
Conflict of interest: None
INTRODUCTION
Asthma is a severe condition that occurs in all age-groups. It is the most prevalent noncommunicable disease, characterized by inflammation and narrowing of the lungs’ small airways. The signs and symptoms of asthma include tightness in the chest, coughing, and shortness of breath. One of the most widely prevalent chronic illnesses worldwide is asthma. Based on research, there are about 300 million people in the world. The Global Initiative for Asthma (GINA) program was started in 1993 with the goal of raising public awareness among government officials and healthcare professionals to lower the morbidity, mortality, and prevalence of asthma.1 According to global asthma epidemiology, there were 43.12 million cases of asthma in 2017, while there were 272.68 million cases (3.57%) and 0.49 million deaths, respectively, due to prevalence and mortality.2
There are five distinct wheezing patterns known as phenotypes: never/infrequent wheeze (52.1%), early onset preschool remitting (23.9%), early onset midchildhood remitting (9%), chronic (7.9%), and late-onset wheeze (7.1%).3 According to the global ranking of asthma, disability-adjusted life year (DALY) in children with asthma were among the top 20 causes of DALY at all ages, with the most common cause of DALY in the 10–19 age range.4 In general, there are two types of asthma in children: nonallergic asthma, which is brought on by indoor chemicals and outdoor air pollution, and allergic asthma, which is brought on by dust mites, mold, pets, and pollen.5
Breathing exercises help school-aged children control their asthma symptoms. The goal of these exercises in asthmatic patients is to regulate breathing patterns by increasing activity in the abdominal and chest muscles, thereby promoting airflow, lowering hyperinflation, and improving lung function.6
The primary component of the Buteyko program is to minimize hyperventilation through times of controlled reduction of breathing, known as ”slow breathing” and ”reduced breathing,” coupled with periods of breath holding, known as ”control pauses” and ”extended pauses.”7
Most often used breathing exercises, like the Buteyko breathing technique.8 School-age children’s asthma severity may be better controlled by using the Buteyko breathing technique.9 It has been discovered that the remedy to the asthmatic condition’s problem is through breathing exercises.
Breathing exercises are a method of treatment that has been used globally to treat asthma in patients. By adjusting the breathing rhythm, the Buteyko breathing technique seeks to manage the symptoms of asthma.10 The Buteyko breathing technique is a special approach that treats a variety of pulmonary problems by using breath control and breath-hold exercises.11
The research backs up the Buteyko breathing technique, which lowers the need for asthma medications and enhances asthma control and quality of life.12 The Buteyko breathing is the combination therapy or alternative that suggests raising the efficacy of the treatment for asthma. It also reduces the impact on the airway by reducing the need for coughing.13 Additionally, the physiological alterations, lung ventilation, and acid-alkali balance markers are all enhanced by the Buteyko breathing technique.7
The Digital Interventional Breathing Technique compared to the Buteyko Breathing Technique to improve pulmonary function. With the use of a headset and a game application with 14 distinct games, artificial intelligence was able to steer participants toward optimal inspiration and expiration. The participant is positioned comfortably to view the smartphone that has been placed on the table.14 The primary benefit of the gaming system was the elimination of the need for intricate and costly display devices. The results lend credence to breathing exercises based on games as a possible therapeutic tool for rehabilitation.15
Therefore, in this study, the main objectives of the breathing games are to increase performance levels and participant motivation. They also aim to grab the user’s attention and provide training via a portable device. However, there is a lack of research regarding digital solutions to asthma. Thus, we aim to compare the effectiveness of the intervention and the protocols used, and thereby provide an interactive environment that is relevant to real-life situations. The game-based breathing system enhances proprioceptive training and biofeedback techniques. Verbal encouragement and visual feedback are used to increase performance.
METHODS
This study was a quasi-experimental study design of pretest and posttest type. It was conducted in the pediatric outpatient department of ACS Medical College and Hospital, Chennai, with a sample size of 30 subjects (boys and girls) aged 7–15 years with wheeze, cough, chest tightness, shortness of breath, and asthmatic condition. The subjects were selected based on inclusion and exclusion criteria and grouped into two groups using simple random sampling (lottery method). The study duration was 6 months, and the intervention duration was 4 weeks, with 5 sessions per week. Subjects below 7 years of age, and those with juvenile diabetes, difficulty catching breath, cyanosis of skin, mouth and finger, hypertension, and noncooperative individuals were excluded from the study. Materials like smartphone, microphone/headphone were used. The outcome measure of this study was to reduce the symptoms of wheeze, cough, and shortness of breath, improve the respiratory and pulmonary functions of the lungs, and reduce breathing difficulty. Ethical clearance was obtained from the Institutional Ethics Committee prior to the study (302/IRB/PHYSIO/2022-2023). The treatment was explained to the patient, and the consent form was signed by the parents. The pretest was measured using the Asthma Control Test and the Becker Asthma Score.
Intervention
The Group A (Buteyko Breathing Technique)
This group consists of 15 subjects diagnosed with asthma and provided with the Buteyko breathing technique. The patient was made to sit on the chair or the floor and maintain an upright posture, with relaxed breathing occurring normally for 30 seconds. The inhalation and exhalation were carried out only through the nose.
The Buteyko breathing consists of control pause exercise and maximum pause exercise. After the relaxed exhalation, the control pause exercise takes place, where the patient is instructed to retain the breath by using the index finger and the thumb for about 5 seconds, which includes an involuntary diaphragmatic movement. After holding the breath for about 5 seconds, the patient is asked to inhale and exhale normally for at least 10 seconds. The total time for the control pause exercise was about 2 minutes, and it was repeated 10 times.
The maximum pause exercise was where the patient was instructed to hold the breath using the index finger and thumb.
The goal was to get the patient to hold the breath as long as possible, which is often twice as long as the Control Pause exercise. Inhalation occurs after the threshold of moderate pain is achieved.
The breathing takes place normally for at least 10 seconds and is repeated about 10 times. The Buteyko breathing technique is provided for 15 minutes and 5 sessions per week. The entire Buteyko breathing technique takes place through the nose. The Buteyko breathing technique includes the regulation of the breathing movements, improves the oxygenation level in the blood, and facilitates pulmonary function. In the Buteyko breathing technique, either the maximum pause or the control pause can be performed according to the severity of the condition.
The Group B (Buteyko Breathing Technique along with Digital Interventional Breathing Technique)
This group consists of 15 subjects. The Buteyko breathing technique was performed for about 15 minutes and carried out along with the interventional digital breathing technique.
The digital breathing technique basically involves the breathing games displayed through the smartphone. The breathing games were played by the patients with the use of headphones/microphone, which were connected to the smartphone.
The patient was placed in a relaxed sitting position, with the phone placed on the table or held by the patient themselves. There are approximately 14 games in the breathing games collection, all of which are chosen and created to provide the user with the best possible guidance for maximal inspiration and expiration via the headset.
The breathing game played by the patient is Ski Jumper 2, where the game character flies into the sky as the patient blows through the microphone present in the headset. The patient inhales and exhales according to the game, and the reading is detected through the microphone and displayed through the smartphone. The game was played for about 15 minutes with regular intervals of resting time after the end of the game. The technique was performed for about 4 sessions per week.
The posttest was measured using the Asthma Control Test and the Becker Asthma Score, and those values were used for the statistical analysis. The schematic diagram of the study is represented in Figure 1.
Fig. 1: Schematic diagram of the study
RESULTS
The Shapiro–Wilk test was used to determine the normality of the data. In this study, the Shapiro–Wilk test indicated that the data are normally distributed for the dependent values (p > 0.05). Therefore, a parametric test was introduced. Paired t-tests were used to find the statistical difference within groups, and an independent t-test (Student t-test) was used to find the statistical difference between groups.
Group A and group B: When comparing average Academic Competence Test (ACT) scores, it is clear that both groups’ posttest averages increased significantly. However, group B (Buteyko breathing with digital breathing technique) shows a higher mean of 21.46 ± 0.915, which is more effective than group A (Buteyko breathing technique) with a value of 19.80 ± 0.774 when p ≤ 0.05 (Table 1). Thus, the null hypothesis is rejected. Comparing the means of group A and group B with Behavioral Assessment Scale (BAS) scores, both groups’ posttest averages increased significantly. However, group B (Buteyko breathing with digital breathing technique) shows 2.46 ± 1.06, which is a lower mean, and is more effective than group A (Buteyko breathing technique) when p ≤ 0.05 (Table 2). Thus, the null hypothesis is rejected. Comparing the ACT and BAS scores of groups A and B, there is a significant difference in the means (p < 0.05).
| Groups | Pretest | Posttest | t-test | Significance | ||
|---|---|---|---|---|---|---|
| Mean | SD | Mean | SD | |||
| Group A | 17.93 | 0.883 | 19.80 | 0.774 | –8.67 | 0.000** |
| Group B | 17.46 | 1.06 | 21.46 | 0.915 | –10.58 | 0.000** |
**p ≤ 0.05—significant; The above table shows the mean, standard deviation (SD), t-value, and p-value between the pretest and posttest in groups A and B. Between groups A and B, there is a statistically significant difference between the pretest and posttest values at p ≤ 0.05
| Groups | Pretest | Posttest | t-test | Significance | ||
|---|---|---|---|---|---|---|
| Mean | SD | Mean | SD | |||
| Group A | 6.00 | 0.845 | 3.80 | 1.01 | 12.60 | 0.000** |
| Group B | 6.06 | 0.798 | 2.46 | 1.06 | 10.73 | 0.000** |
**p ≤ 0.05—significant; The above table shows the mean, standard deviation (SD), t-value, and p-value between the pretest and posttest in groups A and B. Between groups A and B, there is a statistically significant difference between the pretest and posttest values at p ≤ 0.05
At p < 0.05, the results indicated a significant difference in the mean values between the pretest and posttest scores for ACT and BAS scores among groups A and B. As an outcome, patients treated with the Buteyko and digital breathing technique showed substantial improvements in the mean values at p < 0.05 when comparing the pre- and posttest mean values for the Asthma Control Test and the Becker Asthma Score.
DISCUSSION
The purpose of the study was to evaluate and compare the potential of the Buteyko breathing method and the digital breathing technique in asthma patients. The study aimed at evaluating the efficiency of the Buteyko breathing technique and the Buteyko breathing technique along with the digital breathing technique to improve pulmonary function in asthma patients. Both interventions used in this study showed significant improvement in terms of the Asthma Control Test and the Becker Asthma Score analysis.
Additionally, the study conducted by Hassan et al. suggested that the Buteyko breathing technique provides the major difference in asthmatic patients. The asthmatic symptoms can be reduced using the Buteyko breathing technique, and it is also considered to be a complementary therapy.15 Therefore, it was clear that the breathing exercise showed a significant difference in the pre- and posttest values, and the exercise protocols in this study resulted in similar potential effects as those in the literature.
According to Jimcy, Drisya concluded that the experimental and comparison groups’ scores for asthma control differ significantly after the intervention, proving that the advantages of Buteyko breathing are justified.16 According to Bowler et al., practicing Buteyko breathing technique decreased the need for β2-agonists and hyperventilation. These patients showed a trend toward improved quality of life and less use of inhaled steroids, but there were no discernible improvements in the airway caliber measurements.17
By using this approach, a small amount of positive end-expiratory pressure is produced by creating back pressure. For long-term everyday activities, monitoring and rehabilitation of lung function can be very important.
According to Joo et al., portable contemporary technologies are crucial for pulmonary function rehabilitation. Breathing games are smart gaming applications that make daily pulmonary function monitoring easy to set up, simple to use, and affordable. The breathing games might present a compelling opportunity to encourage training sessions for physical exercise at home.18 The findings of this present study strongly agree with the earlier report where the Buteyko breathing technique combined with digital breathing techniques showed beneficial results. The breathing games, based on the mechanism of pursed lip breathing, allow control of oxygenation and ventilation.19 The two major advantages of the digital breathing technique are that it upgrades the treatment and ameliorates the entertainment level of the subject.
According to Leskovsek et al., utilizing an acoustic microphone and a web browser to execute breathing exercises is a feasible method that warrants further investigation. We also suggest that some people may find audio feedback to be more enjoyable.20
Also, this study may introduce the breathing game as an interesting intervention that made the individual more engaged with the game, thereby improving the treatment process for asthmatic patients. It especially grabbed the attention of children, who found it entertaining, concentrative, and fun-filled. The gaming session was accompanied by physiological changes in the body and enhanced pulmonary function with the digital breathing technique. Compared to traditional breathing exercises, there are many benefits to using video games in conjunction with digital breathing techniques.
The Buteyko breathing technique along with the digital breathing technique is more effective than the Buteyko breathing technique alone. Hence, our data support the alternative hypothesis that there is a significant difference between the digital breathing technique and the Buteyko breathing technique in improving pulmonary function in asthma patients. In the future, we expect that further research will find more digital solutions for pulmonary function among the asthma-affected population.
Limitations of the Study
The study had limitations, including a small sample size and short duration. Reliance on self-reported measures like ACT and BAS, unaccounted variations in medication use, and potential confounding factors further limited the generalizability and accuracy of the findings.
CONCLUSION
Based on the results obtained, the study concludes that the Buteyko breathing technique along with the digital breathing technique (group B) is more effective than the Buteyko breathing technique (group A) in improving pulmonary function in asthma patients and showed improvement in the reduction of wheeze, chest tightness, shortness of breath, and cough comparatively.
In spite of the limitations of the current study, the findings paved the way for depicting the role of games in the treatment protocol by improving patient interaction and thereby improving pulmonary function.
ORCID
Carlin Jersha Rachel https://orcid.org/0009-0000-5590-9148
Kaushik Raman https://orcid.org/0009-0007-9838-4012
Ramalakshmi K https://orcid.org/0009-0009-2204-5844
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