Playing With BreathP.M. Bingham,* T. Ashikaga, T. Lahiri

University of Vermont

*Disclosure: co-inventor, UVM’s Breath Biofeedback System and Method (US Patent # 7,618,378)

Competitive Apnea

Spirometer Game Applications

• Training Breathing Muscles (exercise)

• Reinforce breath technique(s)

• Breath Awareness (“symptom detection” proprioception training)

Somatization

www.tonysteelemorgan.co.uk/gallery.php?sort=f...

Respiratory Interoception –can it be learned?

Game Technology

Digital spirometer, Software plots air flow on vertical axis

Points added every second the player keeps the ball on target

… … learning an eye-breath control game …learning an eye-breath control game …

Training “eye-breath” coordination in CF patients:

Distance to target:

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Bingham et al Clin Peds 2010 49:337

What I’m Playing...What I’m Playing...

www.myspace.com/lokummusic

Neural Processing- Primary Breathing Sensors

• Mechanoreceptors

• Nociceptors

• chemoreceptors

Neural Processing of Breath–High Roads and Low Roads

•  Cognitive—spatial, temporal and intensity components (medullary nuclei, pons, thalamus, somatosensory, motor cortex)

• Emotional—dyspnea (amygdala, anterior cingulate, insular cortex)

Convergent:

• Thalamus, insular cortex, anterior cingulate cortex, amygdala

Anterior Insula mediates ‘sense of self’Craig, Nat Neurosci Rev 10 2009

Fink JB, RESPIRATORY CARE • 2007 VOL 52

http://www.nhlbi.nih.gov/health/dci/Diseases/cf/cf_signs.html

Why Forced Expirations?

Fink JB, RESPIRATORY CARE • 2007 VOL 52

Hypothesis: game playing increases forced expirations & alters PFTs

Design: within-subjects randomized crossover trial [A (game) -B (control) or B – A]

• 13 subjects, 7-12 yo• repeated measures analysis (days used)Outcomes: average FEs per day usedChange in pulmonary function measures (FEV1, VC)

Reinforcing Breath Technique – CF

Study Procedures

• subjects received spirometer, computer (games vs control setup)

• both games and control software incite the player to perform forced exhalation maneuvers

• weekly phone contact; “no nagging” policy

Software Usage, FEs, and %PFT Changes

Game Control P(t test)

Days Available 38.6 + 20.2 26.4 + 11.3 0.02

Days Used 10.0 + 11.2 8.5 + 7.2 0.59

Total Minutes Used/Days Used 4.8 ± 4.4 1.6 ± 1.8 0.02

Total HFEs/Days Used 10.2 ± 5.2 11.6 ± 8.2 0.65

% FEV1 Change 4.1 + 16.1 -0.8 + 17.3 0.16

% FEV1 Change/Days Used 0.3 ± 2.4 -2.5 ± 5.2 0.01

% VC Change 4.3+ 10.6 -2.1 + 12.6 0.05

% VC Change/Days Used 0.4 ± 1.7 -2.6 ± 5.3 0.03

Summary

• FE count did not differ (10-12/day) but apparently exceeded baseline

• Players were more engaged with the game than the control software (minutes/day used ~5 vs. ~2)

• Game days increased Vital Capacity (p=.03) and FEV1 (0.01)

Conclusions

• Visual breath biofeedback can engage CF patients with FEs in a research setting

…but for how long?

• Game based visual feedback may improve PFTs

… improved test technique?

… formal clinical trial planned

Acknowledgements

• Families and Subjects with Cystic Fibrosis

• Jason Bates

• Sarah Waterman, Amanda Woods, Gwen Fitz-Gerald, Jackie Swartz

• Vermont Children’s Hospital – Nurses/Staff

• R.W. Johnson Foundation

• NIH SBIR 103370