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Arch Bronconeumol. 2010; 46(11) :600-606

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Review Article

Effectiveness of Therapeutic Education and Respiratory Rehabilitation Programsfor the Patient with Asthma

Roberto Cano-De La Cuerda, * Ana Isabel Useros-Olmo, and Elena Muoz-Hellna Departamento de Fisioterapia, Terapia Ocupacional, Rehabilitacin y Medicina Fsica, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Alcorcn, Madrid, Spain

A R T I C L E I N F O

Article history:Received May 7, 2010Accepted July 13, 2010

Keywords:AsthmaTherapeutic educationPhysiotherapyRespiratory rehabilitationTreatment

Palabras clave:Asma bronquialEducacin teraputicaFisioterapiaRehabilitacin respiratoriaTratamiento

A B S T R A C T

Asthma is a chronic complex and heterogeneous disease, with great variability and has a huge impact, notonly on patients who suffer the disease but also their families and society in general. Educating asthmaticpatients and their families is essential for therapeutic intervention. Through continuous, dynamic andadaptive education, changes in attitudes and behaviours of the patient and family can be achieved, and willundoubtedly lead to an improvement in their quality of life. Among other non-pharmacologicalinterventions, respiratory rehabilitation is an alternative treatment, and is primarily aimed at patients withmoderate to severe asthma. Although the latest clinical practice guidelines published in scientific literaturerecommend two strategies for treatment, the results of relevant publications are diverse. The objective ofthis study was to describe the effectiveness of therapeutic and educational programs in respiratoryrehabilitation of the asthmatic patient.

2010 SEPAR. Published by Elsevier Espaa, S.L. All rights reserved.

Eficacia de los programas de educacin teraputica y de rehabilitacin respiratoriaen el paciente con asmaR E S U M E N

El asma es una enfermedad crnica compleja, heterognea, con una gran variabilidad y que tiene un enormeimpacto, no slo en los pacientes que la padecen sino tambin en sus familias y en la sociedad en general.La educacin del paciente asmtico y su familia son el elemento esencial para la intervencin teraputica. Atravs de la educacin, entendida como un proceso continuo, dinmico y adaptado, se van a poder conseguircambios en las actitudes y conductas del paciente y su familia, que habrn de llevar, sin duda, a mejorar lacalidad de vida de los mismos. Entre otras intervenciones no farmacolgicas, la rehabilitacin respiratoriarepresenta una alternativa de tratamiento, y est dirigida fundamentalmente a los pacientes que padecenasma moderada y severa. Puesto que las ltimas guas de prctica clnica publicadas en la literaturacientfica recomiendan ambas estrategias de tratamiento, pero los resultados de las publicaciones alrespecto son diversos, el objetivo del presente trabajo fue describir la eficacia de los programas de educacinteraputica y el papel de la rehabilitacin respiratoria en el tratamiento del paciente asmtico..

2010 SEPAR. Publicado por Elsevier Espaa, S.L. Todos los derechos reservados.

* Corresponding author.E-mail address: [email protected] (R. Cano-De La Cuerda).

Introduction

Asthma is defined by the Global Initiative for Asthma 1 as a chronicinflammatory disorder of the airways in which many cells andcellular elements play a role. The chronic inflammation causes an

associated increase in airway hyperresponsiveness that leads torecurrent episodes of wheezing, breathlessness, chest tightness, andcoughing, particularly at night or in the early morning. These episodesare usually associated with widespread but variable airflowobstruction that is often reversible either spontaneously or withtreatment.

It is a chronic disease which can occur at any stage of life. Asignificant proportion of people who suffer from asthma show theirfirst symptoms at an early age. There is an intermediate prevalence

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of asthma in Spain, affecting 3%-4% of the adult population and 8% ofinfants. The occurrence of asthma has increased over the last 20 to30 years and is not as marked in developing countries as in developedcountries. One reason for this increase could be due to a possibledisorder in the development of the immunological system in childrenin industrialised countries (hygiene theory). This is considered to bea consequence of insufficient exposure to infectious agents due to

the advanced levels of health care in developed countries.2-5

Today, education is seen as a very important therapeutic practicefor asthmatics. It is a difficult task and requires proper training fordoctors and other health professionals before their skills can betransferred to the patient. The main difficulty stems from the factthat training these chronic patients is extremely different at all levelsas the sufferer group is heterogeneous in age, socio-culturalbackground and needs, and because the motivation to learn willdepend in large part on the sufferers degree of acceptance of theillness and its management. 6 The educational process allows sufferersto take control of and make decisions about their illness and to adaptsome aspects of the treatment as it develops, in accordance with anaction plan developed and agreed upon in writing under doctorsupervision.

Respiratory rehabilitation interventions are designed for theintercrisis phase. In other words, they focus on the consequences ofover-response and bronchial obstruction when alterations areproduced in the airway walls. When the smooth bronchial musclecontracts; the walls become inflamed and oedema forms and thereis exaggerated mucous secretion and an increase in the viscoelasticity,adhesiveness and dehydration of the secretions, so making airflowdifficult. The aim of this study is to describe the effectiveness oftherapeutic educational programmes and the role of respiratoryrehabilitation in treating asthmatic patients.

Effectiveness of Therapeutic Educational Programmesin Asthmatic Patients

Asthma is a chronic, complex, and heterogeneous disease with

great variability and has a huge impact, not only on patients whosuffer from the disease but also on their families and society ingeneral.

Given that there is currently no cure for asthma, despite advancesin pharmacological treatment, the main aim is to control the illness.Although measures for achieving a high level of control and forimproving the quality of life for asthma sufferers exist, the reality isoften different. 7-9 This phenomenon can probably be explained onthe one hand, by the varied nature and complexity of the illness and,on the other, by non-adherence to treatment.

All recommendations, guides and protocols emphasize the role ofeducation as a key component in the management and control ofthis disease. 10-17 The two most recent publications (Global Iniciativefor Asthma and the British Guideline on the Management of Asthma)insist that establishing a partnership between the patient, thepatients family and the doctor should be a priority. 18,19

According to the World Health Organisation (WHO), therapeuticeducation is a continuous process that is integrated in terms of careand is focused on patients. It includes organised activities ofsensitisation, information, learning and psychosocial follow-uprelated to the disease and the treatment prescribed. It aims to helppatients and their close family members to understand the diseaseand the treatment, cooperate with educating professionals, live thehealthiest lifestyle possible and to maintain or improve their qualityof life. Education should make patients able to acquire and maintainthe necessary resources for the optimal management of living withthe disease (table 1). Therapeutic education is aimed at patients withchronic illnesses as opposed to health education for the healthy publicand it helps the patients acquire or maintain the necessary skills for

managing their lives better when living with a chronic illness.20

Evidence of more attention being given to educating asthmaticpatients is shown by the increasing number of articles that arepublished annually. In 1974, only one article was registered ( Medline) ,in 1990 there were 44 articles, and in 2009 more than 2000 articleswere published. 6

A review of the medical literature published over recent yearsallows us to confirm that educational programmes that comply withcertain criteria (general information on asthma, the correct usage ofpeak expiratory flow [PEF], self-management plans, etc. are usefulfor decreasing morbidity and mortality and the need for assistance,both in adults and children (Evidence Level I) (table 2). 21-23

Therefore, educating the asthmatic patient and their family is anessential component of therapeutic intervention. Through continuous,dynamic and adaptive education, changes in the attitude andbehaviour of both patient and familyf can be achieved, leading to animprovement in their quality of life.

We have tried here to answer the following questions: Whyeducate? Who must we educate? Who should provide the education?Diverse studies show that the use of educational programmessignificantly reduces the number of unscheduled visits to the doctorand A&E departments, hospitalisations, absenteeism from schoolwhile they also help towards improving the manner in which anti-inflammatory and bronchodilator medicines are prescribed andused. These results improve with the degree of asthma severity. 24

A systematic review into the effectiveness of therapeutic education

programmes, aimed at self-care for adult asthmatic patients was

Table 1Objectives of therapeutic education

Main Objectives

Decrease morbidity and mortalityImprove quality of life:

Lead a normal life including taking part in physical/sporting activitiesAchieve a minimum level of or no absenteeism from schoolDecrease the number of crises, visits to A&E or hospital admissions

Maintain the best possible lung functionOptimum control of inflammation (for example: FENO)Minimum pharmacological therapy with minimum amount of secondary

effectsHelp the sufferer and his/her family maintain control over the illnessRecognise the signs and symptoms of lack of controlEarly recognition of deterioration and subsequent treatment decided by the

patientMaintain adherence/compliance with the maintenance therapy and with

suitable lifestyles

Specific objectivesGet to know and understand asthma:

Teach the child and their family about asthma and help them to accept itTeach about the physiopathology, symptoms and possible development of

asthma in a straightforward mannerHelp to identify the triggers and how to avoid them as much as possibleHelp to identify the early signs of an attack and the signs of severityTeach the differences between available drugs: alleviators for attacks and

controllers to manage the illness

Learn to dominate certain techniques and skills:Master inhalation techniques and the PEF managementMaster or control some daily situations such as sporting activities or stress

(breathing control and avoiding some triggers)

Adopt a positive attitude, behaviour and lifestyle:Express and learn from the experiences gained from the illnessShow patient guided self-management using a written action planEnable autonomous decision making (self-management): know when to ask for

helpManage the illness in harmony with the persons activities and projectsFor risk situations, develop preventative behaviour for exacerbations

Increase personal satisfaction and confidence in health professionals andtreatment

Decrease costs

Modified from An Pediatr (Barc). 2007;66:496-517.



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carried out by the Cochrane group21 which analysed the results of36 randomised clinical trials (RCT), concluding that these programmeswere more effective in comparison with other types of intervention.The results of this review showed a significant reduction inhospitalisations (RR 0.64, CI 95% 0.50-0.82), absenteeism from workor school (RR 0.79, CI 95% 0.67-0.9) and nocturnal asthma (RR 0.67,CI 95% 0.56-0.79). These programmes are aimed at giving patientsthe skills to adjust their medication using a written action plan thatincludes monitoring their expiratory flow and their symptoms.

Another systematic review carried out by Wolf et al 22 determinedthe effectiveness of education for self-management of asthma inchildren. They identified 45 controlled and randomised clinical trialsof educational programmes of self-management of asthma inchildren and adolescents aged between 2 and 18 years. Thirty two(32) of these were suitable and consisted of 3706 patients. Theauthors found an association between these programmes andimprovements in the measurements of expiratory flow (CI 95% 0.49to 0.08), degrees of self efficiency (CI 95% 0.49 to 0.07), reductions

in the amount of absenteeism from school (CI 95% 0.23 to 0.04),reductions in the amount of days where activity is restricted (CI 95%0.49 to 0.08), reductions in the number of visits to A&E (CI 95% CI0,33 to 0,09) and reductions in the nights that are disturbed byasthma. These effects had a greater impact on cases of moderate tosevere asthma and on the studies that used PEF, than on those thatonly used symptoms (**Evidence Level I).

According to Korta et al, 24 therapeutic education is effective andproduces a reduction in the use of resources and health costs, as wellas an improvement in the patients quality of life. To be effective,programmes should include information on self-management, theuse of a personalised, written action plan, and should includeperiodic reviews of the patient.

When considering who should provide the education, we shouldnot only think about the patient. It is important to educate those incharge of health plans such as health professionals and non-healthcare staff (teachers, trainers, family members or carers), andeven extend such education to the general population.

There are many people responsible for educating asthmaticpatients: doctors or nurses who are either specialised or interestedin asthma, physiotherapists, pharmacists, non-healthcare staff suchas teachers and parents or experienced asthma suffers themselves.This last group is particularly important for asthmatic adolescents.

It is also necessary however to point out the increasing trend inasthma morbidity and mortality, despite scientific advances and newtherapeutic methods. This demonstration of the relativeineffectiveness of medical management emphasizes the importanceof non-pharmacological interventions such as respiratoryrehabilitation programmes, the effects of changes in lifestyl and

environmental factors in asthma management and compliance with

medical prescriptions as co-assisting measures in treating asthmaticpatients. 6

Respiratory Rehabilitation Programmes for Asthmatic Patients

The American Thoracic Society (ATS) and the European RespiratorySociety (ERS) define respiratory rehabilitation as an evidence-based

intervention for patients with chronic respiratory diseases who aresymptomatic and often have decreased daily life activities. Integratedinto the individualized treatment of the patient, pulmonaryrehabilitation is designed to reduce symptoms, optimize functionalstatus, increase participation, and reduce health care costs throughstabilizing or reversing systemic manifestations of the disease. 25 Inpractice, respiratory rehabilitation refers to a group of physicaltechniques that are aimed at eliminating respiratory airway secretionsand improving pulmonary ventilation. This is indicated in a multitudeof chronic respiratory illnesses such as asthma or COPD.

There is currently a growing interesting in respiratory rehabilitationfor asthma in Spain. However, there is a low level of implementation asaccording to the Spanish cardio-respiratory rehabilitation society(Sociedad Espaola de Rehabilitacin Cardiorrespiratoria [SORECAR]),only 6% of these patients carry out respiratory rehabilitation exercises.

Scientific evidence on the effectiveness of such programmes insome respiratory illnesses such as asthma is insufficient, due to suchinherent limitations in these studies as not being able to maintainpatient and therapist blinding and the lack of action protocols.Furthermore, there is a lack of consensus on standard techniqueswhich could be used to compare new emerging techniques and alack of objectivity in the variables measured. 26

A general integrated respiratory rehabilitation programmeconsists of pharmacological treatment, health education andrespiratory rehabilitation. Respiratory rehabilitation in asthmaticpatients is fundamentally directed at those who suffer from moderateto severe asthma. The objectives of these programmes are outlinedin table 3. 27,28

In asthmatic patients, respiratory physiotherapy is designed for

the intercrisis phase and aims to decrease the consequences of over-response and bronchial obstruction. 29 Physiotherapists are specialisedhealth professionals who carry out respiratory rehabilitationtechniques under the supervision of a rehabilitation doctor and/or apneumologist, and they provide the patients with self-drainagetechniques and ventilation patterns, as well as recommendingtherapeutic exercises. The systematic reviews carried out by theCochrane group show that the respiratory techniques most used inthe treatment of asthma are: exercises to re-teach the respiratorypattern, physical training for the respiratory and peripheral muscles,exhalation techniques and instrumental aids for mucociliaryclearance, aerobic exercise and complementary techniques. Thequality levels of the scientific evidence which is used in this studyare shown in table 4.

Re-learning the Respiratory Pattern

Alterations in the respiratory behaviour of asthmatic patientstranslate into bronchoconstriction, an increase in residual pulmonaryvolume and alterations in abdomino-diaphragmatic breathing whichcause increased involvement of the intercostal muscles instead ofthe diaphragm. 30 During exhalation, the inspiratory muscles continueto be used, meaning that abdominal pressure is unable to increase atthe end of exhalation. This therefore puts the diaphragm at amechanical advantage for action, thereby producing pulmonaryhyperinflation.

The aim of re-learning the respiratory pattern is to develop amore effective model for respiration, and consequently reducebreathlessness. This is generally achieved by decreasing the volume

of respiration and activating abdomino-diaphragmatic respiration. It

Table 2Evidence surrounding asthma education (level I)

Education is a fundamental therapeutic component for the self-managementof asthma

Educational intervention for asthmatic patients which includes programmesthat aim to achieve self-management and which are based on agreed goals,improves health results, the use of health resources and costs

The availability of a written action plan, together with the acquisitionof knowledge, skills and the existence of a periodic review are the most effectiveforms of educational intervention

A key educational tool is written, personalised action plans, either basedon symptoms or on PEF measurements

The most effective action plans are those which look at 4 elements: use of thebest personal PEF value, allow modification of the dosage of IGC, allowthe early intervention of oral corticosteroids, understand when to askfor medical assistance

IGC: Inhaled glucocorticoids; PEF: Peak Expiratory Flow.Modified from An Pediatr (Barc). 2007;66:496-517.



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has also been suggested that upon decreasing hyperventilation andhyperinflation, carbon dioxide is increased thereby decreasing theeffects of hypocapnea and asthma-related symptoms. 31

It is important to develop respiratory exercises that are aimed atcontrolling the respiratory pattern, increasing awareness of nasalrespiration and decreasing ventilation in order to re-establish aslower pattern of movement. Practicing respiratory exercises in

patients with asthma has shown benefits regarding their perceivedquality of life. 31 With the aim of assessing the effectiveness of these exercises, the

study carried out by Thomas et al 32 saw 33 asthmatic patients undergorespiratory physiotherapy treatment and therapeutic education asopposed to just a therapeutic education programme on its own, witha follow-up period of 6 months after the end of the study. The authorsconcluded that the physiotherapy programmes centred on re-learning the respiratory pattern obtained greater benefits in theNijmegen Questionnaire and in the Asthma Quality of LifeQuestionnaire (AQLQ) with regard to symptoms, activities, emotionsand environment, in comparison with the education programme onits own (Evidence Level III ).

There are studies with similar methodological designs in whichthe practice of techniques for improving respiratory awareness areanalysed, such as in the case of yoga, as this involves respiratoryexercises as its main component.l 33-35 The study carried out byVedanthan et al33 took 17 asthmatic patients between the ages of 17and 52 and randomly assigned them to a treatment group thatpracticed yoga for 16 weeks and a control group. On a daily basis all

participants recorded any symptoms that occurred and the medicinethey were using and on a weekly basis each participant performed aspirometry test. The results showed that the group that werereceiving yoga treatment (mainly respiratory exercises designed toreduce the respiratory pattern) decreased their intake of beta-2agonists (95% CI 2.94-8.70) although no differences in pulmonaryfunction were seen in comparison with the control group (EvidenceLevel III).

Nagarathna and Nagendra 34 also found differences regarding theintake of beta-2 agonists and the number of asthma attacks by usinga group of 53 patients who practiced yoga for two weeks, withrespiratory exercises designed to reduce the respiratory pattern, incomparison with 53 patients who formed the control group, groupedaccording to age, sex, type and severity of asthma (Evidence LevelIII).

There seems to be a consensus that for respiratory strategies to beeffective they must be practiced regularly by the patient. Whilstlearning the techniques, emphasis should be put on suitableventilation mechanisms and not on the depth of respiration as thislatter aspect could exacerbate bronchial spasms. 36

The instructions given to a patient involve identifying anddifferentiating the movement of the diaphragm and the rib cageduring inhalation and exhalation (elastic retreat of the abdominalmusculature), then learning to synchronise them. At the same time,patients are shown how to expel air, prolonging the expiratory time,by controlling the exit of air through pursed lips or by supracostalrespiration while inhaling. 37 The deflating techniques include pursed-lip breathing, timed exhalation and abbreviated inhalation. Re-learning tends to be practiced sitting down to begin with, in front of

Table 3Objectives of asthma respiratory rehabilitation programmes

Design a personalised action plan depending on severity, age and physical abilityof the patient

Reduce airway obstruction and prevent and treat complications arisingfrom such obstructions

Administer management guidelines for patients and families to controland identify symptoms

Re-teach the respiratory pattern, optimising its function during the intercrisisphase

Increase exhalation with instrumental aidsCarry out the correct inhalation techniquesPractice relaxation techniques for controlling anxiety during attacksTreat soft tissue to achieve suitable ventilation mechanismsIntroduce physical exercise and improve nutritional conditions and quality of life

of the patient.

Table 4Quality levels of the scientific evidence from the Catalan Agency for Health Information, Assessment and Quality ( Agncia dAvaluaci de Tecnologia Mdica , AATM)

Level Strength of evidence Type of design Conditions of scientific rigor

I Appropriate Meta-analysis of RCT Analysis of individual patient dataNo heterogeneityDifferent analysis techniquesMeta-regressionMega-analysisQuality of the studies

II Appropriate Large RCT sample Assessment of statistical powerMulticentreQuality of study

III Good to regular Small RCT sample Evaluation of statistical powerQuality of study

IV Good to regular Prospective, non-randomised controlled trial Controls that coincide in time

MulticentreQuality of studyV Regular Retrospective, non-randomised controlled trial Historical controls

Quality of studyVI Regular Cohort studies Multicentre

MatchingQuality of study

VII Regular Case studies and controls MulticentreQuality of study

VIII Poor Non-controlled clinical series MulticentreDescriptive studies:Epidemiological vigilanceQuestionnairesRegistersDatabasesExpert committeesConsensus conferences

IX Poor Anecdotes or specific cases

Modified from: Jovell AJ, Navarro-Rubio MD. Evaluacin de la evidencia cientfica. Med Clin (Barc) 1995;105:740-743.



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