The Buteyko method or Buteyko Breathing Technique is a practice used for the treatment of asthma. The method takes its name from the late Ukrainian doctor Konstantin Pavlovich Buteyko, who first formulated its principles during the 1960s.
The method is a physical therapy and several small clinical trials have shown that it can safely reduce asthma symptoms and the need for rescue medication, as well as increasing quality of life scores.
However, improvement takes time and commitment, requiring daily exercises over a period of weeks or months.
At the core of the Buteyko method is a series of reduced-breathing exercises that focus on nasal-breathing, breath-holding and relaxation.
Buteyko’s theory was that asthmatics “chronically overbreathe” and the exercises are designed to teach asthmatics to breathe less.The goal is to retrain breathing to a normal pattern, akin to certain forms of Yoga.
The British Guideline on the Management of Asthma 2008 grants permission for health professionals in the United Kingdom to recommend Buteyko.
Stating that the method “may be considered to help patients control the symptoms of asthma”, having noted of primary importance the Cochrane review meta-analysis which concluded that there is “no change in routine measures of lung function”.
Although some high quality trials have suggested benefits of reduced symptoms and bronchodilator use, but no effect on lung function.
The Method
Although variations exist among teachers of the technique in different countries, the three core principles of Buteyko remain the same: Reduced breathing, nasal breathing and relaxation.
Reduced Breathing Exercises. The core Buteyko exercises involve breath control; consciously reducing either breathing rate or breathing volume.
Many teachers refer to Buteyko as ‘breathing retraining’ and compare the method to learning to ride a bicycle. Once time has been spent practicing, the techniques become instinctive and the exercises are gradually phased out as the condition improves.
A common theme in Buteyko exercise is to hold one’s breath until it is uncomfortable – producing a feeling of air hunger. This feeling mimics the feeling of breathlessness that asthmatics typically experience during an asthma attack.
Rather than using traditional peak flow measurements to monitor the condition of asthmatics, Buteyko uses an exercise called the Control Pause (CP), defined as the amount of time that an individual can comfortably hold breath after a normal exhalation.
With regular Buteyko reduced-breathing practice, asthmatics tend to find that their CP gradually increases and in parallel their asthma symptoms decrease.
Nasal Breathing
The Buteyko method emphasizes the importance of nasal breathing, which protects the airways by humidifying, warming, and cleaning the air entering the lungs.
In addition, breathing through the nose helps the body to maintain higher concentrations of carbon dioxide and nitric oxide in the lungs.
A majority of asthmatics have problems sleeping at night, and this is thought to be linked with poor posture or unconscious mouth-breathing.By keeping the nose clear and encouraging nasal breathing during the day, night-time symptoms can also improve.
Other methods of encouraging nasal breathing are full-face CPAP machines – commonly used to treat sleep apnea – or using a jaw-strap or paper-tape to keep the mouth closed during the night.
However, a study in 2009 showed that nasal breathing alone was not enough to cause an improvement in asthma symptoms.
Strictly nasal breathing during physical exercise is another key element of the Buteyko method.
A study in 2008 found that it made exercise safer for asthmatics. While breathing through the nose-only, asthmatics could attain a work intensity great enough to produce an aerobic training effect.
Relaxation
Dealing with asthma attacks is an important factor of Buteyko practice. The first feeling of an asthma attack is unsettling and can result in a short period of rapid breathing.
By controlling this initial over-breathing phase, asthmatics can prevent a “vicious circle of over-breathing” from developing and spiralling into an asthma attack.
This means that asthma attacks may be averted simply by breathing less.
Teachers note that the method is not a substitute for medical treatment and reliever medication should be kept handy at all times and used as required.
Reduction of medication should be done under supervision of the doctor prescribing the medication, as some steroids and other drugs should not be ceased too quickly.
This aspect of Buteyko is merely a change in lifestyle that can minimize the chance of an attack occurring and reduce the severity by remaining calm and in control of breathing.
Clinical Studies
Between 1962 and 1982, thirty five studies were undertaken in Russia that established Buteyko as a safe and effective treatment for asthma and other breathing disorders.
In the West, there have been six published randomised control trials of the Buteyko method since 1999.
All of these trials have shown either significant reductions in the need for medication or improvements in asthma control using the Buteyko method.
The most recent trial, conducted in Canada in 2008, took 129 patients with asthma and randomised them to receive a set of breathing exercises from either a Buteyko practitioner or a chest physiotherapist.
In the Buteyko group the proportion of patients achieving good control of their asthma increased from 40% at baseline to 79% at 6 months. This improvement was associated with a statistically significant reduction in the average dose of inhaled steroid.
Improvements in asthma control were also seen in the group treated with chest physiotherapy.
A common thread among the trials is a large reduction (commonly 80-90%) in reliever medication use. A reduction in steroid medication has been observed, but often over a longer time period.
The Buteyko method has not been shown to improve lung function (or peak-flow), the conventional measurement of asthma, which measures the current level of constriction in the airways.
Authors have noted that lung function does not decrease in these trials, despite the reduction in reliever and preventer medication.
Some of the earliest Buteyko trials suffered from poor administration that could skew results. However, subsequent trials have taken into account these issues and replicated similar results under strictly controlled conditions.
Theory
Chronic Hyperventilation Syndrome has been discussed in the medical literature for most of the last century.
In fact, DaCosta is thought to have been the first to describe some of the symptoms in 1871, following a bizarre symptoms complex (including chronic fatigue) he found in soldiers during the American Civil War.
However, he did not associate these symptoms with over-breathing at that time. It was Goldman who discovered in 1922 that all of the symptoms, listed by DaCosta, were associated with involuntary hyperventilation.
In spite of the long history and many pages that have been written on the condition, chronic hyperventilation is rarely diagnosed by doctors.
Chronic hyperventilation develops from any chronic stress on the body leading to a depletion of carbon dioxide(CO2) and bicarbonate (HCO3-).
The respiratory center, situated in the brain stem, paces breathing in order to maintain pH according to the Henderson-Hasselbach equation:
Hence, to maintain pH, the ratio of CO2 to bicarbonate in the cerebrospinal fluid (CSF) needs to remain constant. Since the blood-brain barrier is extremely permeable to CO2, this is readily accomplished by regulation of breathing.
If the body is stressed, breathing increases, CO2 is reduced and a state of alkalosis develops.If this stress is sustained, the kidneys compensate by dumping bicarbonate in order to re-establish normal pH in the blood.
However, the blood-brain barrier is only very slightly permeable to bicarbonate resulting in a very slow diffusion of bicarbonate from the CSF into the blood if the stress is sustained for a very long time (chronic stress).
When the stress eventually dissipates, the CSF is left with a low bicarbonate concentration.
To maintain pH the CO2 will also have to be kept low and a habituation to low CO2 will have taken place. The resulting low CO2 and bicarbonate results in a profound derangement of normal body chemistry.
The late consultant chest physician Claude Lum, said that chronic hyperventilation “presents a collection of bizarre and often apparently unrelated symptoms which may affect any part of the body, and any organ or any system … for we are dealing with a profound biochemical disturbance, which is as real as hypoglycemia, and more far-reaching in its effects.”
From the Buteyko perspective, the inflammatory hyperresponsiveness and allergic hyper reactivity seen in asthma and bronchitis are the results of immune disturbances caused by chronic hyperventilation because of these biochemical derangements.
The second component of asthma, bronchospasm, is easier to understand from a teleological perspective.
There is clearly a reason for the existence of the smooth muscle in the walls of the bronchioles.
Their role is to optimize ventilation of the lungs so that over ventilated airways (low CO2) can be constricted and under ventilated airways can be dilated. Carbon dioxide is a known muscle relaxant.
One of the well known symptoms in acute hyperventilation is carpopedal spasm, a condition in which the skeletal muscles of fingers and toes go into spasm. Smooth muscle in the walls of some arteries and bronchioles is affected too, by low carbon dioxide.
The smooth muscle in the blood vessels going to the brain contract during hyperventilation, eventually leading to fainting. Blood flow to the brain is reduced by 2% for every 1mm Hg reduction in arterial CO2 tension.
The mechanism behind smooth muscle spasm is thought to be as follows:Carbon dioxide is involved in the transport of Calcium across the cell walls.
During hyperventilation calcium is re-distributed through the tissues, depleting the extra-cellular fluid and accumulating inside the cells. Thus trapped, it is unable to participate in the process of relaxing the smooth muscle, which then remains in spasm.
In people with a genetic predisposition to asthma, over breathing is known to cause bronchospasm.
In fact, in asthmatics even a single deep breath of the kind taken for performing lung function tests, airway resistance is increased by 71% while arterial carbon dioxide tension is reduced by 7 to 16mmHg.
It follows that PEF and FEV1 lung function tests are not appropriate tests for testing asthmatics, because the testing procedure alters the quantity being measured.
There are many other effects of hyperventilation on the body. One of the most significant is poor oxygenation of the cells. Apart from constriction of blood vessels causing a reduction in blood flow, low CO2 increases the affinity of haemoglobin for oxygen.
This is know as the Bohr effect, and results in the haemoglobin not offloading its oxygen where it is needed, returning back to the lungs on a wasted trip. This is the cause of breathlessness and leads to more breathing, aggravating an already serious situation.
The Buteyko method is a simple educational program aimed at reversing chronic hyperventilation. In the same way as chronic stress leads to chronic hyperventilation, so too a deliberate reduction in breathing over a period of time reverses this process to restore CO2 back to a normal level.
