Asthma and COPD

Paul L. Reller L.Ac. / Last Updated: August 03, 2017

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Can Complementary and Integrative Medicine (CIM) Increase the Effectiveness of Standard Medications for Control of Symptoms?

Increasingly, standard medicine has relied on a prescription of multiple medications to control the symptoms of asthma and COPD, with just one type of medication, such as the standard albuterol inhaler, insufficient over time, as the asthma or COPD continues to worsen despite the treatment controlling acute symptoms. Combination drug therapies give greater results in controlling symptoms of asthma and COPD, even though the underlying health may not be improving. Complementary and Integrative Medicine (CIM/TCM) not only addresses the underlying health of the patient to improve the condition and eventually decrease the dependency on symptom controlling drugs, but for many, may be an effective and safe addition to the symptom controlling regimen. There is no reason to ignore chronic side effects of asthma medication overuse, such as the numerous reports of anxiety and depressive mood disorders, tremors, and cognitive and behavioral changes associated with chronic use of leukotriene inhibiting drugs that the U.S. FDA has acknowledged, or the ways that one can improve the response to allergens to decrease the severity and frequency of asthma episodes. Even though most asthma and COPD is related to a broad array of factors, this is not a reason to ignore the problems and just resort to chronic use of problematic medications alone. Integration of short courses of frequent acupuncture treatments with a more prolonged individualized course of therapy with herbal and nutrient medicines in a step-by-step treatment protocol can both decrease chronic dependency on problematic pharmaceutical protocols and help to reverse the worsening pathology so often seen with asthma and COPD.

Large studies now confirm that asthma medications lose effectiveness over time and with overuse. Studies cited by the manufacturer of a standard beta-adrenergic agonist (racemic albuterol, or albuterol sulfate) inhaler show that patients acquired tolerance to, and decreased effect by an average of one third, after 6 weeks of use. The study shows that there was a 22 percent average improvement in bronchodilation at first with the albuterol inhaler, which decreased to an average of 14.6 percent at the end of 6 weeks. If a 14.6 percent bronchodilation effect, or less, is occuring, acupuncture and herbal formulas, which are proven effective, could improve the symptom relief dramatically. Increasing the frequency of use of the inhaler now comes with stern warnings of risk and adverse effects. Since industry studies reported the side effects of only normal use of the inhalers, and normal use for a relatively short period of time, before acquired tolerance occurred, the guidelines used by prescribing medical doctors often do not reflect reality. Most asthma inhalers are a combination of racemic albuterol and corticosteroid, although pure albuterol sulfate inhalers are now generic and can be purchased without a prescription. Different forms of propellant of the albuterol are available, and numerous studies have shown that some inhalers may run out of albuterol before the propellant is depleted, resulting in only the propellant reaching the membranes. The patient needs to be aware of these issues and take a more proactive approach to managing their symptoms.

These industry studies also showed that there was a reversal of effectiveness of the beta-adrenergic agonist (albuterol) inhaler after 2 uses per day for 80 percent of the patients studied. To maintain effectiveness of the albuterol inhaler, patients need to find a way to decrease the chronic use. If you are a patient that needs multiple dosing, you might consider adding Complementary and Integrative Medicine to your regimen to improve underlying health and reduce the need for chronic use of the inhaler. Utilizing a more holistic approach will allow you to decrease the use of an inhaler to below this 2 use per day threshold. While the drug companies have introduced long-acting beta-adrenergic agonists (LABAs) to reduce the use of short-acting inhalers, the U.S. FDA has issued black box warnings and Public Health Advisories that these drugs may increase the chance of triggering a severe, and sometimes fatal, asthma attack, and stressed that LABAs should not be the first medicine used to treat asthma. There is no harm in trying Complementary Medicine to achieve this goal first. A 2015 study at the Fudan University School of Medicine, department of Integrative Medicine, proved in studies of laboratory animals that acupuncture stimulation itself is able to significantly inhibit inflammatory changes, airway hyper-resonsiveness, and mucus secretion, decreasing lymphocytes, eosinophils and neutrophils in bronchial secretions to relieve allergic reactivity, and decreasing leukotrienes linked to allergic asthma. To see this study summary, click here: http://www.ncbi.nlm.nih.gov/pubmed/26612993 . This integration of short periodic courses of acupuncture stimulation can significantly improve the effectiveness of standard pharmaceutical therapy, with the only side effect being improved overall health, and can be combined with a wide variety of individualized herbal and nutrient medicines that are the choice of the patient, and need not be taken continuously for the asthma or COPD care. Each course of such therapy may advance the goal of resolving the underlying health problems in asthma and COPD and result in a long-term outcome of almost no dependency on drugs and inhalers.

Since most patients do not experience adverse effects at first with asthma inhalers, there is an assumption that no adverse effects will occur. Most adverse effects come with chronic use and overdosing, though, onset gradually, and are rarely connected to use of the medication. Common adverse effects of albuterol beta-adrenergic agonists include episodes of rapid heart rate, anxiety, heart palpitations, nervousness, and mild chest pain, which increase with too frequent dosing. Drug interactions with high blood pressure medications, especially beta-adrenergic inhibitors (beta-blockers), and diuretics, as well as digoxin (anti-arrhythmic), and MAO inhibiting or tricyclic antidepressants, is also a problem, potentiating adverse effects on the cardiovascular system. Beta-blockers, now commonly prescribed for hypertension, will negate the effects of beta-adrenergic agonists (albuterol), lead to more frequent use of the inhaler, and increase risk for bronchospasm, or severe asthma episode. Potassium depletion is exacerbated with the concurrent use of albuterol with a common diuretic (non-potassium-sparing). Besides cardiovascular side effects, normal dosing with albuterol increased the incidence of allergic reactions and symptoms, tremor, and nausea in 5-10 percent of patients in the 12-week clinical trial. Concern with long-term use and excessive dosing is apparent. Long-term studies on laboratory animals also showed increased risk of uterine fibroids (leiomyomas), which increased with dosage. There is a host of reasons why the use of beta-adrenergic agonists, or albuterol, should be limited, and integration of Complementary Medicine can safely and effectively help the patient to achieve this goal. Such therapy should be professionally prescribed, though, as herbal medicines are not regulated in the United States, and products bought over the counter are suspect in both dose and content. Professional herbalists, such as Licensed Acupuncturists and herbalists, are also well trained in medical school to observe any contraindication to therapy, as well as effective monitoring of the patient to avoid potential herb-drug negative interactions. The track record of this professional therapy is very sound, with virtually no incident of problems in this regard with physicians trained in Traditional Chinese Medicine.

With chronic use of synthetic corticosteroids and adrenergic inhibitors there is always the problem of ill effects on our adrenal system. Adrenal insufficiency leads to a host of chronic symptoms and contributes to many common chronic diseases. The serious health problem of adrenal suppression and adrenal fatique with chronic overuse of combination corticosteroid/albuterol inhalers has led to drug warnings, and the subsequent development of a new type of inhaler. Ciclesonide glucocorticoid, or Alvesco, was developed to insure that greater than 50 percent of the inhaled dose was delivered to the lung tissue rather than the systemic circulation, which effects that adrenal hypothalamic endocrine system, and suppresses natural cortisol levels. The drug makers bioengineered a drug with smaller airborne particles and a conversion to active des-ciclesonide in the broncial tissues with esterase activity. They also increased lipid conjugation and plasma protein binding, as well as P450 detoxification catabolism in the liver to decrease the threat of adrenal suppression in patients that used asthma inhalers chronically, or more than twice per day. The patient may choose to switch to this inhaler to avoid adrenal suppression. Sometimes the prescribing doctor will add this inhaler to the combination albuterol protocol, but this appears to be a mistake with misunderstanding of the drug, and hence increases overuse and accumulation of corticosteroid, and further adrenal suppression may occur with this protocol, negating the benefit. Adrenal suppression, even in mild circumstance, may lead to decreased cortisol levels, which affect the body's ability to fight infection, control inflammatory increases, and affect the sleep quality and general energy patterns. The fact that a new drug was created to address this problem of adrenal suppression from standard asthma inhalers with corticosteroids should show the patients that this is indeed a real problem. Not only switching to Alvesco, but integrating Complementary Medicine, in the form or acupuncture, herbal and nutrient therapy, can both decrease use of adrenal suppressing medications and improve adrenal health. You may go the article on this website entitled Corticosteroid Risk and Natural Anti-inflammatories to learn more about this important health issue.

More and more scientific study is proving that Complementary and Integrative Medicine (CIM/TCM), in form of acupuncture, herbal, and nutrient medicine, effectively improves control of inflammatory mechanisms, improves health of the respiratory system, addresses comorbid conditions linked to the cause and aggravation of asthma and COPD, and even provides significant symptom relief, often with the same strategies that pharmaceutical medications utilize. The section at the end of this article entitled Information Resources provides numerous links to high quality scientific studies of both acupuncture and herbal medicine. Chemicals in herbs and nutrients achieve bronchodilation, inhibition of excess leukotriene stimulated inflammation, regulation of the autonomic responses, and act as effective adrenergic modulators. These chemicals in herbs and nutrients are not meant to replace important pharmacological remedies for emergency use, but to decrease the incidence of threatening episodes of asthma attack, as well as work synergistically with the more specific and potent asthma pharmaceuticals to provide for more effective relief and less acquired tolerance for the medications. There are virtually no incidences of harm with concurrent use of professionally prescribed herbal and nutrient medicine in the care of asthma and COPD. The treatment with these effective therapeutic tools is individualized and conforms to each patient's needs and level of trust. Since asthma and COPD involves much inherent anxiety, generated by the alarming symptoms, the treatment plan may proceed slowly, and often the initial therapy in TCM helps provide increased calm and ability to cope with, and adapt to, various types of stress, both physical, mental, and emotional. The adoption of a more holistic and proactive approach to these diseases and symptoms helps the patient achieve a better quality of life and sense of security.

A 2014 meta-review of all published scientific evidence by the Technical University of Munich, in Germany, stated that: "Specifically for allergic rhinitis and asthma, acupuncture may be cost-effective in terms of money spent per quality-of-life gained. Acupuncture plays an increasingly important role as an evidenced-based therapy for allergy relief and can be recommended as adjunct therapy for allergic rhinitis" (PMID: 24881629). This assessment still fails to report that real clinical therapy in TCM also provides evidence-based herbal and nutrient medicines, as well as therapy to resolve underlying and contributing health problems, creating an amazing package of care in the same short course of therapy. Such evidence has been apparent for decades, yet remained unpublished in standard medical journals and absent from guidelines until now, due to commercial industry interests. Patients deserve better.

As the realization that standard asthma medications and inhalers lose effectiveness over time and with overuse increases, pharmaceutical companies are now heavily advertising addition of pharmaceutical drugs to the treatment protocol to achieve more success, especially the addition of leukotriene-inhibiting drugs. More and more research around the world is demonstrating that specific Chinese medicinal herbs exerts significant inhibition of leukotriene B4 and decrease bronchial asthma symptoms (see study links below). These natural leukotriene inhibitors in herbal medicines also provide significant antioxidant and detoxifying effects, without side effects, and are inexpensive. There is no reason that a patient should not first try to achieve better control of their asthma with such remedies before adopting pharmaceutical leukotriene inhibiting drugs. The addition of pharmaceuticals to the regimen increases side effects and adds significant costs to the therapy, and this may be avoidable. In addition, the adoption of holistic medicine, with short courses of acupuncture, and a more thorough treatment protocol that is holistic, holds the promise of actually reversing the progression of asthma and COPD. Pharmaceutical therapy does not provide this promise, only managing symptoms in a scenario where the disease is expected to progress with age.

How Acupuncture Stimulation itself Benefits the Asthma and COPD Patient - Scientific Elucidation of these Mechanisms put the Subject of Acupuncture in Perspective

Scientific studies of acupuncture in the treatment of asthma and COPD have expanded beyond just clinical trials to see if short courses of acupuncture consistently decrease the severity and frequency of asthma attacks. Of course, acupuncture treatments were never meant to replace the albuterol inhaler to relieve acute asthmatic symptoms. The treatment strategy in Traditional Chinese Medicine (TCM) has always been to utilize short courses of acupuncture stimulation to improve the overall health, while utilizing herbal medicine to both relieve symptoms and correct the underlying health problems driving the asthmatic syndrome, or COPD (Chronic Obstructive Pulmonary Disease). In standard medicine the treatment strategy has been to let the asthma and COPD syndrome continue to worsen, but to provided medicine to relieve the acute episodes of alarming difficulty in breathing. In recent years, there has finally been a move to expand this protocol to reducing chronic inflammatory imbalance with leukotriene inhibitors, but research shows that the inflammatory imbalance is much more complex than these drugs can address. There needs to be a more complex and holistic approach if we are to finally provide the asthma and COPD sufferer a means to actually reverse their disease. TCM stresses a holistic treatment regimen combining short courses of acupuncture stimulation with individualized herbal and nutrient medicines taken in short courses and altered to address the changes in the pathological course of the disease, individualized dietary changes, and instruction in therapeutic exercises and lifestyle regimens to reverse the course of asthma and COPD.

We see that acupuncture stimulation is just a part of the treatment strategy in TCM, but still, patients wonder how simple needle stimulation can provide dependable help with their chronic asthma and COPD. Much research, some of which is cited in the following section with links to scientific studies, has shown that acupuncture stimulation does indeed consistently reduce the need for asthma inhalers and lessen the severity of asthma and COPD attacks. In 2010, researchers at the Federal University of Sao Paulo, Brazil, found that electroacupuncture performed on laboratory animals decreased inflammatory problems in bronchial tissues and relieved membrane swelling by achieving better balance between the T-helper cell Type 1 and T-helper cell type 2 (Th-1/Th2) groups of pro-inflammatory and anti-inflammatory cytokines that our bodies immune systems uses to maintain tissue health and fight infection. The electroacupuncture stimulation increased IL-1 and interferon gamma (IFN-gamma), while decreasing IL-4, IL-10, nitric oxide and LTB-4 (leukotriene B4) in bronchial membranes and pulmonary tissues. Leukotriene B4 is the target of the leukotriene inhibitors in standard therapy (PMID: 20231101). We see from this study that while short courses of acupuncture stimulation are not as potent in inhibiting Leukotriene B4, that the effects are broader and more balanced, working to reprogram the immune responses, and of course, come with no adverse side effects. Even these measurable benefits of treatment do not tell the whole story of benefit, though, but are only those benefits measured in this study. In other scientific studies, other benefits are explored and measured, and we see even more proof of beneficial modulating effects. The question of how acupuncture works is indeed complex, because it just stimulates the body's own homeostatic mechanisms and helps restore normal function. These homeostatic mechanisms are complex, and so as much as we keep asking for just that one simple explanation of how acupuncture works to treat asthma and COPD, there is no simple answer.

To show how standard TCM therapy works, though, we can look to a 2009 study at the National Chung Hsing University, in Taichung, Taiwan, where high-dose Vitamin C achieved this same Th-1 Th-2 modulating balance to decrease eosinophil infiltration and decrease airway swelling (PMID: 19831405). Currently, the Licensed Acupuncturist and herbalist, such as myself, may prescribe a quality high-dose Vitamin C formula, combined with immune modulators such as Astragalus, and provide a course of 3-6 treatments of electroacupuncture, achieving this same Th-1 Th-2 balance in the membranes, lessening the intensity and frequency of asthmatic and COPD symptoms. Of course, other herbal and nutrient medicines may also be prescribed in short courses to increase the benefits, and the physician may refer the patient to instructions in breathing exercises, dietary protocols, and lifestyle changes that benefit their condition. This therapy is integrated with standard treatment, not presented as an alternative, in order to decrease the problematic needs for drug therapies and adverse effects, and actually advance the course of the disease toward resolution and improvement, gradually improving both airway tissue health and restoring the natural homeostatic mechanisms that the patient had before acquiring the asthmatic and COPD syndrome. This holistic protocol should not be judged by whether it completely cures the patient in a short period of time, or is more convenient than just using the inhaler and taking a pill, but in the actual gradual increases and complex improvements that are proven to occur in these scientific studies.


Herbal and nutrient supplement products

A variety of herbal formulas are prescribed in the treatment of asthma and CPOPD, depending upon the individual and the needs of the case. Some herbs are very effective to calm bronchospasm and constriction. Ephedra is still the most effective bronchodilator in the world and is used in small doses infrequently for safety and effectiveness, and in formulas that modify its effects. Substitutes for ephedra are also very effective and frequently used since the controversies concerning overuse of ephedra in so many diet products, sports supplements and phen-fen causing health problems. In addition, a variety of formulas successfully both calm asthmatic triggers and aid the immune responses. Studies comparing simple herbal formulas to the most common pharmacueutical products showed that herbal formulas could perform better than the pharmaceuticals. Researchers at Stanford, Mount Sinai and other prestigious universities conducted rigorous studies that surprised the medical profession. A knowledgeable herbalist is the key. In severe cases, the herbal protocol needs to be adjusted in response to changes in symptoms and course of the disease. The goal of herbal therapy is not just a suppression of symptoms, so symptoms may change and vary during the course of the therapy. Monitoring of these changes and effective response by the herbalist is often important.

One of the heavily researched formulas of Chinese herbs was called MSSM-02, or the second in the common formulas heavily researched in the treatment of allergic asthma. This formula consists of Ling zhi (reishi mushroom), gan cao (licoric root), ku shen (sophorae flavascentis root), su zi (perilla seed), ting li zi (lepidii seed), xing ren (the inner core of the prune pit), huang qin (scutellaria baicalensis), dang gui, bai shao (peony root), ge gen (kudzu), jie geng (balloon flower root, or platycodi), zhen zhu mu (mother of pearl powder), da zao (jujube fruit), and sheng jiang (fresh ginger). Documentation of the effectiveness is found below in a link to the NIH PubMed database of health science published studies. Many professional herbal formulas used to treat asthma contain these herbs, and the TCM physician, or Licensed Acupuncturist and herbalist, utilizes these formulas based in individual types and conditions, as well as the progression of the disease and the progression of treatment. A growing body of scientific evidence supports herbal medicine in the treatment of asthma and COPD. The choice in not between pharmaceuticals or herbal medicines, but the intelligent integration of the two strategies to achieve the best results with the lowest health risk, and the addressing of the underlying health as well as management of symptoms.

Combining acupuncture, diet and lifestyle changes and herbal medicine offers a complete and effective package for both managing and curing asthma and COPD. Persistence and consistency in the treatment usually results in eventually being able to bring these problems down to a mild case that no longer requires regular treatment or products. Research is also uncovering specific nutrient medicines that can be added to the holistic protocol that will help lung function, immune health, and reduce symptoms in COPD. For instance, a one year study in China found that a high dose N-acetyl cysteine significantly improved lung function, reduced symptoms and flare-ups (see study link below). N-acetyl cysteine (NAC), which is also called N-acetyl L-cysteine, benefits the glutathione cell detoxification pathway, as well as immunomodulating pathways, and is found in small quantities in wheat germ, steel cut oats, whey protein, onion, garlic, shallots, red peppers, and brussel sprouts.

Study of COPD and metabolic disorders has also revealed the importance of the metabolic hormone leptin in maintenance of the lung and respiratory immune responses, as well as a central nervous system role in the regulation of autonomic control of breathing, acting centrally in the hypothalamus and other regulatory centers. Leptin has become well known due to its relationship to insulin and ghrelin, and is important in the regulation of appetite and cellular energy, but research has uncovered the large array of significant regulation in the body affected by leptin, both centrally and peripherally. A study at Maastricht University Medical Center, in the Netherlands (see study link below) is exploring the exact mechanisms of leptin both in the inflammatory cause of the disease, as well as regulation and maintenance in chronic disease. Leptin excess is commonly seen in Metabolic Syndrome and with insulin resistance, as well as obesity, but we see that COPD may be implicated in this imbalance as well, and that leptin excess and resistance in Metabolic Syndrome may also exacerbate the COPD pathology. Nutrient formulas with acacia tree gum and various nutrient molecules have been researched to help normalize the leptin metabolism, and may apply to COPD as well.

As with all chronic diseases with inflammatory parameters, the antioxidant capacity, or ability to clear reactive oxygen species of molecules, has also been a subject of much research with COPD. A study of antioxidant levels and markers as a predictor of severity in COPD was conducted at Jundishapur University Medical School, in Iran, in 2012, and it was found that deficiencies of Vitamin C, Vitamin A, and glutathione capacity were correlated with worsening stages of the disease. A study at Chung Shan Medical University, in Taichung, Taiwan, in 2010, also found that COPD patients showed low plasma levels of Vitamin C, Vitamin A, Carotenoids, alpha- and beta-carotene, and Vitamin E tocopherols, with Vitamin C and beta-carotene levels most associated with antioxidant deficiency in relation to COPD (see study link below). Studies in Italy also found that COPD patients with severe disease benefited dramatically from supplementation with essential amino acids (see study link below). In a randomized, controlled study both lung function and quality of life were improved by 12 weeks of essential amino acid supplement, with oxygen saturation, muscle strength, cognitive function, and other parameters improved. Essential amino acids include methionine (SAMe), L-lycine, leucine and isoleucine, L-phenylalanine, and L-tryptophan.

Dietary changes and Asthma

Asthmatic patients with potential allergies should consider a dual strategy when it comes to dietary changes. One, decrease or avoid foods that may trigger or worsen the asthma or allergy: and Two, increase foods that will help the body to deal with inflammatory regulation and antioxidants.

The most studied triggers in asthmatic patients in our common diet are sulfites, preservatives, glutens, chocolate, shellfish and dairy. Of these, the sulfites are the most important for most patients. This includes aged cheeses and meats, many wines and beers, cola drinks, olives, pickles, packaged food with sulfite preservatives, dried fruits, shellfish, dried fish, and some prepared restaurant foods such as guacamole, salad bars, cole slaw and potato salad. In fact, large commercial supermarkets sometimes spray the vegetables and fruit with sulfite preservative. Foods with benzoic acid preservatives should also be avoided, especially those with artificial colors, yellow dye #5 being the worst, vanillin, monosodium glutamate, BHT-BHA, benzoates, benzyldehyde amd eucapytol. Commercial pastries, peanuts, soy, alfalfa, beets, pork, turkey and white, brown and beet sugar should be decreased or avoided if possible.

Foods to increase in the diet include fresh, whole organic foods, fresh dandelion greens, burdock, garlic, onions, berries, unprocessed oils such as toasted walnut, avocado, pumpkin seed, sesame seed, and fresh ocean fish. The diet should be relatively high in healthy proteins and low in simple carbohydrates. Fresh herbs in cooking are a good idea, as well as watercress. For asthma with with phlegm or mucus that is clear of white, and cool extremities, fresh ginger, mustard greens, basil marjoram, garlic walnut, almond, molasses and anise are recommended. For asthma with much mucus or phlegm, or difficulty breathing when lying down, consume lemon, lime, raw honey, horseradish mustard, aduki beans and slippery elm tea. For asthma with heat flush accompanying difficult breathing and occasional yellow mucus or phlegm, dry stools or darker urine, consume apricots, limes, lemons, daikon radish and nettle leaf. For asthma with low energy and lassitude, shortness of breath, difficult breathing with exertion, consume whole or steel cut oats, barley, buckwheat, rice, black beans, walnuts, figs and perhaps regular small doses of Chinese ginseng.

Research in 2000, at the Misasa Medical Branch, Tottori, Japan found that dietary sources of alpha-linolenic acid, such as is found in the Chinese medicinal herb perilla seed (Zi su zi), commonly used for centuries to treat asthma and COPD, may act as an effective leukotriene inhibitor (see study link below). By 2013, clinical human trials of this therapy are being conducted in the United States. Research has identified that both these omega-6 and omega-3 essential fatty acids exert potent inflammatory regulation, and can easily be added to the diet and medical protocol. Perilla seed may be easily obtained from any supplier of Chinese medicinal herbs, and incorporated into the diet, ground along with flax seeds for example, and added to foods, or be obtained as an extract in formula, or simply as a seed oil, useful in salads or cooking, or taken as a supplement capsule. Other essential fatty acids have also been proven to benefit asthma sufferers. A 2008 study at the University of Moncton, Moncton, NB, Canada, found that increasing GLA (gamma linolenic acid) and EPA (eicosapentaenoic acid) are proven to decrease leukotriene synthesis (acting like common pharmaceutical leukotriene inhibitors) and in a randomized, clinical human trial were found to improve patient quality of life and decrease use and reliance on asthma medications (see study link below in additional information).

Breathing exercises are proven to reduce asthma intensity and frequency of episode

In 2012, a meta-review of studies of breathing techniques taught to relieve asthmatic symptoms was conducted by the U.S. Agency for Healthcare Research and Quality (AHRQ) and found that behavioral modifications teaching patients chronic hyperventilation reduction techniques can both improve asthma symptoms and reduce dependence on medication over a period of 6-12 months, and evidence supporting a daily yoga breathing routine shows promising results in India, but not in the United States, where yoga is primarily performed less frequently in classes and workshops, not daily (PMID: 23101047). Yogic breathing, which employs slow relaxed deep breaths, rather than shallow breathing, was supported by the authors, though, if the patient is willing to "undertake intensive training" with yogic instruction. The apparent reluctance to support yogic breathing techniques fully apparently stems from the long-standing confusion that is generated by two apparently opposite approaches achieving the same result, as most chronic hyperventilation reduction techniques utilize shallow breathing. Some of these hyperventilation reduction techniques are now routinely taught in medical schools in Russia, though, and are approved for payment by government health programs and insurance policies in much of Europe. One such technique is the Buteyko Method, developed in 1952 by a Russian doctor, Konstantin Buteyko, who studied breathing patterns in research and discovered that traditional breathing techniques relieve both migraine headaches and asthmatic dyspnea, as well as hypertension. Both specialized clinics supported by the Buteyko Institute in the U.S. and YouTube instructional videos have benefited many patients. In general, most patients report that simplistic training and instruction does not result in significant benefit, though, and whatever method is chosen, good instruction and persistence in neuromuscular breathing retraining is the key to success.

General instructions for the Buteyko Method include gently bringing forward the sternum, relaxing the diaphragm, holding the head upright with the mouth closed, gently practicing slightly relaxed nasal inhalation while looking upward, and breathing shallowly to alter the balance of carbon dioxide to oxygen in the blood. Techniques vary between therapists, though, creating some confusion. One aspect of the method that seems universal is the control pause, or time spent in a relaxed state after exhalation before the next inhalation, and emphasis is on gradual neuromuscular retraining, not instant change in breathing technique, or dependence on these short sessions of alter breathing alone. Results may not be apparent for months. The theory that guides Buteyko Method is that triggers develop that alter the automatic (autonomic) pattern of breathing, and a conscious effort must be used to restore this homeostatic mechanism for many patients. The theories of chronic dysfunction of homeostatic breathing include a prevalent notion that daily stress often produces an autonomic reaction of increased breathing despite the lack of need for this increased air. Stress reduction with breathing techniques are also proven useful to reduce both migraines and asthmatic symptoms. Other methods of breathing technique to alter the carbon dioxide content of the blood, and reduce the subsequent reactions in the brain to high CO2 and acidity, include slowed deep breathing followed by a forceful rapid outbreath, and some therapists try alternating these methods, although the physiological effects are opposite of the Buteyko Method. This conundrum of apparently opposed theories of physiological causes and corrections of asthmatic dysfunction has long produced a confusing reaction in standard healthcare, and lack of acceptance for these simple integrative therapies. So far, the Buteyko Method seems to have become more popular than other breath training techniques, although more patients may now tout yogic breathing as helpful with the increased popularity of yoga.

Understanding the debate over neuromuscular retraining with breathing is not as simple as it seems. Homeostatic regulation of autonomic functions are complex, and chronic alterations of breathing pattern, as well as chronic acidity in the blood, and lack of effective alkalizing due to calcium dysregulation, all may play a part in dysfunctional regulation of breathing and oxygen absorption. With chronic dysfunction and dysregulation, autonomic controls may be altered, and hypereactivity may occur in the breathing centers of the brain. For instance, plasma carbon dioxide (PCO2) is one of the chief alkalizers in our bodies, and our breathing centers in the brain read this PCO2 to stimulate rates of breathing and oxygen intake. The ability of our hemoglobin to bind to oxygen is inversely related to blood acidity (the Bohr effect), and either an increase in pH or decrease in CO2 will result in the release of oxygen from hemoglobin. Chronic hyperventilation will reduce PCO2 and deprive the brain of oxygen, and may increase oxidative stress as well. In reaction to these changes, the kidneys will respond with bicarbonate (HCO3), and the metabolism may switch to a more anaerobic energy metabolism, producing lactic acid that will bind to or use up available HCO3 bicarbonate. In general, a protocol of decreased intake of acid-forming foods, such as simple carbohydrates, improved hormonal balance and calcium regulation, clearing of gastric dysfunction that may create nutritional deficiencies of calcium and magnesium, and properly implemented breathing techniques to alter oxygen and carbon dioxide balance, are perhaps more effective than one breathing technique alone. Acid-base balance is closely tied to oxygen and carbon dioxide levels in blood circulation, and a number of factors may alter this acid-base balance, such as alcohol consumption, diet, stress, mineral deficiency (especially magnesium and potassium), calcium dysregulation, chronic inflammation, chronic kidney disease, IBS with diarrhea, anxiety that affects breathing, sleep disorders, adrenal dysfunction, and use of various medications, such as newer birth control pills, synthetic hormones, diuretics, aspirin, and some types of iron supplements. Obviously, a more holistic therapeutic protocol would insure greater chance of success.

While many patients are now trying to learn these breathing techniques from books and instructional videos, effective technique should be taught by an experienced therapist, as these techniques are difficult to perform and understand, and while simple in essence, are often not performed well enough to achieve measurable results unless the patient persists with learning and improves the techniques over time. Therapeutic instruction may also be important to keep the patient focused on practice over a period of months, as immediate results are not expected. Gentle aerobic exercise also utilizes oxygen and thus decreases carbon dioxide excess in relation to oxygen. For this reason, the Buteyko Method also incorporates breathing exercises during gentle aerobic exercise, such as a brisk walk. No matter what you choose to pursue in your overall therapeutic regimen, though, you may now rest assured that scientific study validates neuromuscular breathing retraining.