Publications by authors named "Anne Bruton"

35 Publications

Mixed methods process evaluation of my breathing matters, a digital intervention to support self-management of asthma.

NPJ Prim Care Respir Med 2021 06 4;31(1):35. Epub 2021 Jun 4.

Centre for Clinical and Community Applications of Health Psychology, School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK.

This study aimed to explore user engagement with 'My Breathing Matters', a digital self-management intervention for asthma, and identify factors that may influence engagement. In a mixed methods design, adults with asthma allocated to the intervention arm of a feasibility trial (n = 44) participated in semi-structured interviews (n = 18) and a satisfaction questionnaire (n = 36) to explore their views and experiences of the intervention. Usage data highlighted that key intervention content was delivered to most users. The majority of questionnaire respondents (78%; n = 28) reported they would recommend the intervention to friends and family. Interviewees expressed positive views of the intervention and experienced several benefits, mainly improved asthma control, medication use, and breathing technique. Factors that may influence user engagement were identified, including perceptions of asthma control, current self-management practices, and appeal of the target behaviours and behaviour change techniques. Findings suggested My Breathing Matters was acceptable and engaging to participants, and it was used as intended.
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http://dx.doi.org/10.1038/s41533-021-00248-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8178311PMC
June 2021

Changes in quantifiable breathing pattern components predict asthma control: an observational cross-sectional study.

Asthma Res Pract 2021 Apr 6;7(1). Epub 2021 Apr 6.

Institute for Sound and Vibration Research, University of Southampton, Southampton, UK.

Background: Breathing pattern disorders are frequently reported in uncontrolled asthma. At present, this is primarily assessed by questionnaires, which are subjective. Objective measures of breathing pattern components may provide additional useful information about asthma control. This study examined whether respiratory timing parameters and thoracoabdominal (TA) motion measures could predict and classify levels of asthma control.

Methods: One hundred twenty-two asthma patients at STEP 2- STEP 5 GINA asthma medication were enrolled. Asthma control was determined by the Asthma Control Questionnaire (ACQ7-item) and patients divided into 'well controlled' or 'uncontrolled' groups. Breathing pattern components (respiratory rate (RR), ratio of inspiration duration to expiration duration (Ti/Te), ratio of ribcage amplitude over abdominal amplitude during expiration phase (RCampe/ABampe), were measured using Structured Light Plethysmography (SLP) in a sitting position for 5-min. Breath-by-breath analysis was performed to extract mean values and within-subject variability (measured by the Coefficient of Variance (CoV%). Binary multiple logistic regression was used to test whether breathing pattern components are predictive of asthma control. A post-hoc analysis determined the discriminant accuracy of any statistically significant predictive model.

Results: Fifty-nine out of 122 asthma patients had an ACQ7-item < 0.75 (well-controlled asthma) with the rest being uncontrolled (n = 63). The absolute mean values of breathing pattern components did not predict asthma control (R = 0.09) with only mean RR being a significant predictor (p < 0.01). The CoV% of the examined breathing components did predict asthma control (R = 0.45) with all predictors having significant odds ratios (p < 0.01). The ROC curve showed that cut-off points > 7.40% for the COV% of the RR, > 21.66% for the CoV% of Ti/Te and > 18.78% for the CoV% of RCampe/ABampe indicated uncontrolled asthma.

Conclusion: The within-subject variability of timing parameters and TA motion can be used to predict asthma control. Higher breathing pattern variability was associated with uncontrolled asthma suggesting that irregular resting breathing can be an indicator of poor asthma control.
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http://dx.doi.org/10.1186/s40733-021-00071-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8022412PMC
April 2021

One year later: Highlighting the challenges and opportunities in disseminating a breathing-retraining digital behaviour change intervention.

Digit Health 2020 Jan-Dec;6:2055207620936441. Epub 2020 Jul 14.

School of Psychological Science, University of Bristol, UK.

Digital behaviour change interventions can provide effective and cost-effective treatments for a range of health conditions. However, after rigorous evaluation, there still remain challenges to disseminating and implementing evidence-based interventions that can hinder their effectiveness 'in the real world'. We conducted a large-scale randomised controlled trial of self-guided breathing retraining, which we then disseminated freely as a digital intervention. Here we share our experience of this process after one year, highlighting the opportunities that digital health interventions can offer alongside the challenges that must be addressed in order to harness their effectiveness. Whilst such treatments can support many individuals at extremely low cost, careful dissemination strategies should be proactively planned in order to ensure such opportunities are maximised and interventions remain up to date in a fast-moving digital landscape.
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http://dx.doi.org/10.1177/2055207620936441DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7364807PMC
July 2020

Feasibility trial of a digital self-management intervention 'My Breathing Matters' to improve asthma-related quality of life for UK primary care patients with asthma.

BMJ Open 2019 11 12;9(11):e032465. Epub 2019 Nov 12.

Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.

Objective: To assess the feasibility of a randomised controlled trial (RCT) and acceptability of an asthma self-management digital intervention to improve asthma-specific quality of life in comparison with usual care.

Design And Setting: A two-arm feasibility RCT conducted across seven general practices in Wessex, UK.

Participants: Primary care patients with asthma aged 18 years and over, with impaired asthma-specific quality of life and access to the internet.

Interventions: 'My Breathing Matters' (MBM) is a digital asthma self-management intervention designed using theory, evidence and person-based approaches to provide tailored support for both pharmacological and non-pharmacological management of asthma symptoms.

Outcomes: The primary outcome was the feasibility of the trial design, including recruitment, adherence and retention at follow-up (3 and 12 months). Secondary outcomes were the feasibility and effect sizes of specific trial measures including asthma-specific quality of life and asthma control.

Results: Primary outcomes: 88 patients were recruited (target 80). At 3-month follow-up, two patients withdrew and six did not complete outcome measures. At 12 months, two withdrew and four did not complete outcome measures. 36/44 patients in the intervention group engaged with MBM (median of 4 logins, range 0-25, IQR 8). Consistent trends were observed to improvements in asthma-related patient-reported outcome measures.

Conclusions: This study demonstrated the feasibility and acceptability of a definitive RCT that is required to determine the clinical and cost-effectiveness of a digital asthma self-management intervention.

Trial Registration Number: ISRCTN15698435.
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http://dx.doi.org/10.1136/bmjopen-2019-032465DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6858238PMC
November 2019

Evaluation of a breathing retraining intervention to improve quality of life in asthma: quantitative process analysis of the BREATHE randomized controlled trial.

Clin Rehabil 2019 Jul 27;33(7):1139-1149. Epub 2019 Feb 27.

5 Primary Care and Population Sciences, University of Southampton, Southampton, UK.

Objective: Explore qualitative differences between interventions (DVD and booklet (DVDB) versus face-to-face and booklet (F2FB) versus usual care) in the BREATHE (Breathing Retraining for Asthma Trial of Home Exercises) trial of breathing retraining for asthma.

Design: Quantitative process analysis exploring group expectancy, experience and practice before and after intervention delivery for the main trial.

Setting: Primary care.

Subjects: Adults with asthma (DVD and booklet,  = 261; F2FB,  = 132).

Main Measures: Baseline - expectancy about breathing retraining; follow-up 3, 6 and 12 months - self-efficacy, treatment experience (enjoyment of treatment, perceptions of physiotherapist, perceptions of barriers), amount of practice (weeks, days/week, times/day), continued practice; all time points - anxiety (Hospital Anxiety and Depression Scale), AQLQ (Asthma Quality of Life Questionnaire).

Results: No group differences in baseline expectancy. Statistically significant results ( < 0.05) indicated that at follow-up, F2FB participants perceived greater need for a physiotherapist than DVD and booklet participants (3.43 (0.87) versus 2.15 (1.26)). F2FB participants reported greater enjoyment of core techniques (such as stomach breathing: 7.42 (1.67) versus 6.13 (1.99) (DVD and booklet)). Fewer F2FB participants reported problems due to doubts (24 (22.9%) versus 90 (54.2%)). F2FB participants completed more practice sessions (75.01 (46.38) versus 48.56 (44.71)). Amount of practice was not significantly related to quality of life. In the DVD and booklet arm, greater confidence in breathing retraining ability explained 3.9% of variance in quality of life at 12 months.

Conclusion: Adults with asthma receiving breathing retraining face-to-face report greater enjoyment and undertaking more practice than those receiving a DVD and booklet. Greater confidence in ability to do breathing retraining is associated with improved QoL.
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http://dx.doi.org/10.1177/0269215519832942DOI Listing
July 2019

Hypocapnia correction as a working mechanism for breathing retraining in asthma - Authors' reply.

Lancet Respir Med 2018 04;6(4):e15

Faculty of Health Sciences, University of Southampton, Southampton, SO16 5ST, UK.

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http://dx.doi.org/10.1016/S2213-2600(18)30068-7DOI Listing
April 2018

Physiotherapy breathing retraining for asthma: a randomised controlled trial.

Lancet Respir Med 2018 01 14;6(1):19-28. Epub 2017 Dec 14.

NIHR Southampton Biomedical Research Centre, Southampton, UK; Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK; Asthma UK Centre for Applied Research, University of Edinburgh, Edinburgh, UK. Electronic address:

Background: Despite effective pharmacotherapy, asthma continues to impair quality of life for most patients. Non-pharmacological approaches, including breathing retraining, are therefore of great interest to patients. However, clinicians rarely advocate breathing retraining and access to this intervention is restricted for most patients due to the limited availability of suitable physiotherapists and poor integration of breathing retraining into standard care. We aimed to assess the effectiveness of a digital self-guided breathing retraining intervention.

Methods: In this randomised controlled trial, we recruited patients from 34 general practices in the UK. Eligibility criteria for patients with asthma were broad, comprising a physician diagnosis of asthma, age of 16-70 years, receipt of at least one anti-asthma medication in the previous year, and impaired asthma-related quality of life (Asthma Quality of Life Questionnaire [AQLQ] score of <5·5). We developed a self-guided intervention, which was delivered as a DVD plus a printed booklet (DVDB). Participants were randomly assigned to receive either the DVDB intervention, three face-to-face breathing retraining sessions, or standard care, in a 2:1:2 ratio, for 12 months. Randomisation was achieved using the Southampton Clinical Trials Unit telephone randomisation service by use of random number generators. The primary outcome was the AQLQ score in the intention-to-treat population at 12 months. The trial was powered to show equivalence between the two active intervention groups, and superiority of both intervention groups over usual care. Secondary outcomes included patient-reported and physiological measures of asthma control, patient acceptability, and health-care costs. This trial was registered with International Standard Randomised Controlled Trial Number registry, number ISRCTN88318003.

Findings: Between Nov 5, 2012 and Jan 28, 2014, invitations to participate in the study were sent to 15 203 patients with general practitioner-diagnosed asthma, of whom 655 were recruited into the study. AQLQ scores at 12 months were significantly higher in the DVDB group (mean 5·40, SD 1·14) than in the usual care group (5·12, SD 1·17; adjusted mean difference 0·28, 95% CI 0·11 to 0·44), and in the face-to-face group (5·33, SD 1·06) than in the usual care group (adjusted mean difference 0·24, 95% CI 0·04 to 0·44); AQLQ scores were similar between the DVDB group and the face-to-face group (0·04, 95% CI -0·16 to 0·24). There were no significant differences between the randomisation groups in FEV1 or fraction of exhaled nitric oxide. 744 adverse events occurred in 272 patients: 101 (39%) of 261 patients in the DVDB group, 55 (42%) of 132 patients in the face-to-face group, and 132 (50%) of 262 in the usual care group, with patients reporting one or more event. 11 (4%) patients in the DVDB group, four (3%) patients in the face-to-face group, and 20 (8%) patients in the usual care group had a serious adverse event.

Interpretation: Breathing retraining programmes improve quality of life in patients with incompletely controlled asthma despite having little effect on lung function or airway inflammation. Such programmes can be delivered conveniently and cost-effectively as a self-guided digital audiovisual programme, so might also reduce health-care costs.

Funding: UK National Institute of Health Research.
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http://dx.doi.org/10.1016/S2213-2600(17)30474-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5757422PMC
January 2018

Breathing pattern recordings using respiratory inductive plethysmography, before and after a physiotherapy breathing retraining program for asthma: A case report.

Physiother Theory Pract 2018 Apr 10;34(4):329-335. Epub 2017 Nov 10.

a Faculty of Health Sciences, Highfield Campus , University of Southampton, Southampton , UK.

Breathing retraining (BR) improves symptoms, psychological well-being and quality of life in adults with asthma; but there remains uncertainty as to mechanism of effect. One of the intuitively logical theories is that BR works through altering breathing pattern. There is currently no evidence, however, that BR does result in measurable changes in breathing pattern. In this case report we describe the effects of physiotherapy BR on a 57-year-old female with a 10-year history of asthma. Data were collected before and after a physiotherapy BR program comprising three sessions over 18 weeks: breathing pattern (respiratory inductive plethysmography (RIP); physiology (end tidal carbon dioxide (ETCO), heart rate, oxygen saturations, spirometric lung function); questionnaires (Asthma Control Questionnaire (ACQ), Hospital Anxiety and Depression Score, Nijmegen Questionnaire); and medication usage. After BR, the patient's symptoms improved. Her physiology was largely unchanged, although her FEV increased by 0.12L, peak flow by 21L/min. The patient reported using less Salbutamol, yet her asthma control improved (ACQ down 1.5). Her Nijmegen score dropped from positive to negative for hyperventilation (from 39 to 7). Her anxiety-depression levels both reduced into 'normal' ranges. The patient's expiratory time increased, with longer respiratory cycles and slower respiratory rate. No changes were seen in relative contributions of ribcage and abdomen. Controlled trials are now needed to determine the generalizability of these findings.
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http://dx.doi.org/10.1080/09593985.2017.1400139DOI Listing
April 2018

Motivational interviewing in respiratory therapy: What do clinicians need to make it part of routine care? A qualitative study.

PLoS One 2017 31;12(10):e0187335. Epub 2017 Oct 31.

Faculty of Health Sciences, University of Southampton, Southampton, United Kingdom.

Motivational interviewing (MI) is a method for building motivation for behaviour change that has potential for use in respiratory contexts. There is a paucity of published research exploring the feasibility of this intervention from the clinicians' perspective. This study aimed to explore respiratory clinicians' views of MI: Is it perceived as useful? Could it be integrated into practice? What training would be required to make it part of routine care? Nine respiratory clinicians attended a one-day MI workshop and a semi-structured face-to-face interview two weeks later. All interviews were audio-recorded, transcribed verbatim and analysed with thematic analysis. Four main themes are presented-1) MI's suitability for use in respiratory contexts: participants saw potential in using MI to motivate their patients to engage with prescribed respiratory interventions, such as increased physical activity. Those who experimented with new skills post-workshop were encouraged by patient responsiveness and outcomes. 2) MI's relationship with routine clinical practice: some believed they already used elements of MI, but most participants felt MI was fundamentally 'different' to their normal style of working. 3) Implementation issues: additional time would need to be made available to enable an appropriate depth of conversation. 4) Training issues: Participants sensed the complexity of MI could make it difficult to learn and that it would take them time to become competent. On-going supervision was perceived as necessary. One key challenge identified was how to suppress behaviours that are antithetical to MI. These findings lend support to the feasibility of using MI in respiratory contexts such as pulmonary rehabilitation programmes, but highlight implementation and training issues that would need to be overcome. The insights have informed the development of another study, testing the effect of a tailored training package on MI skill, specifically for respiratory clinicians delivering pulmonary rehabilitation programmes.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0187335PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5663487PMC
November 2017

Barriers and facilitators of effective self-management in asthma: systematic review and thematic synthesis of patient and healthcare professional views.

NPJ Prim Care Respir Med 2017 Oct 9;27(1):57. Epub 2017 Oct 9.

Academic Unit of Psychology, University of Southampton, Highfield, Southampton, SO17 1BJ, UK.

Self-management is an established, effective approach to controlling asthma, recommended in guidelines. However, promotion, uptake and use among patients and health-care professionals remain low. Many barriers and facilitators to effective self-management have been reported, and views and beliefs of patients and health care professionals have been explored in qualitative studies. We conducted a systematic review and thematic synthesis of qualitative research into self-management in patients, carers and health care professionals regarding self-management of asthma, to identify perceived barriers and facilitators associated with reduced effectiveness of asthma self-management interventions. Electronic databases and guidelines were searched systematically for qualitative literature that explored factors relevant to facilitators and barriers to uptake, adherence, or outcomes of self-management in patients with asthma. Thematic synthesis of the 56 included studies identified 11 themes: (1) partnership between patient and health care professional; (2) issues around medication; (3) education about asthma and its management; (4) health beliefs; (5) self-management interventions; (6) co-morbidities (7) mood disorders and anxiety; (8) social support; (9) non-pharmacological methods; (10) access to healthcare; (11) professional factors. From this, perceived barriers and facilitators were identified at the level of individuals with asthma (and carers), and health-care professionals. Future work addressing the concerns and beliefs of adults, adolescents and children (and carers) with asthma, effective communication and partnership, tailored support and education (including for ethnic minorities and at risk groups), and telehealthcare may improve how self-management is recommended by professionals and used by patients. Ultimately, this may achieve better outcomes for people with asthma.
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http://dx.doi.org/10.1038/s41533-017-0056-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5634481PMC
October 2017

Patients' experiences of breathing retraining for asthma: a qualitative process analysis of participants in the intervention arms of the BREATHE trial.

NPJ Prim Care Respir Med 2017 Oct 5;27(1):56. Epub 2017 Oct 5.

Faculty of Health Sciences, University of Southampton, Southampton, UK.

Poor symptom control and impaired quality of life are common in adults with asthma, and breathing retraining exercises may be an effective method of self-management. This study aimed to explore the experiences of participants in the intervention arms of the BREATHE trial, which investigated the effectiveness of breathing retraining as a mode of asthma management. Sixteen people with asthma (11 women, 8 per group) who had taken part in the intervention arms of the BREATHE trial (breathing retraining delivered by digital versatile disc (DVD) or face-to-face sessions with a respiratory physiotherapist) took part in semi-structured telephone interviews about their experiences. Interviews were analysed using thematic analysis. Breathing retraining was perceived positively as a method of asthma management. Motivations for taking part included being asked, to enhance progress in research, to feel better/reduce symptoms, and to reduce medication. Participants were positive about the physiotherapist, liked having the materials tailored, found meetings motivational, and liked the DVD and booklet. The impact of breathing retraining following regular practice included increased awareness of breathing and development of new habits. Benefits of breathing retraining included increased control over breathing, reduced need for medication, feeling more relaxed, and improved health and quality of life. Problems included finding time to practice the exercises, and difficulty mastering techniques. Breathing retraining was acceptable and valued by almost all participants, and many reported improved wellbeing. Face to face physiotherapy was well received. However, some participants in the DVD group mentioned being unable to master techniques.

Asthma: PATIENTS RECEPTIVE TO BREATHING RETRAINING: Patients with asthma taught how to change their unconscious breathing patterns generally like non-pharmacological interventions. Researchers in the UK, led by Mike Thomas from the University of Southampton, interviewed 16 people about their experiences in a trial that tested breathing retraining exercises delivered by DVD or face-to-face sessions with a respiratory physiotherapist. Overwhelmingly, trial participants reported that breathing retraining sessions gave them greater control over their symptoms, helped them relax, improved their quality of life and reduced the need for medications. Some participants who received DVD instruction said they had trouble mastering the techniques, and many in both groups found it hard to find time to practice the exercises. Overall, however, patients were positive about the experience. The authors conclude that breathing exercises are likely to be a well-received method of asthma management.
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http://dx.doi.org/10.1038/s41533-017-0055-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5629205PMC
October 2017

A randomised controlled study of the effectiveness of breathing retraining exercises taught by a physiotherapist either by instructional DVD or in face-to-face sessions in the management of asthma in adults.

Health Technol Assess 2017 09;21(53):1-162

Southampton Clinical Trials Unit, University of Southampton, Southampton, UK.

Background: Asthma control is suboptimal, resulting in quality of life (QoL) impairment and costs. Breathing retraining exercises have evidence of effectiveness as adjuvant treatment, but are infrequently used.

Objectives: To transfer the contents of a brief (three-session) physiotherapist-delivered breathing retraining programme to a digital versatile disc (DVD) and booklet format; to compare the effectiveness of the self-guided intervention with that of 'face-to-face' physiotherapy and usual care for QoL and other asthma-related outcomes; to perform a health economic assessment of both interventions; and to perform a process evaluation using quantitative and qualitative methods.

Design: Parallel-group three-arm randomised controlled trial.

Setting: General practice surgeries in the UK.

Participants: In total, 655 adults currently receiving asthma treatment with impaired asthma-related QoL were randomly allocated to the DVD ( = 261), physiotherapist ( = 132) and control (usual care) ( = 262) arms in a 2 : 1 : 2 ratio. It was not possible to blind participants but data collection and analysis were performed blinded.

Interventions: Physiotherapy-based breathing retraining delivered through three 'face-to-face' respiratory physiotherapist sessions or a self-guided programme (DVD plus our theory-based behaviour change booklet) developed by the research team, with a control of usual care.

Main Outcome Measures: The primary outcome measure was asthma-specific QoL, measured using the Asthma Quality of Life Questionnaire (AQLQ). Secondary outcomes included asthma symptom control [Asthma Control Questionnaire (ACQ)], psychological state [Hospital Anxiety and Depression Scale (HADS)], hyperventilation symptoms (Nijmegen questionnaire), generic QoL [EuroQol-5 Dimensions (EQ-5D)], assessments of airway physiology (spirometry) and inflammation (exhaled nitric oxide) and health resource use and costs. Assessments were carried out at baseline and at 3, 6 and 12 months post randomisation. Patient engagement and experience were also assessed using quantitative and qualitative methods.

Results: Primary efficacy analysis was between-group comparison of changes in AQLQ scores from baseline to 12 months in the intention-to-treat population with adjustments for prespecified covariates. Significant improvements occurred in the DVD group compared with the control group [adjusted mean difference 0.28, 95% confidence interval (CI) 0.11 to 0.44;  < 0.001] and in the face-to-face physiotherapy group compared with the control group (adjusted mean difference 0.24, 95% CI 0.04 to 0.44;  < 0.05), with equivalence between the DVD and the face-to-face physiotherapy groups (adjusted mean difference 0.04, 95% CI -0.16 to 0.24). In all sensitivity analyses, both interventions remained significantly superior to the control and equivalence between the interventions was maintained. In other questionnaire outcome measures and in the physiological measures assessed, there were no significant between-group differences. Process evaluations showed that participants engaged well with both of the active interventions, but that some participants in the DVD arm would have liked to receive tuition from a professional. Asthma health-care costs were lower in both intervention arms than in the control group, indicating 'dominance' for both of the interventions compared with the control, with lowest costs in the DVD arm. The rate of adverse events was lower in the DVD and face-to-face physiotherapy groups than in the control group.

Conclusions: Only 10% of the potentially eligible population responded to the study invitation. However, breathing retraining exercises improved QoL and reduced health-care costs in adults with asthma whose condition remains uncontrolled despite standard pharmacological therapy, were engaged with well by patients and can be delivered effectively as a self-guided intervention. The intervention should now be transferred to an internet-based platform and implementation studies performed. Interventions for younger patients should be developed and trialled.

Trial Registration: Current Controlled Trials ISRCTN88318003.

Funding: This project was primarily funded by the NIHR Health Technology Assessment programme and will be published in full in ; Vol. 21, No. 53. See the NIHR Journals Library website for further project information. Additional financial support was received from Comprehensive Local Research Networks.
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http://dx.doi.org/10.3310/hta21530DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5632761PMC
September 2017

A qualitative study of GP, nurse and practice manager views on using targeted case-finding to identify patients with COPD in primary care.

NPJ Prim Care Respir Med 2017 Aug 29;27(1):49. Epub 2017 Aug 29.

NIHR CLAHRC Wessex, Faculty of Health Sciences, University of Southampton, Southampton, SO17 1BJ, UK.

'Finding the missing millions' with chronic obstructive pulmonary disease became part of the Department of Health strategy for England in 2010. Targeted case-finding within primary care is one potential pro-active strategy, but currently little is known about the views of healthcare professionals on this approach. In this study, 36 healthcare professionals (12 GPs, 14 nurses, and 10 practice managers) from 34 UK practices participated in semi-structured telephone interviews about targeted case-finding. Interviews followed an interview guide, were audio-recorded, transcribed verbatim, coded and analysed using 'Framework Approach'. Most of those interviewed practiced opportunistic case-finding. The main perceived barriers to wider case-finding programmes were the resource implications associated with running such programmes and identifying more chronic obstructive pulmonary disease patients. Financial incentives, support from specialist clinicians, and comprehensive guidance were viewed as facilitators. While targeted case-finding is conceptually accepted by primary care staff, scepticism surrounding (1) the value of identifying those with mild disease and (2) the availability of effective targeted case-finding methods, may lead some to favour an opportunistic approach. Key concerns were a lack of unequivocal evidence for the relative benefits vs. disadvantages of diagnosing patients earlier, and resource constraints in an already over-burdened system. Barriers to practical implementation of case-finding studies may be addressed with financial, human and educational resources, such as additional staff to undertake searches and perform spirometry tests, and practical and educational support from specialist teams.

Chronic Obstructive Pulmonary Disease: SUPPORT NEEDED TO IDENTIFY THOSE UNDIAGNOSED: Additional staff and resources would facilitate targeted searches for patients showing symptoms of early-stage chronic lung disease. Chronic obstructive pulmonary disease (COPD) costs the UK economy billions of pounds each year, yet disparate symptoms mean patients aren't always diagnosed in the early, treatable stages of the disease. Recent guidelines suggest introducing 'targeted case-finding', where symptomatic patients with known risk factors are identified and approached for testing by doctors. Rachael Summers and colleagues at the University of Southampton analyzed the opinions of healthcare professionals on implementing targeted case-finding in primary care. While most of the 36 professionals interviewed agreed that diagnosing COPD earlier had clear benefits, concerns were raised regarding negative patient responses and increased stress for patients, alongside the added strain on already stretched resources. Employing independent staff and enhancing resources may facilitate such a program.
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http://dx.doi.org/10.1038/s41533-017-0049-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5575077PMC
August 2017

Giving hope, ticking boxes or securing services? A qualitative study of respiratory physiotherapists' views on goal-setting with people with chronic obstructive pulmonary disease.

Clin Rehabil 2017 Jul 20;31(7):978-991. Epub 2016 Jul 20.

7 Arbeitsbereich Interdisziplinäre Alternswissensschaft, Goethe-Universitat Frankfurt am Main, Main, Germany.

Objective: To explore respiratory physiotherapists' views and experiences of using goal-setting with people with chronic obstructive pulmonary disease in rehabilitation settings.

Participants: A total of 17 respiratory physiotherapists with ⩾12 months current or previous experience of working with patients with chronic obstructive pulmonary disease in a non-acute setting. Participants were diverse in relation to age (25-49 years), sex (13 women), experience (Agenda for Change bands 6-8) and geographic location.

Method: Data were collected via face-to-face qualitative in-depth interviews (40-70 minutes) using a semi-structured interview guide. Interview locations were selected by participants (included participants' homes, public places and University). Interviews followed an interview guide, were audio-recorded and transcribed verbatim.

Data Analysis: Data were analysed using thematic analysis; constant comparison was made within and between accounts, and negative case analysis was used.

Results: Three themes emerged through the process of analysis: (1) 'Explaining goal-setting'; (2) 'Working with goals'; and (3) 'Influences on collaborative goal-setting'. Goal-setting practices among respiratory physiotherapists varied considerably. Collaborative goal-setting was described as challenging and was sometimes driven by service need rather than patient values. Lack of training in collaborative goal-setting at both undergraduate and postgraduate level was also seen as an issue.

Conclusion: Respiratory physiotherapists reflected uncertainties around the use of goal-setting in their practice, and conflict between patients' goals and organisational demands. This work highlights a need for wider discussion to clarify the purpose and implementation of goal-setting in respiratory rehabilitation.
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http://dx.doi.org/10.1177/0269215516658937DOI Listing
July 2017

Interactive digital interventions to promote self-management in adults with asthma: systematic review and meta-analysis.

BMC Pulm Med 2016 May 23;16(1):83. Epub 2016 May 23.

Institute of Health and Wellbeing, University of Glasgow, Glasgow, G12 9LX, UK.

Background: To identify, summarise and synthesise the evidence for using interactive digital interventions to support patient self-management of asthma, and determine their impact.

Methods: Systematic review with meta-analysis. We searched MEDLINE, EMBASE, CINAHL, PsycINFO, ERIC, Cochrane Library, DoPHER, TROPHI, Social Science Citation Index and Science Citation Index. The selection criteria requirement was studies of adults (16 years and over) with asthma, interventions that were interactive digital interventions and the comparator was usual care. Outcomes were change in clinical outcomes, cost effectiveness and patient-reported measures of wellbeing or quality of life. Only Randomised Controlled Trials published in peer-reviewed journals in English were eligible. Potential studies were screened and study characteristics and outcomes were extracted from eligible papers independently by two researchers. Where data allowed, meta-analysis was performed using a random effects model.

Results: Eight papers describing 5 trials with 593 participants were included, but only three studies were eligible for inclusion for meta-analysis. Of these, two aimed to improve asthma control and the third aimed to reduce the total dose of oral prednisolone without worsening control. Analyses with data from all three studies showed no significant differences and extremely high heterogeneity for both Asthma Quality of Life (AQLQ) (Standardised Mean Difference (SMD) 0.05; 95 % Confidence Interval (CI) 0.32 to -0.22: I2 96.8) and asthma control (SMD 0.21; 95 % CI -0.05 to .42; I2 = 87.4). The removal of the third study reduced heterogeneity and indicated significant improvement for both AQLQ (SMD 0.45; 95 % CI 0.13 to 0.77: I2 = 0.34) and asthma control (SMD 0.54; 95 % CI 0.22 to 0.86: I2 = 0.11). No evidence of harm was identified.

Conclusion: Digital self-management interventions for adults with asthma show promise, with some evidence of small beneficial effects on asthma control. Overall, the evidence base remains weak due to the lack of large, robust trials.
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http://dx.doi.org/10.1186/s12890-016-0248-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4876566PMC
May 2016

Use of the Nijmegen Questionnaire in asthma.

ERJ Open Res 2015 May 16;1(1). Epub 2015 Jul 16.

Centre for Application of Health Psychology, University of Southampton, Southampton, UK.

http://ow.ly/OuOX5.
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http://dx.doi.org/10.1183/23120541.00033-2015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5005143PMC
May 2015

The Relationship Between Crackle Characteristics and Airway Morphology in COPD.

Respir Care 2015 Mar 25;60(3):412-21. Epub 2014 Nov 25.

National Institute for Health Research, Southampton Respiratory Biomedical Research Unit, Southampton Centre for Biomedical Research, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom.

Background: Crackles in COPD are believed to be generated by the re-opening of collapsed airways, which result from chronic inflammation, secretions, and loss of cartilaginous support through inflammation. However, it is unclear whether crackle characteristics can be used to identify COPD. This is the first study to examine the relationship between specific added lung sounds (crackles) and measurements of conductive airways and emphysema score obtained from high-resolution computed tomography (HRCT) in vivo in humans. A predictive relationship might permit the use of lung sounds as a biomarker for COPD.

Methods: A convenience sample of 26 subjects was recruited into the study and consisted of 9 healthy non-smokers, 9 healthy smokers, and 8 subjects with mild or moderate COPD. Lung sound data were recorded using a digital stethoscope connected to a laptop computer. Airway diameter, emphysema score, and percentage of wall area were measured from HRCT scans.

Results: The analysis showed that there were no statistically significant differences in crackle characteristics (the number of crackles per breathing cycle and crackle 2-cycle duration) between the 3 subject groups. Both crackle 2-cycle duration and crackle number showed some significant correlation with airway parameters at some branch generations, but due to the large number of correlations performed, these were consistent with chance findings.

Conclusions: Although there were some significant correlations between crackle characteristics and measurements of the conductive airways and emphysema score, the possibility that these correlations have occurred by chance cannot be ruled out. Therefore, this study provides no conclusive evidence that crackle characteristics are related to HRCT variables in COPD.
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http://dx.doi.org/10.4187/respcare.03543DOI Listing
March 2015

Uncertainty prior to pulmonary rehabilitation in primary care: A phenomenological qualitative study in patients with chronic obstructive pulmonary disease.

Chron Respir Dis 2014 08 30;11(3):173-180. Epub 2014 Jun 30.

Faculty of Health Sciences, University of Southampton, UK.

Pulmonary rehabilitation (PR) is recommended for patients functionally restricted by chronic obstructive pulmonary disease (COPD). However, attendance and adherence to PR remains suboptimal. No previous research has explored COPD patient experiences during the key period from referral to initiation of PR in the United Kingdom. This research aimed to explore the lived experience of COPD patients referred to PR programmes prior to participation. COPD participants were recruited from referrals to two community PR programmes. Semi-structured interviews with COPD participants occurred following PR referral, but prior to programme initiation. Data were analyzed using applied interpretive phenomenology. Twenty-five COPD participants aged 42-90 were interviewed. 'Uncertainty' affected participants throughout their lived experience of COPD that negatively impacted illness perceptions, PR perceptions and increased participant's panic and anger. Participants who perceived COPD less as a chronic condition and more as a cyclical process experienced fewer feelings of panic or anger. The experience of uncertainty was disabling for these COPD participants. Recognition of the role that uncertainty plays in patients with COPD is the first step towards developing interventions focused on reducing this uncertainty, thereby reducing the burden of the disease for the individual patient and facilitating PR attendance.
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http://dx.doi.org/10.1177/1479972314539981DOI Listing
August 2014

Patients' perceptions of the potential of breathing training for asthma: a qualitative study.

Prim Care Respir J 2013 Dec;22(4):449-53

Academic Unit of Psychology, Faculty of Social and Human Sciences, University of Southampton, Southampton, UK.

Background: Poor symptom control is common in asthma. Breathing training exercises may be an effective adjunct to medication; it is therefore important to understand facilitators and barriers to uptake of breathing training exercises.

Aims: To gain insight into patients' perceptions of breathing training exercises designed to help control asthma symptoms.

Methods: Semi-structured think-aloud interviews were conducted with 29 people with asthma about their views of a booklet on breathing training exercises.

Results: Thematic analysis showed breathing training exercises were seen as acceptable in principle because they were viewed as nonpharmacological, holistic, unobtrusive, and likely to increase patient confidence in managing symptoms. Anticipated disadvantages included the time required and perceived irrelevance for those with well-controlled asthma. These views were influenced by prior experience of changing breathing, wanting to self-manage asthma, negative views of medication, and perceived asthma control/severity. Anticipated barriers to carrying out the exercises included difficulties with nose breathing, remembering to do them, and persevering with them. Anticipated facilitators included monitoring tools and social support.

Conclusions: The idea of breathing training was viewed positively as an acceptable non-pharmacological treatment that patients can do discreetly to help them breathe more easily and reduce their reliance on medication. Uptake of breathing training may be greater among those who perceive their asthma as severe and/or have negative views of medication. To enhance uptake, it might be helpful to present breathing training exercises as holistic skills that can also benefit those with mild symptoms.
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http://dx.doi.org/10.4104/pcrj.2013.00092DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6442861PMC
December 2013

Are crackles an appropriate outcome measure for airway clearance therapy?

Respir Care 2012 Sep 17;57(9):1468-75. Epub 2012 Feb 17.

School of Health Sciences, University of Aveiro, Campus de Santiago, Aveiro, Portugal.

Background: There is an urgent need to develop new outcome measures for respiratory therapy, to evaluate its effectiveness. Adventitious sounds generated from the lungs (crackles and wheezes), can now be quantified and characterized objectively with computer technology. To our knowledge, this is the first reported study designed to assess any change in lung crackles before and after a single session of airway clearance therapy.

Methods: Twenty-three stable bronchiectasis patients were recruited from United Kingdom out-patient clinics and treated with a single session of airway clearance therapy, using the active cycle of breathing technique. Sound recordings were made before and after the session at 7 anatomical chest locations. Computerized lung sound analysis was used to measure crackle parameters: 2-cycle deflection width (2CD), and crackle number per breath cycle (nBC). Perceived breathlessness, lung function, and oxygen saturation data were also recorded.

Results: Crackle mean 2CD and mean nBC increased post intervention. Sixteen participants (70%) showed a statistically significant difference in mean crackle 2CD before and after the session at ≥ 1 chest location. Thirteen (57%) participants had a difference between mean crackle 2CD before and after the intervention > 1 Smallest Real Difference (SRD, mean SRD = 2.23 ms) at ≥ 1 chest location. Differences in mean crackle nBC before and after the intervention did not exceed the SRD (mean SRD = 32 crackles per breath cycle) in any participant. Perceived breathlessness was significantly reduced post intervention; no significant changes were observed in either lung function or oxygen saturation.

Conclusions: Crackle duration (2CD) was found to change after a single session of airway clearance therapy, and shows promise as a new outcome measure for respiratory therapy interventions.
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http://dx.doi.org/10.4187/respcare.01625DOI Listing
September 2012

Respiratory physiotherapy: towards a clearer definition of terminology.

Physiotherapy 2011 Dec 6;97(4):345-9. Epub 2011 May 6.

Highfield Campus, University of Southampton, Southampton SO17 1BJ, UK.

Interventions used in clinical practice and research need to be described in sufficient detail to permit accurate replication. Since words and phrases can change their meaning over time, it is important that authors choose their words carefully and define anything which might be ambiguous. 'Breathing exercises' is a phrase which covers a multitude of therapeutic approaches. Recent randomised controlled trials have established the value of teaching patients with asthma to retrain their breathing. However, the descriptions of the breathing interventions are generally inadequate. This problem stems partly from a degree of confusion surrounding terms such as 'diaphragmatic breathing' which has been variously interpreted. A more structured approach to reporting such interventions is proposed. This approach will help to avoid confusion, and will permit the transfer of those interventions found to be effective in research trials into routine clinical practice.
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http://dx.doi.org/10.1016/j.physio.2010.12.005DOI Listing
December 2011

Asthma and psychological dysfunction.

Prim Care Respir J 2011 Sep;20(3):250-6

Academic Primary Care, University of Aberdeen, Foresterhill Health Centre, Westburn Road, Aberdeen, UK.

Despite effective treatment, asthma outcomes remain suboptimal. Anxiety and depression occur more commonly in people with asthma than expected, and are associated with poor asthma outcomes. The direction of the relationship and the mechanisms underlying it are uncertain. Whether screening for and treating co-morbid anxiety and depression can improve asthma outcomes is unclear from the current evidence. Primary care clinicians treating asthma should be aware of the possibility of psychological dysfunction in asthmatics, particularly those with poor control. Further research is required to assess the importance of detecting and treating these conditions in community asthma care.
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http://dx.doi.org/10.4104/pcrj.2011.00058DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6549858PMC
September 2011

The importance of movement for people living with chronic obstructive pulmonary disease.

Qual Health Res 2011 Sep 21;21(9):1239-48. Epub 2011 Apr 21.

School of Health Sciences and Social Care, Brunel University, West London, United Kingdom.

Chronic obstructive pulmonary disease (COPD) is a chronic respiratory disease that gives rise to symptoms of breathlessness, chronic fatigue, and cough. The impact of COPD on people's activity has been widely acknowledged, yet it appears that we know little about how individuals experience activity. We employed a grounded theory study with 18 participants with COPD to explore their dimensions of activity. We identified two core concepts that captured participants' experience of activity; these were stagnation and movement. We found fresh air to be the single most important aspect affecting participants' experience of stagnation and movement; this was linked to a changed perception of symptoms. We identified the environment as an important context influencing the experience of COPD and activity. Our stagnation-movement theory explains the experience of activity within its environmental context, and how this experience might be affected on physical, social, and psychological levels.
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http://dx.doi.org/10.1177/1049732311405801DOI Listing
September 2011

Ambulatory oxygen: why do COPD patients not use their portable systems as prescribed? A qualitative study.

BMC Pulm Med 2011 Feb 11;11. Epub 2011 Feb 11.

School of Health Sciences, Highfield Campus, University of Southampton, Hampshire, UK.

Background: Patients with COPD on long term oxygen therapy frequently do not adhere to their prescription, and they frequently do not use their ambulatory oxygen systems as intended. Reasons for this lack of adherence are not known. The aim of this study was to obtain in-depth information about perceptions and use of prescribed ambulatory oxygen systems from patients with COPD to inform ambulatory oxygen design, prescription and management.

Methods: A qualitative design was used, involving semi-structured face-to-face interviews informed by a grounded theory approach. Twenty-seven UK community-dwelling COPD patients using NHS prescribed ambulatory systems were recruited. Ambulatory oxygen systems comprised cylinders weighing 3.4 kg, a shoulder bag and nasal cannulae.

Results: Participants reported that they: received no instruction on how to use ambulatory oxygen; were uncertain of the benefits; were afraid the system would run out while they were using it (due to lack of confidence in the cylinder gauge); were embarrassed at being seen with the system in public; and were unable to carry the system because of the cylinder weight. The essential role of carers was also highlighted, as participants with no immediate carers did not use ambulatory oxygen outside the house.

Conclusions: These participants highlighted previously unreported problems that prevented them from using ambulatory oxygen as prescribed. Our novel findings point to: concerns with the lack of specific information provision; the perceived unreliability of the oxygen system; important carer issues surrounding managing and using ambulatory oxygen equipment. All of these issues, as well as previously reported problems with system weight and patient embarrassment, should be addressed to improve adherence to ambulatory oxygen prescription and enhance the physical and social benefits of maintaining mobility in this patient group. Increased user involvement in both system development and service provision planning, could have avoided many of the difficulties highlighted by this study.
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http://dx.doi.org/10.1186/1471-2466-11-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3045998PMC
February 2011

The role of breathing training in asthma management.

Curr Opin Allergy Clin Immunol 2011 Feb;11(1):53-7

Faculty of Health Sciences, Highfield Campus, University of Southampton, Southampton, UK.

Purpose Of Review: There is considerable public interest in the use of breathing modification techniques in the treatment of asthma. Surveys suggest many people with asthma use them, often without the knowledge of their medical attendants. Extravagant claims have been made about the effectiveness of some techniques, resulting in scepticism from orthodox clinicians. The evidence supporting breathing training for asthma was previously weak, and limited by the small size and methodological limitations of published research.

Recent Findings: The evidence base for the effectiveness of breathing training has recently improved, with reports from several larger and more methodologically robust controlled trials. These trials are reviewed in this study, and the findings placed in context. Trials have investigated a variety of breathing training programmes delivered by different therapists in different ways. All incorporate some instruction in breathing pattern, usually focusing on slow, regular, nasal, abdominal breathing and reduced ventilation, with patients instructed to practise exercises at home and when symptomatic.

Summary: Current evidence suggests that breathing training programmes can be effective in improving patient-reported outcomes such as symptoms, quality of life and psychological impact; and may reduce the use of rescue bronchodilator medication. There is little evidence that airways physiology, hyper-responsiveness or inflammation is affected by such training. The optimal way of providing breathing training within the context of routine asthma care is still uncertain.
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http://dx.doi.org/10.1097/ACI.0b013e3283423085DOI Listing
February 2011

Acupuncture for respiratory disorder: what's the point?

Expert Rev Respir Med 2010 Feb;4(1):29-37

Physiotherapy Department, Southampton University Hospitals NHS Trust, Southampton, Tremona Road, Southampton, 5016 6YD, UK.

Acupuncture has been an integral part of Traditional Chinese Medicine for thousands of years. It has been used for the treatment of many painful and nonpainful conditions. Its use within Western medicine has increased since the 1970s and acupuncture is now practiced by a variety of healthcare practitioners across Europe. There is an accepted body of evidence to support the use of acupuncture for back or neck pain. Anecdotal evidence from both clinicians and patients suggests there may be some beneficial effect of acupuncture in the treatment of respiratory symptoms, such as bronchospasm, breathlessness and hyperventilation syndromes. Some respiratory clinicians are introducing acupuncture as a treatment modality for the management of respiratory symptoms, despite the lack of available objective evidence to support this practice. This article reviews the available evidence for the use of acupuncture in respiratory disorders and provides discussion of the methodological issues that are evident within this literature. It also highlights reasons for the lack of objective evidence to support acupuncture for respiratory conditions and the difficulties faced by acupuncture researchers when designing randomized, placebo-controlled trials. Currently, there is insufficient evidence to support a recommendation for the use of acupuncture in respiratory disorders.
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http://dx.doi.org/10.1586/ers.09.63DOI Listing
February 2010

The reliability of lung crackle characteristics in cystic fibrosis and bronchiectasis patients in a clinical setting.

Physiol Meas 2009 Sep 30;30(9):903-12. Epub 2009 Jul 30.

Escola Superior de Saúde, Universidade de Aveiro, Campus Santiago Edifício II, 3810-19,3 Aveiro, Portugal.

Lung sounds provide useful information for assessing and monitoring respiratory patients, but standard auscultation is subjective. Computer aided lung sound analysis (CALSA) enables the quantification and characterisation of added lung sounds (e.g. crackles). At present, little is known about the reliability of these sound characteristics. Therefore, the aim of this study was to explore the reliability of crackle initial deflection width (IDW) and two-cycle deflection (2CD) in a clinical population. Fifty-four subjects (37 bronchiectasis, 17 cystic fibrosis) were recruited from out-patient clinics. Three repeated lung sound recordings were taken at seven anatomical sites with a digital stethoscope connected to a laptop computer. The intra-subject reliability of crackle IDW and 2CD was found to be 'good' to 'excellent', estimated by the analysis of variance, intraclass correlation coefficient (IDW 0.76;0.85, 2CD 0.83;0.94), Bland and Altman 95% limits of agreement (IDW -0.50;0.47 ms, 2CD -2.12;1.87 ms) and smallest real difference (IDW 0.30;0.66 ms, 2CD 1.57;2.42 ms). Crackle 2CD was found to be more reliable than IDW. It is concluded that crackle IDW and 2CD characterized by CALSA have good test-retest reliability. This technique requires further evaluation since CALSA has potential to diagnose or monitor respiratory conditions, and provide an objective physiological measure for respiratory interventions.
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http://dx.doi.org/10.1088/0967-3334/30/9/003DOI Listing
September 2009

The effect of pulmonary rehabilitation on perceptions of breathlessness and activity in COPD patients: a qualitative study.

Prim Care Respir J 2010 Mar;19(1):45-51

School of Health and Social Care, University of Reading, Reading, UK.

Aim: The aim of this study was to explore, using qualitative research methods, how pulmonary rehabilitation (PR) programmes affect the experience of activity and breathlessness of people with COPD.

Methods: A qualitative, interview-based approach was employed. Participants were interviewed pre- and post-PR. Data were analysed using systematic strategies informed by grounded theory methods.

Results: Nine participants (three female) took part. A change in participants' perception of breathlessness and lessening of fear of activity were the main themes identified. PR appeared to impact on the experience of physical social activities, allowing participants to overcome feelings of social isolation.

Conclusions: Prior to PR, participants associated activities with breathlessness and panic; post PR, participants reported reduced fear and felt able to increase their activities. These findings add to our understanding of the impact of PR on individuals' experience of activity and may contribute to improved programmes by addressing patients' needs.
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http://dx.doi.org/10.4104/pcrj.2009.00044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6827610PMC
March 2010
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