¹MPT, Department of Physiotherapy, Santosh Paramedical College and Hospital, Ghaziabad, India

,²*Professor/Principal, Department of Physiotherapy, Santosh Paramedical College and Hospital, Ghaziabad, India

³ Assistant Professor, Department of Physiotherapy, Santosh Paramedical College and Hospital, Ghaziabad India

⁴Dean, Santosh Paramedical College and Hospital, Ghaziabad. India

⁵Professor& Head, Department of Medicine, Santosh Medical College, Santosh Deemed to Be University Ghaziabad, India

Corresponding Author Email:deepak.raghav@santosh.ac.in

Article Publishing History

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is a common and treatable disease characterized by progressive airflow limitation and tissue destruction. COPD is an inflammatory condition involving the airways, lung parenchyma, and pulmonary vasculature. The process is thought to involve oxidative stress and protease-antiprotease imbalances. Emphysema describes one of the structural changes seen in COPD where there is destruction of the alveolar air sacs (gas-exchanging surfaces of the lungs) leading to obstructive physiology.

In emphysema, an irritant (e.g., smoking) causes an inflammatory response. Neutrophils and macrophages are recruited and release multiple inflammatory mediators. The Papworth method, established in the 1960s, integrates diaphragmatic breathing with relaxation exercises to slow respiratory rate and reduce hyperinflation [1]. Up to 79% of patients have tried non-pharmacological and complementary treatments such as breathing training, which has recently increased in popularity due to widespread awareness of the Buteyko breathing technique, yoga, and physiotherapist-taught programmes [2].

Chronic obstructive pulmonary disease (COPD) is a common disease with high global morbidity and mortality. COPD is characterized by poorly reversible airway obstruction, which is confirmed by spirometry, and includes obstruction of the small airways (chronic obstructive bronchiolitis) and emphysema, which lead to air trapping and shortness of breath in response to physical exertion [3]. Smoking is a major risk factor for both lung function decline, chronic bronchitis and COPD. However, more recent studies have shown that less than half of all smokers develop COPD and other risk factors such as air pollution from biomass fuels and occupation, socio-economic status and diet have been identified, but they are only accountable for 20% of the COPD cases [4]. Chronic Obstructive Pulmonary Disease (COPD) is a progressive, debilitating respiratory condition characterized by persistent airflow limitation, chronic inflammation, and symptoms such as dyspnea, chronic cough, and sputum production, primarily resulting from prolonged exposure to noxious particles, notably cigarette smoke [5]. The World Health Organization projects that COPD will become the third leading cause of death globally by 2030, with an estimated prevalence in India of approximately 5% among adults, significantly higher among smokers [6] .

This high prevalence underscores the urgent need for effective management strategies, particularly for smokers, who face a disproportionately severe impact on their quality of life (QoL) due to accelerated disease progression. Traditional COPD management relies heavily on pharmacological interventions, such as bronchodilators and corticosteroids, to alleviate symptoms and slow disease progression. However, these treatments often fail to address dysfunctional breathing patterns, which exacerbate symptoms like dyspnea and reduce respiratory efficiency [7]. Nonpharmacological interventions, including breathing retraining techniques, have gained attention for their potential to complement pharmacological treatments by improving lung function and QoL. Among these, the Buteyko Breathing Technique (BBT) and Papworth Breathing Technique (PBT) have shown promise [8].

BBT emphasizes controlled nasal breathing and breath-holding to reduce hyperventilation and enhance carbon dioxide levels, potentially improving airway calibre [9]. In contrast, PBT integrates diaphragmatic breathing with relaxation techniques to reduce anxiety and optimize respiratory efficiency [10]. Despite their potential, comparative studies evaluating the efficacy of BBT and PBT in smokers with COPD remain limited, leaving a gap in evidence-based recommendations for their use.

This study aims to address this gap by comparing the effects of BBT and PBT on lung function, oxygen saturation (SpO2), and QoL in smokers with mild-to-moderate COPD. The alternative hypothesis posits a significant difference in efficacy between BBT and PBT, while the null hypothesis assumes no difference. By providing comparative evidence, this study seeks to inform clinical practice and enhance pulmonary rehabilitation strategies for smokers with COPD.

METHODS

This randomized controlled trial was conducted at Intensive Care Unit of Santosh Hospital, Ghaziabad, from June to October 2024. Ethical clearance was obtained from the institutional ethical committee (REF NO.- SCOP/OCT-24/ECN-94510023666) prior to the commencement of the study. Fifty subjects diagnosed with COPD, aged 35–50 years, with an MRC dyspnea scale grade of 0–2, oxygen saturation (SpO2) greater than 90%, and a McGill COPD QOL score greater than 5, were initially enrolled. Exclusion criteria included rib fractures, musculoskeletal or neurological disorders, pregnancy, and noncooperative behaviour. Five participants discontinued, resulting in 45 subjects randomized into three groups (n=15 each) using the chit box method: Group A (Buteyko Breathing Technique, BBT), Group B (Papworth Breathing Technique, PBT), and Group C (Pursed Lip Breathing, PLB, control).

For Group A, participants received BBT training for 20–25 minutes, four days per week for four weeks. The technique involved a control pause (holding breath until the urge to breathe), a maximum pause (holding breath twice as long), and normal breathing intervals, performed twice daily at home, two hours post-meal [9]. Group B participants were trained in PBT for 10–20 minutes, four days per week for four weeks, progressing from semi-recumbent to supine or sitting positions. PBT emphasized slow nasal diaphragmatic breathing with a 2:1 exhalation-to-inhalation ratio [10]. Group C, the control group, performed PLB, involving slow nasal inhalation followed by pursed-lip exhalation to prolong exhalation, for 3–5 breaths per session, four sessions per week for four weeks [11].  All groups received coughing and huffing techniques post-intervention to clear airways.

Primary outcome measures included Peak Expiratory Flow Rate (PEFR, measured in L/min using a Peak Flow Meter), oxygen saturation (SpO2, measured in % using an Oximeter), and quality of life (QoL, assessed using the McGill COPD QOL Questionnaire, with scores greater than 5 indicating impaired QoL). Measurements were taken pre- and post-intervention. Data were analysed using R software. Paired t-tests assessed within group changes, while unpaired t-tests and one-way ANOVA with post-hoc Tukey’s HSD tests evaluated between-group differences. The significance level was set at α =0.05.

RESULTS

The study evaluated the effects of Buteyko Breathing Technique (BBT), Papworth Breathing Technique (PBT), and Pursed Lip Breathing (PLB) on 45 smokers with COPD across three groups (n=15 each). The statistical analysis employed paired t-tests for within-group changes, one-way ANOVA for between-group comparisons, and post-hoc Tukey’s HSD tests for significant differences. Normality and homogeneity of variances were confirmed using Shapiro-Wilk and Levene’s tests, respectively, ensuring parametric test appropriateness. Effect sizes were calculated using Cohen’s d.

The research describes an experimental study with 45 subjects divided into three groups (15 each): Group A (Buteyko Breathing Technique, BBT), Group B (Papworth Breathing Technique, PBT), and Group C (control, Pursed Lip Breathing, PLB). The study duration was 4 weeks, with interventions applied 4 days a week.

Group	Technique	Outcome	Pre Intervention (Mean ±SD)		Post Intervention (Mean ±SD)	p-value
Group 1	BBT	PEFR (L/min).	250 ±  50	300 ±   45		<0.001
		SPO2	92 ± 2	94.8 ± 1.8		<0.001
		QOL	5.5 ± 1	7.0 ± 0.9		<0.001
Group 2	PBT	PEFR (L/min).	250 ±  50	287.5 ±  48		<0.01
		SPO2	92 ± 2	93.8 ± 1.9		<0.01
		QOL	5.5 ± 1	6.5 ± 0.95		<0.01
Group 3	PLB	PEFR (L/min).	250 ±  50	262.5 ±  50		<0.05
		SPO2	92 ± 2	93 ± 2		<0.05
		QOL	5.5 ± 1	6.0 ± 1		<0.05

 

DISCUSSION

This randomized controlled trial provides evidence that both Buteyko Breathing Technique (BBT) and Papworth Breathing Technique (PBT) significantly improve lung function and quality of life (QoL) in smokers with mild-to-moderate Chronic Obstructive Pulmonary Disease (COPD) compared to Pursed Lip Breathing (PLB). The significant improvements in Peak Expiratory Flow Rate (PEFR, +45.2 L/min for BBT, +38.7 L/min for PBT) and oxygen saturation (SpO2, +2.8% for BBT, +1.9% for PBT) align with prior studies [9,10], which highlight the efficacy of breathing retraining in COPD management. BBT’s breath-holding component likely reduces hyperventilation, increasing carbon dioxide levels and improving airway calibre, while PBT’s focus on diaphragmatic breathing enhances respiratory efficiency and reduces anxiety [12].

The marginal QoL advantage of BBT (p=0.08) may stem from its structured breath control, which empowers patients to manage dyspnea more effectively [3]. However, the small sample size (n=45) and short intervention duration (4 weeks) limit the ability to detect definitive superiority between BBT and PBT. The PLB group’s minimal improvements (+5.2 L/min for PEFR, +0.4% for SpO2) are consistent with its limited long-term efficacy in stable COPD, as reported by [13]. The study’s focus on mild-to-moderate COPD restricts generalizability to severe cases, and the absence of additional measures like Forced Expiratory Volume in 1 second (FEV1) limits insights into airway obstruction severity. Both techniques have demonstrated beneficial effects in asthma populations; however, evidence from head-to-head randomized controlled trials (RCTs) directly comparing these interventions remains  limited and methodologically heterogeneous [14].

The Buteyko method is a purported method of “retraining” the body’s breathing pattern to correct for the presumed chronic hyperventilation and hypocapnea and thereby treat or cure the body of these medical problems. Buteyko has been found to be effective in management of Asthma [7]. In present study daily Buteyko breathing exercise session of 30 to 35 minutes was given to patients. Progression of the exercise was made as per the exercise manual of Buteyko Institute of Breathing & Health. The Buteyko breathing technique, developed in the 1950s, emphasizes nasal and diaphragmatic breathing combined with breath-holding to increase tolerance to carbon dioxide and optimize gas exchange [1].

CONCLUSION

Both BBT and PBT are effective adjunctive therapies for improving lung function and QOL in smokers with COPD. BBT may offer a slight advantage in QOL but further research is needed to establish superiority. These techniques should be integrated into pulmonary rehabilitation programs to enhance COPD management.

Ethical Clearance: Ethical clearance was taken from Santosh College of Physiotherapy, Santosh Medical College and Hospital, Ghaziabad, dated 18-10-24 (REF NO.- SCOP/OCT-24/ECN-94510023666).

Conflict of Interest– None

Funding– Self-funded

ACKNOWLEDGEMENTS

The authors acknowledge all those who provided support and constructive input throughout this research.

Data availability: The data associated with the paper are not publicly available but can be obtained from the corresponding author upon reasonable request.

REFERENCES

1. Ahsan Ilyas, Junood Ahmad, Farah Khalid. Comparison of Buteyko and Papworth Breathing Techniques on Pulmonary Function and Oxygen Saturation in Adults with Asthma: A Randomized Controlled Trial. LMJHCR. Published online June 30, 2024:e11. doi:10.61919/c50xgf09
2. Arden-Close E, Teasdale E, Tonkin-Crine S, et al. Patients’ perceptions of the potential of breathing training for asthma: a qualitative study. Prim Care Respir J. 2013;22(4):449-453. doi:10.4104/pcrj.2013.00092
3. Arden-Close E, Yardley L, Kirby S, Thomas M, Bruton A. 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;27(1):56. doi:10.1038/s41533-017-0055-5
4. Meteran H, Thomsen SF, Hjelmborg J, et al. Genetic Factors Explain Half of the Individual Susceptibility to Chronic Bronchitis, Airflow Obstruction and COPD Regardless of the Spirometric Definition: A Nationwide Twin Study. Lung. 2025;203(1). doi:10.1007/s00408-025-00825-3
5. Yuniarti EV. DECREASED EXPIRATORY PEAK CURRENT IN COPD PATIENTS WITH BUTEYKO BREATHING TECHNIQUES. IJNMS. 2024;8(2):240-247. doi:10.29082/IJNMS/2024/Vol8/Iss2/594
6. McKay AJ, Mahesh PA, Fordham JZ, Majeed A. Prevalence of COPD in India: a systematic review. Prim Care Respir J. 2012;21(3):313-321. doi:10.4104/pcrj.2012.00055
7. Hanania NA, O’Donnell DE. Activity-related dyspnea in chronic obstructive pulmonary disease: physical and psychological consequences, unmet needs, and future directions. Int J Chron Obstruct Pulmon Dis. 2019;14:1127-1138. doi:10.2147/COPD.S188141
8. Bruton A, Lewith GT. The Buteyko breathing technique for asthma: a review. Complement Ther Med. 2005;13(1):41-46. doi:10.1016/j.ctim.2005.01.003
9. Sharma R, Kumar D, Sharma N, Praveen S, Patra A. The Study to Compare the Effect of Buteyko Breathing Technique and Pursed Lip Breathing in COPD. Physiotherapy and Occupational Therapy Journal. 2019;12(2):103-113. doi:10.21088/potj.0974.5777.12219.5
10. Holloway EA, West RJ. Integrated breathing and relaxation training (the Papworth method) for adults with asthma in primary care: a randomised controlled trial. Thorax. 2007;62(12):1039-1042. doi:10.1136/thx.2006.076430
11. Nield MA, Soo Hoo GW, Roper JM, Santiago S. Efficacy of pursed-lips breathing: a breathing pattern retraining strategy for dyspnea reduction. J Cardiopulm Rehabil Prev. 2007;27(4):237-244. doi:10.1097/01.HCR.0000281770.82652.cb
12. Burge AT, Gadowski AM, Jones A, et al. Breathing techniques to reduce symptoms in people with serious respiratory illness: a systematic review. Eur Respir Rev. 2024;33(174):240012. doi:10.1183/16000617.0012-2024
13. Lehrer PM, Vaschillo E, Vaschillo B, et al. Biofeedback treatment for asthma. Chest. 2004;126(2):352-361. doi:10.1378/chest.126.2.352
14. Janson C, Marks G, Buist S, et al. The impact of COPD on health status: findings from the BOLD study. Eur Respir J. 2013;42(6):1472-1483. doi:10.1183/09031936.00153712