Nasal Breathing Exercise and its Effect on Symptoms of Allergic Rhinitis

Abstract

Allergic rhinitis (AR) is a common and chronic health problem with a high prevalence and a significant effect on the health care expenditure. Intranasal steroid spray is recommended as the first line therapy for patients with moderate to severe AR. Our study clinically analysed the use of nasal breathing exercise (NBE) as an adjunct to intranasal steroid spray as a cheap and effective mode of management of AR. A 3 month, parallel, randomized study was carried out in a zonal and tertiary care referral center. In this study, participants (N = 60) with symptomatic AR were administered either a intranasal steroid spray fluticasone propionate (group A) or fluticasone propionate nasal spray and NBE (group B). Participants assessed their symptom severity daily over the 3 month treatment period. The mean total nasal symptom scores were lower in both the groups (5.1 vs. 3.8333 for group A and 5.2 vs. 2.6777 for group B) and the difference was statistically significant (P < 0.05). The patients showed a definite improvement in overall and individual symptoms for both groups with significantly greater reduction in individual symptoms in the group B (P < 0.05). In our study we have found that both treatments provided clinically meaningful responses, but the overall results favored fluticasone propionate and the NBE group. Hence NBE is a simple and cost effective measure to reduce symptoms of AR and improve patient satisfaction.

Introduction

Allergic rhinitis (AR) is a common health problem that leads to frequent visits to primary care physicians and to ear, nose and throat specialists. It contributes to a significant amount of health care expenditure due to direct costs arising from physician visits, as well as indirect costs related to missed days at work and a general loss of productivity due to a decrease in life-quality of those affected [1–4]. AR is a global health problem that affects patients of all ages and ethnic groups with an estimated prevalence of 30% in the general population [5].

AR treatment includes allergen avoidance, pharmacotherapy and immunotherapy. Intranasal corticosteroids (INS) are recommended as first-line therapy for patients with moderate-to-severe disease, especially when nasal congestion is a major component of symptoms [6].

Due to the chronicity of disease and the variable response to therapy, a large number of patients resort to complimentary and alternate medication for AR. Our aim of the study was to identify the efficacy of nasal breathing exercises (NBE) in patients of AR.

Materials and Methods

The study design was a prospective analysis performed at a zonal and tertiary care referral hospital and was approved by the institutional ethical committee. Between Jan 1, 2008 and Dec 31, 2008, 98 patients of AR were prospectively enrolled in the study.

Eligibility criteria for inclusion were established criteria for AR as per ARIA 2007 and age >18 years. Exclusion criteria were pregnancy, lactation, significant psychological problems, inability to comply with the study protocol, recent nasal and paranasal surgery and treatment with systemic steroids during the previous 30 days or use of topical steroids, antihistamines, decongestants, or cromolyn in the preceding 2 weeks or immunotherapy in the last 2 years.

Overall 80 patients met the criteria for participation. The study population was randomly divided into two groups of 40 each. Group A was treated with INS spray fluticasone propionate (FP) twice daily in both nostrils and group B with INS spray and NBE after the spray.

To have uniformity in the procedure the NBE was demonstrated to the patient and the same was repeated by the patient in front of the examiner. The exercise in this study is deep inspiration followed by expiration through one nostril with the other nostril blocked by finger with humming or production of sound hmm… or om…. The exercise was repeated five times each nostril after INS spray by the patients of group B.

Each patient recorded symptom scores in a diary once a day. Subjects reported sneezing, rhinorrhea, nasal congestion, and itching on a four-point verbal descriptor scale.

0	Never	No problem
1	Rarely	Problem present but not disturbing
2	Quite often	Disturbing problem but not hampering any activity or sleep
3	Very often	Problem hampering some activities or sleep

A total symptom score was calculated daily for each symptom and the monthly score was evaluated for a period of 3 months after treatment. The individual symptom as well as total symptom scores before treatment was compared with scores after treatment for statistical significance.

Data was tabulated in excel worksheet and statistical analysis performed by SPSS 18. Descriptive analysis was performed and analytical statistics performed by independent sample t test. P < 0.05 was considered statistically significant.

Results

The study included 80 patients out of which seven patients of group A and four patients of group B were lost to follow up during the 3 months post treatment. Hence a computer generated random sample of 30 patients was taken in each group for further statistical evaluation. Group A consisted of 30 patients with a mean age of 30.7 years and group B included 30 patients with a mean age of 32.4 years.

Sneezing and nasal discharge was the commonest symptoms in both the groups (Table 1). On evaluation of the symptom score before treatment, group A had a mean score of 5.100 (SD 1.34805, SE 0.24612) and group B had a mean score of 5.200 (SD 1.60602, SE 0.29322). The mean difference was 0.100 (SE diff. 0.3828, 95% CI 0.6663–0.8663) which was not found to be statistically significant (P = 0.795).

Table 1.

Number of patients with symptoms in group A and B before and after treatment

Symptoms	Group A (n = 30)		Group B (n = 30)
	Before (%)	After (%)	Before (%)	After (%)
Sneezing	25 (83.3)	21 (70)	27 (90)	20 (66.6)
Itching	17 (56.6)	13 (43.3)	20 (66.6)	11 (36.6)
Nasal obstruction	20 (66.6)	18 (60)	18 (60)	9 (30)
Nasal discharge	22 (73.3)	18 (60)	21 (70)	14 (46.6)

On comparing the symptom scores of group A and B before and after treatment it was seen that the mean scores after treatment for group A was 3.8333 (SD 2.4223, SE 0.4422) and for group B was 2.6667 (SD 1.6470, SE 0.3007). The mean difference after treatment for group A was 1.2666 (SE diff. 0.5061, 95% CI 0.2457–2.2858) and for group B was 2.5333 (SE diff. 0.420, 95% CI 1.6926–3.3740). The difference in pre and post treatment symptom scores were found to be statistically significant (P value group A = 0.016 and P value group B = 0.000).

We also compared the symptom scores post treatment between both the groups to find the mean difference of 1.1666 (SE diff. 0.5348, 95% CI 0.0961–2.2371) which was also statistically significant (P = 0.033).

On evaluation of individual symptoms (sneezing, itching of eyes and nose, nasal obstruction and nasal discharge) before and after treatment, both groups showed improvement of symptoms after treatment (Fig. 1). The difference in individual symptom improvement post treatment exhibited a statistical significance in group B (Table 2).

Fig. 1.

Individual symptom scores before and after treatment

Table 2.

Difference in symptom scores for individual symptoms after treatment

Symptoms	Group A				Group B
	Mean diff.	SE diff.	CI	P	Mean diff.	SE diff.	CI	P
Sneezing	0.3666	0.2495	0.1328–0.8661	0.147	0.6333	0.2339	0.1649–1.1017	0.009
Itching	0.2000	0.1787	0.1578–0.5578	0.268	0.5000	0.2046	0.0903–0.9096	0.018
Nasal obstruction	0.2333	0.2715	0.3103–0.7770	0.394	0.7333	0.2645	0.2029–1.2634	0.008
Nasal discharge	0.4666	0.2823	0.0984–1.03	0.104	0.6666	0.2521	0.1611–1.1721	0.011

SE diff. standard error of difference, CI 95% confidence interval, P level of significance

Discussion

AR is an upper airway disease that’s caused by an IgE-mediated inflammatory reaction after allergen exposure, and it could contribute to decreased social activity, a poor quality of school life and decreased productivity in moderate-to-severe symptomatic patients [2–4].

AR is a highly prevalent disease, with a large economic burden on the state due to the direct and indirect costs associated with this disease. Direct costs relate to use of various medication for AR whereas indirect costs are attributed to time lost from work and costs attributed to at-work productivity loss. In this era of limited health care economic resources, it is vitally important to distinguish which therapy for AR is most clinically effective and cost effective [2–4].

Currently, as per ARIA 2008 update numerous medical treatments are available for the treatment of AR, including oral decongestants, antihistamines, mast cell stabilizers, INS sprays, leukotriene receptor antagonists, nasal anticholinergics, and immunotherapy. INS are recommended as first-line therapy especially when nasal congestion is a major component of symptoms. The major advantage of INS administration is that high concentrations of the drug, with rapid onset of action, can be delivered directly into the target organ, so that systemic effects are avoided or minimized.

FP is the first of a third generation of inhaled steroid. It has less potential for systemic adverse effects because it is very poorly absorbed in the gastrointestinal tract and is subject to extensive first-pass metabolism in the liver. Various studies have evaluated the efficacy of FP nasal spray and found it to be effective in the reduction of total nasal symptom score and total orbital symptom scores [7–9]. We used FP in our study and our results shows similar symptomatic efficacy for INS as studies in literature [7–9].

AR due to its chronic nature represents serious public health problem and need for medication on a long term basis. Though the side effects of long term use of medication for AR is minimal there is a fear among many patients of side effects of synthetic drugs. This fear influences many patients to seek complementary and alternative medicine (CAM). The literature suggests CAM use is high among rhinology patients (65%) [10].

The NBE used in this study is a simple procedure which is reproducible and can be performed easily. Due to its similarity to popular breathing exercise of yoga, the exercise could be easily explained to our study group and the patients had no reservations performing it. Though the study does not directly analyse the mechanism of NBE and its effects on AR, the author proposes a plausible explanation for the improvement in symptoms after NBE with the available literature on the subject. Various studies on nasal nitric oxide (nNO) in humans have revealed nitric oxide to be maximally produced from the nasal and paranasal sinus [11–13]. There have been also interesting analysis of humming and increased nNO as compared with normal quiet nasal exhalation suggesting improved paranasal sinus ventilation with this maneuver [14, 15]. Humming causes the air to oscillate, which in turn seems to increase the exchange of air between the sinuses and the nasal cavity. Though there are various studies in literature on the mechanism of improved ventilation of sinus, there are no studies which have evaluated the symptoms of AR and its effects with breathing exercises. The author considers the effect of the NBE after INS leads to improved distribution of the medication in the nasal cavity and paranasal sinus which could have resulted in the significant improvement of the patient symptoms.

When the total symptom scores after treatment were examined, the mean score of patients in the NBE group was numerically lower than that of patients in the INS group, and the magnitude of the difference reached statistical significance. All the individual symptom scores of both groups were also reduced after treatment and NBE demonstrated a statistical superiority in the reduction of individual symptoms of AR. Perhaps a longer study would show larger differences between the treatment arms and individual symptoms. In summary, our data indicate that the combination treatment of NBE and INS offers a statistical advantage over treatment with the INS alone for AR.

Our study has both strengths and limitations. The strength of the study is the fact that we have provided the first study which has clinically compared the effects of NBE on symptoms of AR. The major confounding factor in the study is use of INS in both groups which could not be avoided as the institute ethical committee did not accept the use of only NBE with no medical treatment as a third group in this study. Nevertheless, our findings add to the current literature and hopefully pave the way to larger studies aimed at confirming the value of NBE which can lead to improved patient satisfaction and reduce direct and indirect cost of treatment of AR.

Conclusions

AR is a common and chronic health problem having a high prevalence in the population. The direct cost of treatment as well as indirect cost due to loss of productivity is significantly high in AR. Our data indicate that the combination treatment of NBE and INS offers a statistical advantage over treatment with the intranasal steroid FP for AR. Hence NBE is a simple and cost effective measure to reduce symptoms of AR and improve patient satisfaction.