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Nasal Breathing Exercise and its Effect on Symptoms of Allergic Rhinitis

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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.
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ORIGINAL ARTICLE
Nasal Breathing Exercise and its Effect on Symptoms
of Allergic Rhinitis
Satish Nair
Received: 21 January 2010 / Accepted: 13 June 2010 / Published online: 12 April 2011
Association of Otolaryngologists of India 2011
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 flutica-
sone 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.
Keywords Allergic rhinitis Intranasal steroid spray
Fluticasone propionate Nasal breathing exercise
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 signifi-
cant 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 pro-
ductivity due to a decrease in life-quality of those affected
[14]. 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, pharmaco-
therapy 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 psychologi-
cal problems, inability to comply with the study protocol,
S. Nair (&)
Army Hospital (R&R), Delhi, India
e-mail: aachku@yahoo.com
123
Indian J Otolaryngol Head Neck Surg
(April–June 2012) 64(2):172–176; DOI 10.1007/s12070-011-0243-5
recent nasal and paranasal surgery and treatment with
systemic steroids during the previous 30 days or use of
topical steroids, antihistamines, decongestants, or cromo-
lyn 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 hmmor 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 conges-
tion, 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 treat-
ment was compared with scores after treatment for sta-
tistical significance.
Data was tabulated in excel worksheet and statistical
analysis performed by SPSS 18. Descriptive analysis was
performed and analytical statistics performed by indepen-
dent sample ttest. 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).
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
(Pvalue group A =0.016 and Pvalue 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 improve-
ment of symptoms after treatment (Fig. 1). The difference
in individual symptom improvement post treatment
exhibited a statistical significance in group B (Table 2).
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 mod-
erate-to-severe symptomatic patients [24].
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
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)
Indian J Otolaryngol Head Neck Surg (April–June 2012) 64(2):172–176 173
123
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 [24].
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 anti-
cholinergics, 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.
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 PMean 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, Plevel of significance
174 Indian J Otolaryngol Head Neck Surg (April–June 2012) 64(2):172–176
123
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
[79]. We used FP in our study and our results shows similar
symptomatic efficacy for INS as studies in literature [79].
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 medi-
cation for AR is minimal there is a fear among many
patients of side effects of synthetic drugs. This fear influ-
ences 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 exer-
cise 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 expla-
nation 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 para-
nasal sinus [1113]. There have been also interesting
analysis of humming and increased nNO as compared with
normal quiet nasal exhalation suggesting improved para-
nasal sinus ventilation with this maneuver [14,15]. Hum-
ming 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 con-
siders the effect of the NBE after INS leads to improved
distribution of the medication in the nasal cavity and par-
anasal 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 statis-
tical 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 sig-
nificantly high in AR. Our data indicate that the combi-
nation 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.
Conflict of Interest None.
Financial Support None.
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... The combination treatment of nasal breathing exercise and INS offers a statistical advantage over treatment with the intranasal steroid fluticasone propionate for AR. [18] A randomized controlled study on 241 patients of mild to moderate persistent chronic bronchial asthma (121 patients of the yoga group and 120 patients of the control group) patients and concluded significant improvement in biochemical profile of asthmatics in the yoga group; superoxide dismutase activity also improved in yoga group than the controls. [19] They also reported that asthma symptom scores decreased significantly after the practice of asanas, pranayama, and meditation for the period of 6-month practice in the yoga group in comparison to controls. ...
... 27 A study demonstrated that isotonic exercise effectively reduces the resistance of the nasal cavity and decreases nasal cavity blood flow. 28 Similar to the results reported by Nair,29 nasal breathing exercise causes the air to sway, which in turn increases the exchange of air between the sinuses and nasal cavity with decreased nasal nitric oxide, which could have resulted in the improved rhinitis symptoms. The improvement is most likely related to Pranayama, which is an integral part of Hatha yoga. ...
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Nitric oxide (NO) is present in air derived from the nasal airways. However, the precise origin and physiological role of airway-derived NO are unknown. We report that NO in humans is produced by epithelial cells in the paranasal sinuses and is present in sinus air in very high concentrations, close to the highest permissible atmospheric pollution levels. In immunohistochemical and mRNA in situ hybridization studies we show that an NO synthase most closely resembling the inducible isoform is constitutively expressed apically in sinus epithelium. In contrast, only weak NO synthase activity was found in the epithelium of the nasal cavity. Our findings, together with the well-known bacteriostatic effects of NO, suggest a role for NO in the maintenance of sterility in the human paranasal sinuses.
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To estimate trends between 1972-6 and 1996 in the prevalences of asthma and hay fever in adults. Two epidemiological surveys 20 years apart. Identical questions were asked about asthma, hay fever, and respiratory symptoms at each survey. Renfrew and Paisley, two towns in the west of Scotland. 1,477 married couples aged 45-64 participated in a general population survey in 1972-6; and 2,338 offspring aged 30-59 participated in a 1996 survey. Prevalences were compared in 1,708 parents and 1,124 offspring aged 45-54. Main outcome measures: Prevalences of asthma, hay fever, and respiratory symptoms. In never smokers, age and sex standardised prevalences of asthma and hay fever were 3.0% and 5.8% respectively in 1972-6, and 8.2% and 19. 9% in 1996. In ever smokers, the corresponding values were 1.6% and 5.4% in 1972-6 and 5.3% and 15.5% in 1996. In both generations, the prevalence of asthma was higher in those who reported hay fever (atopic asthma). In never smokers, reports of wheeze not labelled as asthma were about 10 times more common in 1972-6 than in 1996. With a broader definition of asthma (asthma and/or wheeze), to minimise diagnostic bias, the overall prevalence of asthma changed little. However, diagnostic bias mainly affected non-atopic asthma. Atopic asthma increased more than twofold (prevalence ratio 2.52 (95% confidence interval 1.01 to 6.28)) whereas the prevalence of non-atopic asthma did not change (1.00 (0.53 to 1.90)). The prevalence of asthma in adults has increased more than twofold in 20 years, largely in association with trends in atopy, as measured indirectly by the prevalence of hay fever. No evidence was found for an increase in diagnostic awareness being responsible for the trend in atopic asthma, but increased awareness may account for trends in non-atopic asthma.
Article
The discovery that the gas nitric oxide (NO) is an important signaling molecule in the cardiovascular system earned its Nobel prize in 1998. NO has since been found to play important roles in a variety of physiologic and pathophysiologic processes in the body including vasoregulation, hemostasis, neurotransmission, immune defense, and respiration. The surprisingly high concentrations of NO in the nasal airway and paranasal sinuses has important implications for the field of otorhinolaryngology. NO provides a first-line defense against micro-organisms through its antiviral and antimicrobial activity and by its upregulation of ciliary motility. Nasal treatments such as polypectomy, sinus surgery, removal of hypertrophic adenoids and tonsils, and treatment of allergic rhinitis may alter NO output and, therefore, the microbial colonization of the upper airways. Nasal surgery aimed at relieving nasal obstruction may do the same but would also be expected to improve pulmonary function in patients with asthma and upper airway obstruction. NO output rises in a number of conditions associated with chronic airway inflammation, but not all of them. Concentrations are increased in asthma, allergic rhinitis, and viral respiratory infections, but reduced in sinusitis, cystic fibrosis, primary ciliary dysfunction, chronic cough, and after exposure to tobacco and alcohol. Therefore, NO, similar to several other inflammatory mediators, probably subserves different functions as local conditions dictate. At present, it seems that the measurement of NO in the upper airway may prove valuable as a simple, noninvasive diagnostic marker of airway pathologies. The objective of this review is to highlight some aspects of the origin, physiology, and functions of upper airway NO, and to discuss the particular methodological problems that result from the complex anatomy.
Article
The paranasal sinuses are major producers of nitric oxide (NO). We hypothesized that oscillating airflow produced by humming would enhance sinus ventilation and thereby increase nasal NO levels. Ten healthy subjects took part in the study. Nasal NO was measured with a chemiluminescence technique during humming and quiet single-breath exhalations at a fixed flow rate. NO increased 15-fold during humming compared with quiet exhalation. In a two-compartment model of the nose and sinus, oscillating airflow caused a dramatic increase in gas exchange between the cavities. Obstruction of the sinus ostium is a central event in the pathogenesis of sinusitis. Nasal NO measurements during humming may be a useful noninvasive test of sinus NO production and ostial patency. In addition, any therapeutic effects of the improved sinus ventilation caused by humming should be investigated.
Article
We performed a systematic review of randomized, controlled trials to determine whether intranasal corticosteroids offered an advantage over topical antihistamines in the treatment of allergic rhinitis. We searched for studies using MEDLINE, Embase, Cinahi, and Cochrane databases, pharmaceutical companies, and references of included trials. Criteria for considering trials included: 1) published randomized controlled trials; 2) single- or double-blind studies; and 3) presence of one of the following clinical outcomes: nasal symptoms, eye symptoms, global symptoms evaluation of quality of life and side effects. Nine studies including 648 subjects (mean age 30.4 years, range 13 to 73) with allergic rhinitis were selected. Intranasal corticosteroids produced significantly greater reduction of total nasal symptoms (standardized mean difference -0.36, 95% confidence interval -0.57 to -0.14), sneezing (-0.41, -0.57 to -0.24), rhinorrhea (-0.47, -0.64 to -0.29), itching (-0.38, -0.56 to -0.19), and nasal blockage (-0.86, -1.07 to -0.64) than did topical antihistamines. There was no significant difference between treatments for ocular symptoms (-0.07, -0.27 to 0.12). The effects on sneezing, rhinorrhea, itching, and ocular symptoms were significantly heterogeneous between studies. Other outcomes (total nasal symptom score and nasal blockage) were homogeneous between studies. Subgroup and sensitivity analysis suggested that most of the heterogeneity of outcomes could be explained on the basis of the methodologic quality of studies. Intranasal corticosteroids produced greater relief of nasal symptoms than did topical antihistamines (topical H1 receptor antagonists). However, there was no difference in the relief of the ocular symptoms.
Article
The increasing use of complementary and alternative medicine (CAM) by the general population1–5 reflects a potentially positive involvement with self-care. This report describes the prevalence of CAM use in patients attending 6 different practices in Scotland. The findings indicate that CAM use in primary care attenders is even greater than in the general population.