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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
[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, 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 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 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 [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
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 [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 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
[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 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 [11–13]. 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.
References
1. Bousquet J, Khaltaev N, Cruz AA, Denburg J, Fokkens WJ,
Togias A et al (2008) Allergic rhinitis and its impact on asthma
(ARIA) 2008 update (in collaboration with the World Health
Organization, GA(2)LEN and AllerGen). Allergy 63(Suppl 86):
8–160
2. Canonica GW, Bousquet J, Mullol J, Scadding GK, Virchow JCA
(2007) Survey of the burden of allergic rhinitis in Europe. Allergy
62(Suppl 85):17–25
3. Crystal-Peters J, Crown WH, Goetzel RZ, Schutt DC (2000) The
cost of productivity losses associated with allergic rhinitis. Am J
Manag Care 6:373–378
4. van Oene CM, van Reij EJ, Sprangers MA, Fokkens WJ (2007)
Quality assessment of disease-specific quality of life question-
naires for rhinitis and rhinosinusitis: a systematic review. Allergy
62(12):1359–1371
5. Upton MN, McConnachie A, McSharry C, Hart CL, Smith GD,
Gillis CR, Watt GCM (2000) Intergenerational 20 year trends in
the prevalence of asthma and hay fever in adults: the midspan
family study surveys of parents and offspring. Br Med J
321(7253):88–92
6. Ya
´n
˜ez A, Rodrigo GJ (2002) Intranasal corticosteroids versus
topical H1 receptor antagonists for the treatment of allergic rhi-
nitis: a systematic review with metaanalysis. Ann Allergy
Asthma Immunol 89:479–484
Indian J Otolaryngol Head Neck Surg (April–June 2012) 64(2):172–176 175
123
7. Chan KO, Huang ZL, Wang DY (2003) Acoustic rhinometric
assessment of nasal obstruction after treatment with fluticasone
propionate in patients with perennial rhinitis. Auris Nasus Larynx
30(4):379–383
8. Martin BG, Andrews CP, van Bavel JH, Hampel FC, Klein KC,
Prillaman BA, Faris MA, Philpot EE (2006) Comparison of flu-
ticasone propionate aqueous nasal spray and oral montelukast for
the treatment of seasonal allergic rhinitis symptoms. Ann Allergy
Asthma Immunol 96(6):851–857
9. DeWester J, Philpot EE, Westlund RE, Cook CK, Rickard KA
(2003) The efficacy of intranasal fluticasone propionate in the
relief of ocular symptoms associated with seasonal allergic rhi-
nitis. Allergy Asthma Proc 24(5):331–337
10. Featherstone C, Godden D, Gault C, Emslie M, Took-Zozaya M
(2003) Prevalence study of concurrent use of complementary and
alternative medicine in patients attending primary care services in
Scotland. Am J Public Health 93:1080–1082
11. Djupesland PG, Chatkin JM, Qian W, Haight JS (2001) Nitric
oxide in the nasal airway: a new dimension in otorhinolaryn-
gology. Am J Otolaryngol 22:19–32
12. Lundberg JON, Farkas-Szallasi T, Weitzberg E (1995) High
nitric oxide production in human paranasal sinuses. Nat Med
1:370–373
13. Maniscalco M, Weitzberg E, Sundberg J, Sofia M, Lundberg JO
(2002) Assessment of nasal and sinus nitric oxide output using
single-breath humming exhalations. Eur Respir J 22:323–329
14. Weitzberg E, Lundberg JO (2002) Humming greatly increases
nasal nitric oxide. Am J Respir Crit Care Med 166:144–145
15. Maniscalco M, Sofia M, Weitzberg E, De Laurentis G, Stanziola
A, Rosillo V (2004) Humming induced release of nasal nitric
oxide for assessment of sinus obstruction in allergic rhinitis; pilot
study. Eur J Clin Invest 34(8):555–560
176 Indian J Otolaryngol Head Neck Surg (April–June 2012) 64(2):172–176
123
