Background: Digital interventions offer a potentially cost-effective means to support patient self-management in primary care, but evidence for the feasibility, acceptability and cost-effectiveness of digital interventions remains mixed. This programme focused on the potential for self-management digital interventions to improve outcomes in two common, contrasting conditions (i.e. hypertension and asthma) for which care is currently suboptimal, leading to excess deaths, illness, disability and costs for the NHS. Objectives: The overall purpose was to address the question of how digital interventions can best provide cost-effective support for patient self-management in primary care. Our aims were to develop and trial digital interventions to support patient self-management of hypertension and asthma. Through the process of planning, developing and evaluating these interventions, we also aimed to generate a better understanding of what features and methods for implementing digital interventions could make digital interventions acceptable, feasible, effective and cost-effective to integrate into primary care. Design: For the hypertension strand, we carried out systematic reviews of quantitative and qualitative evidence, intervention planning, development and optimisation, and an unmasked randomised controlled trial comparing digital intervention with usual care, with a health economic analysis and nested process evaluation. For the asthma strand, we carried out a systematic review of quantitative evidence, intervention planning, development and optimisation, and a feasibility randomised controlled trial comparing digital intervention with usual care, with nested process evaluation. Setting: General practices (hypertension, n = 76; asthma, n = 7) across Wessex and Thames Valley regions in Southern England. Participants: For the hypertension strand, people with uncontrolled hypertension taking one, two or three antihypertensive medications. For the asthma strand, adults with asthma and impaired asthma-related quality of life. Interventions: Our hypertension intervention (i.e. HOME BP) was a digital intervention that included motivational training for patients to self-monitor blood pressure, as well as health-care professionals to support self-management; a digital interface to send monthly readings to the health-care professional and to prompt planned medication changes when patients’ readings exceeded recommended targets for 2 consecutive months; and support for optional patient healthy behaviour change (e.g. healthy diet/weight loss, increased physical activity and reduced alcohol and salt consumption). The control group were provided with a Blood Pressure UK (London, UK) leaflet for hypertension and received routine hypertension care. Our asthma intervention (i.e. My Breathing Matters) was a digital intervention to improve the functional quality of life of primary care patients with asthma by supporting illness self-management. Motivational content intended to facilitate use of pharmacological self-management strategies (e.g. medication adherence and appropriate health-care service use) and non-pharmacological self-management strategies (e.g. breathing retraining, stress reduction and healthy behaviour change). The control group were given an Asthma UK (London, UK) information booklet on asthma self-management and received routine asthma care. Main outcome measures: The primary outcome for the hypertension randomised controlled trial was difference between intervention and usual-care groups in mean systolic blood pressure (mmHg) at 12 months, adjusted for baseline blood pressure, blood pressure target (i.e. standard, diabetic or aged > 80 years), age and general practice. The primary outcome for the asthma feasibility study was the feasibility of the trial design, including recruitment, adherence, intervention engagement and retention at follow-up. Health-care utilisation data were collected via notes review. Review methods: The quantitative reviews included a meta-analysis. The qualitative review comprised a meta-ethnography. Results: A total of 622 hypertensive patients were recruited to the randomised controlled trial, and 552 (89%) were followed up at 12 months. Systolic blood pressure was significantly lower in the intervention group at 12 months, with a difference of –3.4 mmHg (95% confidence interval –6.1 to –0.8 mmHg), and this gave an incremental cost per unit of systolic blood pressure reduction of £11 (95% confidence interval £5 to £29). Owing to a cost difference of £402 and a quality-adjusted life-year (QALY) difference of 0.044, long-term modelling puts the incremental cost per QALY at just over £9000. The probability of being cost-effective was 66% at willingness to pay £20,000 per quality-adjusted life-year, and this was higher at higher thresholds. A total of 88 patients were recruited to the asthma feasibility trial (target n = 80; n = 44 in each arm). At 3-month follow-up, two patients withdrew and six patients did not complete outcome measures. At 12 months, two patients withdrew and four patients did not complete outcome measures. A total of 36 out of 44 patients in the intervention group engaged with My Breathing Matters [with a median of four (range 0–25) logins]. Limitations: Although the interventions were designed to be as accessible as was feasible, most trial participants were white and participants of lower socioeconomic status were less likely to take part and complete follow-up measures. Challenges remain in terms of integrating digital interventions with clinical records. Conclusions: A digital intervention using self-monitored blood pressure to inform medication titration led to significantly lower blood pressure in participants than usual care. The observed reduction in blood pressure would be expected to lead to a reduction of 10–15% in patients suffering a stroke. The feasibility trial of My Breathing Matters suggests that a fully powered randomised controlled trial of the intervention is warranted. The theory-, evidence- and person-based approaches to intervention development refined through this programme enabled us to identify and address important contextual barriers to and facilitators of engagement with the interventions. Future work: This research justifies consideration of further implementation of the hypertension intervention, a fully powered randomised controlled trial of the asthma intervention and wide dissemination of our methods for intervention development. Our interventions can also be adapted for a range of other health conditions. Trial and study registration: The trials are registered as ISRCTN13790648 (hypertension) and ISRCTN15698435 (asthma). The studies are registered as PROSPERO CRD42013004773 (hypertension review) and PROSPERO CRD42014013455 (asthma review). Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 11. See the NIHR Journals Library website for further information.

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 2 = 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 2 = 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.

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.

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.

Introduction: The goal of asthma management is to achieve optimal asthma control. Dysfuctional breathing patterns are common in asthma. However breathing patterns are primarly assessed indirectly via Nijmegen questionnaire (NQ). Aim: To examine whether quantifiable components of breathing patterns are associated with levels of asthma control and NQ scores. Methods: Structured Light Plethysmography was used to record breathing patterns for 5 minutes in adults with mild to severe asthma. Mean respiratiry rate (RR), inspiration time over expiration time (Ti/Te), ribcage displacement over abdominal displacement (RC/AB) and within-individiual variability (CoV%) were calculated. Asthma control was asessed using Asthma Control Questionnaire (ACQ) and dysfuctional breathing via NQ. Relationships between outcomes were sought. Results: 122 adults with asthma (75 females) with mean age (SD) 44.75 years (15.98), mean BMI 25.74 kg/m2 (3.95) on GINA Step 3 to 4 (73%) or Step 2 treatment were recruited. 59 patients had ACQ<0.75 and 59 patients had NQ≥10. Binary multiple logistic regression showed poor prediction of ACQ(R2:0.09) when mean RR, Ti/Te and RC/AB were used whereas CoV% of these variables predicted poor asthma control (R2:0.45) with all predictors having significant odds ratios (p<0.01). The area under the ROC curve (AUC) of the model including CoV% of breathing components for predciting asthma control was 0.895 (95%CI:0.839-0.951). Similar results were found for predcitions of NQ with the AUC being 0.791 (95%CI:0.708-0.873). Conclusion: High variability of quantified elements of breathing patterns can predict lower asthma control and presence of breathing pattern disorders.

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, n = 261; F2FB, n = 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 (P < 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.

ObjectiveTo 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 settingA two-arm feasibility RCT conducted across seven general practices in Wessex, UK.ParticipantsPrimary 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.OutcomesThe 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.ResultsPrimary 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.ConclusionsThis 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 numberISRCTN15698435.

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.

With great interest we read the Article by Anne Bruton and colleagues,1Bruton A Lee A Yardley L et al.Physiotherapy breathing retraining for asthma: a randomised controlled trial.Lancet Respir Med. 2018; 6: 19-28Summary Full Text Full Text PDF PubMed Scopus (68) Google Scholar which showed that “Breathing retraining programmes improve quality of life in patients with incompletely controlled asthma despite having little effect on lung function or airway inflammation.” A strength of this study is the sound methodology, including the use of the Asthma Quality of Life Questionnaire as the primary endpoint and several secondary outcome measures, among which the Nijmegen Questionnaire was used to evaluate any effect on symptoms related to hyperventilation and dysfunctional breathing. Unfortunately, no attempt was made to reveal any effect of the intervention on hypocapnia as a possible working mechanism. Indications exist that asthma is frequently accompanied by hypocapnia. In acute asthma, hyperventilation is a well recognised concomitant.2McFadden Jr, ER Lyons HA Arterial-blood gas tension in asthma.N Engl J Med. 1968; 278: 1027-1032Crossref PubMed Scopus (250) Google Scholar Scientific data also support the presence of hypocapnia in patients with asthma when the disease is in a stable state. For instance, Osborne and colleagues3Osborne CA O'Connor BJ Lewis A Kanabar V Gardner WN Hyperventilation and asymptomatic chronic asthma.Thorax. 2000; 55: 1016-1022Crossref PubMed Scopus (49) Google Scholar found the presence of hypocapnia (partial carbon dioxide pressure [PaCO2] <4·67 kPa) in seven (30%) of 23 patients with stable asthma using arterial blood-gas analysis. Previously, in a study by Tai and Read,4Tai E Read J Blood-gas tensions in bronchial asthma.Lancet. 1967; 1: 644-646Summary PubMed Google Scholar hypocapnia was found in 14 (22%) of 64 patients with mild-to-moderate stable asthma. In two other studies, a substantially lower resting end-tidal carbon dioxide tension was seen in patients with stable asthma than in healthy volunteers.5Hormbrey J Jacobi MS Patil CP Saunders KB CO2 response and pattern of breathing in patients with symptomatic hyperventilation, compared to asthmatic and normal subjects.Eur Respir J. 1988; 1: 846-851PubMed Google Scholar, 6van den Elshout FJ van Herwaarden CL Folgering HT Effects of hypercapnia and hypocapnia on respiratory resistance in normal and asthmatic subjects.Thorax. 1991; 46: 28-32Crossref PubMed Scopus (94) Google Scholar Hypocapnia is relevant in the pathophysiology of asthma because of the deleterious effect it can have on the airways.6van den Elshout FJ van Herwaarden CL Folgering HT Effects of hypercapnia and hypocapnia on respiratory resistance in normal and asthmatic subjects.Thorax. 1991; 46: 28-32Crossref PubMed Scopus (94) Google Scholar Additionally, data from a study in dogs showed that hypocapnia can cause airway inflammation and can impair β2-adrenergic agonist-induced relaxation.7Davis MS Freed AN Repeated hyperventilation causes peripheral airways inflammation, hyperreactivity, and impaired bronchodilation in dogs.Am J Respir Crit Care Med. 2001; 164: 785-789Crossref PubMed Scopus (67) Google Scholar In line with these observations, effective interventions resulting in correction of hypocapnia could be of value in the clinical management of asthma because of their potential disease-modifying effect. Breathing retraining, as in the study by Bruton and colleagues, has the potential to affect hypocapnia. However, this finding should be confirmed in a further study including PaCO2 measurements. The absence of an effect or only a small effect on hypocapnia from breathing retraining would not necessarily disqualify its clinical value. Instead, such a situation could be conceived as a stimulus to identify relevant subgroups for this intervention and to further research alternative methods to target hypocapnia in asthma. We declare no competing interests. Hypocapnia correction as a working mechanism for breathing retraining in asthma – Authors' replyWe thank Alex Jan van 't Hul and colleagues for their letter regarding our Article1 on breathing retraining for asthma delivered by physiotherapists. Our study showed that a digital programme was equivalent to three face-to-face physiotherapist sessions in improving asthma-related quality of life, and that both of these treatments are superior to usual care, and it was the latest in a series of studies on this topic that we have done following the Medical Research Council guidance on developing and evaluating complex interventions. Full-Text PDF Physiotherapy breathing retraining for asthma: a randomised controlled trialBreathing 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. Full-Text PDF Open Access

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.

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 12months 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 (25-49years), 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 (40-70minutes) 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.

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.

Indroduction: Structured Light Plethysmography (SLP) is a motion analysis system which uses PC gaming/imaging techniques to record breathing movements and extrapolate timing and volume estimates. Measurement validity of SLP compared to other non-invasive devices has not been determined. Aim: To examine the measurement validity of SLP by comparing recording at rest and after exercise on a cycle ergometer with data from the current “reference” standard non-invasive device- Respiratory Inductive Plethysmography (RIP). Methods: Fifty healthy adults (30 males) with mean age 29 (SD 6.79) were studied at rest and after 10 minutes moderate exercise. Simultaneous breathing pattern recordings were taken by RIP and SLP. Bland and Altman plots (plus 95%LOA) were used to examine agreement between devices. Paired-Sample T-tests looked for significant differences between measurements. Results: Good agreement with no significant differences (pu003e0.05) betweent the devices was found for all timing indices (respiratory rate, inspiration/expiration times) before and after exercise. Good agreement was found between devices for ribcage and abdominal contributions to chest wall motion at rest but not after exercise. When “customised” regional contributions from SLP were compared to respective measurements from RIP, closer agreement was found after exercise. Low agreement and significant differences (p Concusion: SLP can be considered as an acceptable recording method to assess and quantify timing parameters and chest wall motion in healthy adults at rest.

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.

'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.

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 (n = 261), physiotherapist (n = 132) and control (usual care) (n = 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; p < 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; p < 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 Health Technology Assessment; Vol. 21, No. 53. See the NIHR Journals Library website for further project information. Additional financial support was received from Comprehensive Local Research Networks.

Throughout the United States, an increasingly strong emphasis is placed on interprofessional personnel preparation, particularly in the field of early intervention/education. Teams of professionals representing multiple disciplines work collaboratively to provide optimal services for young children (birth through age eight) with delays or disabilities; therefore, university students representing multiple disciplines are educated together in preparation for them to collaborate with other professionals and family members when they began their careers. The purpose of this article is to describe how faculty members from multiple disciplines (e.g., early childhood special education, general early childhood, physical therapy, occupational therapy) and schools at the University of Alabama at Birmingham (UAB) prepare graduate students through an interprofessional development program. Students are taught to collaborate and serve as team members using transdisciplinary procedures. Cases of young children with delays or disabilities are used to illustrate how to collaboratively address the issues and challenges identified in each case. This article explains the case-based process that is used at UAB to prepare graduate students to provide transdisciplinary services and includes the development of teaming skills and practices that are responsive to cultural and economic diversity.

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 18weeks: breathing pattern (respiratory inductive plethysmography (RIP); physiology (end tidal carbon dioxide (ETCO2), 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 FEV1 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.

Background: Pulmonary rehabilitation (PR) is the key treatment to improve physical, emotional and social functioning for patients with COPD (NICE 2010), but anxiety and depression often prevents patients gaining maximum benefit. Any therapy that reduces anxiety or depression should therefore increase effectiveness of PR. Acupuncture has been found to reduce anxiety in other groups, but its impact on COPD associated anxiety is unknown. Aim: Feasibility study of ear acupuncture (EA) as adjunctive treatment to patients with COPD attending PR programmes. Method: Patients diagnosed with COPD and referred for PR at University Hospital Southampton NHS foundation Trust, were eligible. Participants were randomised into 2 groups: Group A had real EA in the form of indwelling gold plated “seeds” at the appropriate acupuncture point; Group B had sham EA (seeds placed on an area of the ear with no known EA points). Seeds in both groups were to be pressed whenever participants felt anxious or breathless. Seeds were replaced once weekly, for six weeks. Primary Outcome: Hospital Anxiety and Depression Scale (HADS). Results: 17 participants were recruited. 1participant found EA unacceptable and withdrew. The remaining 16 participants found wearing the ear seeds acceptable. There were significant improvements from baseline to outcome in both anxiety (p=0.015) and depression (p=0.01) on HADS, within the real EA treatment group, but not the sham group. No between group differences were detected at outcome. Conclusion: Ear acupuncture was a feasible adjunctive treatment option for this sample of patients with COPD, attending PR. A larger trial is needed to confirm efficacy.

Background: MI has potential to improve PR engagement and adherence. The integrity of MI delivery is known to influence patient outcomes, but the extent to which PR clinicians can learn to deliver this complex counselling method is unknown. Aim: To evaluate the impact of a tailored training package on the integrity of MI delivered by PR clinicians. Method: 24 PR clinicians (16 physiotherapists, 6 nurses, 1 physiotherapy technician, 1 exercise specialist) from 4 NHS organisations participated. MI training involved a 2-day workshop and 5 individualised coaching sessions, with a manual (PREAMP) to guide the integration of MI into PR. MI skill was measured through MI Treatment Integrity coding (MITI 3.1.1) of audio-recorded PR consultations at baseline, post-workshop, post-coaching and at 4 months. Results: MI integrity increased following training. Mean scores on most MITI components surpassed competency targets at 4-months. No participant achieved all thresholds simultaneously. Training did not alter the relative frequency and depth of reflective listening sufficiently, which may explain why patient language seldom showed patterns predictive of change in MI. Participant drop-out was a problem at each stage, with only 15 clinicians completing all training activities, and 12 contributing to the 4-month follow-up. Service issues rather than negative perceptions of MI were responsible. Conclusion: Prior to widespread adoption of MI as part of PR, it is essential to ensure that physiotherapists and other clinicians responsible for MI delivery can do so competently. A sub-set of clinicians from this study have been interviewed to identify how training may be optimised.