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Buteyko Breathing Technique – Nothing to Hyperventilate About

A reader recently sent in a link to a New York Times article that discussed an alternative breathing technique developed in Russia for the treatment of asthma called the Buteyko Method, or the Buteyko Breathing Technique (BBT), and asked for an evaluation of the claims on SBM.  This post will attempt to be a reasonably comprehensive evaluation of Buteyko and his therapy so that subsequent discussions, should they be necessary, may be more terse.

The NYT article is primarily an anecdote of a friend of the author who suffered from severe asthma, but who had improved since he began using the BBT.  The author briefly discusses asthma, the history and theory behind Buteyko and hyperventilation before wrapping up with an attempt to provide evidence to support the legitimacy of the story.  The friend’s pulmonologist is quoted to confirm that “based on objective data, his breathing has improved…”  She cites controlled clinical trials “in Australia and elsewhere” where patients have reduced their use of medications, including a purported British study of 384 patients where patients had a 90% reduction in rescue inhaler use and 50% reduction in steroids.  She ends by pointing out that the British Thoracic Society has given BBT a “B” rating, and an admonition to “the pharmaceutically supported American medical community to explore this nondrug technique.”

Never having heard of BBT before, the NYT article left me with several questions.  Who was Buteyko?  How did he develop the BBT?  What is BBT, what does it claim to do, and how does it claim to work?  Is the evidence as presented in the NYT article accurate? And finally, what evidence exists within the literature that BBT is an effective treatment for asthma?

Who was Konstantin Buteyko?

Given the relative obscurity of BBT in the US and in modern medicine in general, I am using the sites of Buteyko’s primary presence in the US, the Buteyko Center, and the Buteyko Institute of Breathing and Health as my primary sources of its theory and history.

Buteyko’s story is proudly presented in great length (but frequently lacking in critical detail) on the Buteyko Center website.  I encourage you to read it in its entirety for full effect, for it is fascinating and bears a striking similarity to that of the other founding figures of alt med belief systems (D.D. Palmer, Hulda Clarke, Mikao Usui, Samuel Hahnemann). What follows are the high points from a full bio on Buteyko by Sasha Yakovlev-Fredrickson, a Buteyko Specialist at the Buteyko Center USA.

Born in 1923 in the Ukraine, he trained as a mechanic until World War II, where he served in the Soviet military on the Eastern Front and became fascinated by the injuries he witnessed.  After the war ended he joined the First Medical Institute in Moscow and began his medical training.

Somehow, while still a medical student he is said to have specialized in hypertension.  Around the same time and while still in his 20’s, he is diagnosed with “a severe and lethal form” of hypertension that left him with months to live in 1952.  We are given no more detail, and the story is already bordering on medical incoherence.

His discovery apparently came in a moment of insight, or perhaps revelation.  One night in 1952, as he stood alone staring out at the night sky and contemplating his illness, he was dazzled by a bright light, and that “in the midst of his impending demise” he noticed that he was breathing heavily as was struck with the revelation that the heavy breathing he was experiencing was not a symptom, but the cause of his problems.  He intentionally slowed his breathing, and as he did so, he felt immediately better.  Following this revelation we are told that he went around the hospital telling people to breathe more slowly and that they immediately felt better as well.  Based on these experiences he created the Buteyko Breathing Technique.

It might be that he stumbled in this moment onto an immensely powerful and hitherto unknown insight into human pathophysiology.  On the other hand, there may a more simple explanation. We have in Buteyko a young man recently returned from the battle lines of WW II, suffering from hypertension (extremely uncommon in a young man), who is experiencing hyperventilation, flashing lights, and an apparent feeling of impending doom.  One would be hard pressed to find a better setup for and description of a panic attack.  Slow, controlled breathing that Buteyko described using can not only resolve the acute symptoms of a panic attack, but can also return a sense of control to the person afflicted, reducing their anxiety, and potentially alleviating hypertension.  Panic attack or stroke of stunning inspiration; Occam’s razor might have something to say on the matter.

Nevertheless, smitten with his new theory and armed with his very personal n=1, Buteyko began to treat patients.  The subsequent decades of his life are full of stories of persecution and suppression, physical intimidation and destruction of his laboratory, professional sabotage and fears of incarceration.  Undaunted, Buteyko continued using and promoting his therapy, and supposedly discovered that BBT could cure at least 150 different diseases and disorders!  Buteyko compared himself to Dr Semmelweis, and the power of his technique to atomic energy.  In 1987, having obtained a “top secret” patent on BBT from the Soviet government, he established the Buteyko clinic.

Never one to rest on his laurels, Buteyko continued to explore the power of BBT.  He is said to have hardly slept, and to have lived without food for 50 days at a time.  It is further claimed that he became an advanced spiritual practitioner with the ability to read people’s thoughts, predict the future, and at one point declared that civilization would die if we didn’t stop hyperventilating.

I’ll let these claims stand on their own without further comment, other than to reflect on the reliability of the mind that makes such statements.

What is Buteyko Breathing Therapy?

Eccentricity of the eponymous inventor of BBT aside, what can we say about the therapy itself?

How Buteyko researched and practiced his treatment from his revelation in 1952 until the establishment of his clinic in 1987 is obscure at best.  Per the history given on the Buteyko Center site, at the same time that he is enduring professional ridicule and sabotage and hiding his practice from the government for fear of imprisonment, he is also able to treat enough people to discern over 150 different uses for BBT and be offered (and then refuse) a job with the Russian Space Agency.  Despite what one would expect to be a wealth of data to support claims of efficacy for so many different conditions, Buteyko himself never published a single paper, and not until 1995 does any reference to his name appear in the medical literature.

Even according to the history provided by the Buteyko Center, not until 1981, nearly 30 years after Buteyko’s revelation/discovery was a second trial conducted regarding BBT’s efficacy; it is never peer reviewed or published.  The same source then tells that soon after acquiring his “top secret” patent for BBT, in 1985 the Soviet Public Health Ministry issued a recommendation that all medical professionals treat patients with his method.  After establishing his clinic in 1987 he treated people with asthma, allergies, hypertension, kidney problems, cardiac problems, gastrological problems, immune deficiency, cancer, and even victims of Chernobyl and AIDS patients.

The list of diseases treated by BBT didn’t end there.  On the Buteyko site you can peruse the list of 150 curable diseases and conditions Buteyko believed he could treat.

But what is BBT?  How can one therapy treat the varied legion of diseases on that list?  Again, I’ll let the Buteyko Center and the BIBH speak for themselves on the matter here and here.

As you can see if you follow the links, there is a lot of talk about hyperventilation, but they are rather sparse on the details.  If you want the details, break out your wallet.  The Buteyko Center and BIBH are willing to start doling out details in exchange for the digits on you credit card.

What of BBT’s Physiologic Plausibility?

So BBT’s origins are highly dubious, but what of its plausibility?

Let’s examine the physiologic explanation provided by the Buteyko Center for why it cures not only asthma, but all of the myriad conditions listed on their site.  They are kind enough to have Ira Packman, M.D. provide an explanation for doctors derived from that of Buteyko himself that can be found here.  (Buteyko’s is here.)

The explanation can be distilled down to this:

-When people hyperventilate, their arterial CO2 drops, making their blood alkaline.

-An alkaline pH increases hemoglobin’s affinity for oxygen.

-If hemoglobin holds onto oxygen more tightly, it won’t release as much to tissues.

-Less oxygen released by hemoglobin will cause hypoxic damage to tissues.

-Kidneys will try to correct the alkalosis by eliminating bicarbonate.

-Along with bicarbonate loss phosphorus and magnesium will be lost.

-Hypophosphatemia will compromise the creation of ATP.

-A lack of ATP will impair the function of afflicted tissues.

-A low level of CO2 can cause vasospasm and further reduce the blood supply to tissues.

Ignore the gross oversimplifications and important omissions in the explanation for the moment and take it at face value.  These are all testable hypotheses.  If Buteyko is correct, and chronic hyperventilation is the cause of all (or any) of the diseases listed on their site, then one would expect to see a high pH, low CO2, low bicarbonate, low phosphorus, low magnesium, and signs of anaerobic metabolism such as a low mixed venous O2 saturation or elevated serum lactate level.

These are extremely common labs that physicians (especially ICU physicians such as myself) are intimately familiar with.  According to Buteyko, this lab pattern should be a nearly universal feature of all disorders cured by BBT.  Guess how many actually routinely display anything remotely resembling it.

None.

This hypothesis also predicts that an asthmatic who begins to retain CO2 should have both their symptoms and pathophysiology improve.  In truth, elevation of CO2 in a symptomatic asthmatic is one of the more ominous signs in critical care medicine, and is the harbinger of respiratory failure and death.

What about the omissions and inaccuracies? First, the mechanisms Buteyko and Packman discuss to maintain blood pH are highly efficient, and are capable of correcting dramatic derangements in pH over the span of hours to days.  This is superbly demonstrated by chronic hypoventilation, where for a variety of reasons people retain carbon dioxide and yet have a normal pH.  With a normal pH the Bohr effect is neutralized.

Second, even if the Bohr effect remained in play, it is a minor determinant of oxygen delivery, easily compensated for by numerous other mechanisms, and insufficient to independently cause hypoxic injury or dysfunction.

Third, Packman says there is an “over excretion of bicarbonate.”  Even within his flawed concept of physiology, loss of bicarbonate would be an appropriate response to balance the blood’s pH, and the kidney will not overcompensate, therefore the term “over excretion” is inappropriate and implies a nonexistent pathology.

Fourth, the electrolyte interactions described by Packman are very confused.  The electrolytes most closely tied to the kidney’s bicarbonate management are sodium and chloride, not magnesium and phosphate.  Phosphorus does play a smaller role in the buffering capacity of the kidney, but contrary to Packman’s claim that a state of alkalosis will result in loss of phosphate, it is in fact when excessive hydrogen ions are secreted during a state of acidosis that phosphate is lost in the form of H2PO4.  It is true that hypophosphatemia can induce loss of bicarbonate through the actions of parathyroid hormone, but the inverse, that loss of bicarbonate induces phosphate loss, is not true.

Finally, though extreme hypophosphatemia can indeed compromise the body’s ability to create ATP, the resulting energy failure will cause a metabolic crisis which will not only be clinically and biochemically apparent, but which will cause the exact opposite pH-based effects upon which Buteyko’s hypothesis depends.

Now the lack of physiologic plausibility does not in and of itself mean that Buteyko method is ineffective.  What it does mean is that the physiologic explanation for its mechanism is likely dramatically wrong, and that the primary proponents of the technique have not only failed to recognize this fact, but have ignored elementary flaws in their hypothesis apparent in both theory and practice.

Buteyko Breathing Therapy and the Literature – Not Burdened by an Overabundance of Evidence

Buteyko and his devotees have made some remarkable claims while providing almost no evidence; an unrestricted Pubmed search of “Buteyko” yields a grand total of 21 hits.  But 21 is (slightly) more than zero, so let’s look at the published literature.  Virtually all of these 21 Pubmed hits discuss the use of BBT for asthma, as was indicated in the NYT article that triggered this post.  There are no published studies evaluating BBT for any of the other 149 diseases Buteyko claimed to cure.

The following are the sum total of published clinical trials regarding BBT’s use without regard to quality, design, size, bias, or result:

1) Buteyko breathing techniques in asthma: a blinded randomized controlled trial. Bowler SD et al. Med J Aust 1998:  39 subjects. Significant reduction in use of both chronic and rescue inhalers, but no change in lung function tests (PEF or FEV1) or end tidal CO2.

2) Effect of two breathing exercises (Buteyko and pranayama) in asthma: a randomized controlled trial. Cooper S. et al. Thorax 2003. 90 subjects enrolled, 69 completed the study.  Improved symptoms and reduced bronchodilator use with BBT, but no change in lung function tests (FEV1), number of exacerbations or amount of steroids used.

3) Buteyko Breathing Technique for asthma: an effective intervention. McHugh P et al. N Z Med J. 2003. McHugh: 38 subjects. 50% reduction in steroids and 85% reduction in rescue inhaler use at 6 months in BBT compared to no change in steroid use and 37% reduction in rescue inhalers in the control group, but no change in pulmonary function tests (FEV1).

4) A clinical trial of the Buteyko Breathing Technique in asthma as taught by a video. Opat AJ et al. J Asthma 2000. Opat: 36 subjects.  Participants viewed a video of BBT or a placebo video twice daily for 4 weeks.  Modest improvement in quality of life and a reduction in bronchodilator use, but no improvement in pulmonary function tests.

5) A randomized controlled trial of the Buteyko technique as an adjunct to conventional management of asthma. Cowie RL et al. Respir Med. 2008.  129 subjects.  Significant reduction in the amount of steroid used in BBT group, but no difference in asthma control between the two groups.

6) Effect of mouth taping at night on asthma control – a randomized single-blind crossover study. Cooper S. Respir Med. 2009.  51 subjects.  No difference in pulmonary function tests or symptom scores resulted from forced nasal breathing overnight.

7) Investigating the claims of Konstantin Buteyko, M.D., Ph.D.: the relationship of breath holding time to end tidal CO2 and other proposed measures of dysfunctional breathing. Courtney R et al. J Altern Complement Med. 2008.  83 subjects.  Breath Holding Time as defined by Buteyko was found to have the exact opposite correlation with alveolar CO2 that his theories predicted it would have.

8 ) The effects of carbon dioxide on exercise-induced asthma: an unlikely explanation for the effects of Buteyko breathing training. Al-Delaimy WK et al. Med J Aust. 2001. 10 subjects.  Patients were supplemented with CO2 to test Buteyko’s hypothesis that a higher CO2 would result in a reduction in asthma symptoms. Breathing 3% CO2 did not prevent exercise-induced asthma.

Notably absent from this list is the British study containing 384 patients touted and linked to in the NYT article.  As it turns out, that was not a peer-reviewed study, but instead only an abstract at the 2003 British Thoracic Society Winter Meeting.  In spite of its remarkable results, it has not in the following 6 years been published in a peer-reviewed journal.  It is, for all intents and purposes, a non-study.

The three studies designed to test Buteyko’s proposed mechanisms of action (6, 7, and 8 ) do not support Buteyko’s theories, and are in keeping with my earlier analysis of its plausibility.

The five studies comparing BBT to a control for treatment of asthma (1-5) show a variable though reasonably consistent reduction in both rescue and maintenance drug use.  Even more consistent however is the utter lack of any change in the participant’s pulmonary function tests.

Given the most charitable interpretation and taken at face value, these studies imply that BBT can alter a patient’s perception of their symptoms, and perhaps prevent overuse of asthma medications.  However, they also provide evidence that BBT does very little to alter the underlying pathophysiology of asthma, and absolutely no evidence to support Buteyko’s claim that BBT can cure asthma.

Buteyko Breathing Therapy and Asthma – A Broken Clock is Still Right Two Seconds Per Day

Taken as a whole, this reading of the literature is in keeping with the British Thoracic Society’s Guidelines, which state:

The Buteyko breathing technique specifically focuses on control of hyperventilation and any ensuing hypocapnia. Four clinical trials suggest benefits in terms of reduced symptoms and bronchodilator usage but no effect on lung function.  Buteyko breathing technique may be considered to help patients to control the symptoms of asthma.  Grade B”

Though I think that the BTS authors were overly generous in ranking the four evaluated articles as 1+ level of evidence (meaning a well conducted meta-analysis, systematic review, or RCTs with a low risk of bias), their conclusions are not unreasonable within the framework of Evidence Based Medicine.

Of course, as I consider this small set of literature from the perspective of Science Based Medicine, I’m reminded of John Ioannidis’ essay “Why Most Published Research Findings Are False.

…a research finding is less likely to be true when the studies conducted in a field are smaller; when effect sizes are smaller; when there is a greater number and lesser preselection of tested relationships; where there is greater flexibility in designs, definitions, outcomes, and analytical modes; when there is greater financial and other interest and prejudice; and when more teams are involved in a scientific field in chase of statistical significance.”

These studies can be found wanting on nearly every point outlined by Ioannidis. Already weak when viewed through the lens of Evidence Based Medicine, through that of Science Based Medicine the Buteyko literature looses much of its remaining impact.

SUMMARY

Buteyko reminds me in many ways of D.D. Palmer.  Starting from an erroneous observation, using flawed logic, lacking prior plausibility, forsaking scientific validation, and promoting their techniques as virtual panaceas, they each nevertheless may have found small medical niches where their techniques may have some limited utility.  Palmer’s niche appears to be treatment of low-back pain, and for Buteyko, it may be the symptomatic relief of mild asthma symptoms.

If however, you are looking for the Buteyko Breathing Technique to cure your asthma, I wouldn’t hold my breath.

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