Article Review: Buteyko breathing techniques in asthma: a blinded randomised controlled trial.

Published: Medical Journal of Australia, 1998 Dec 7-21;169(11-12):575-8.
By: Bowler SD, Green A, Mitchell CA.
I recommended to first read this abstract of the original article.

This article reports on the first trial on Buteyko Breathing to take place outside of the former Soviet Union. The trial was done according to the gold standard: a blind randomized controlled trial. It was specifically aimed at testing what Buteyko does for asthma patients. The trial found extremely positive results for Buteyko Breathing. However, the published article shows various signs of bias against Buteyko by the authors who have multiple conflicts of interest.

Trial results in brief:

  • 1) Buteyko lowered minute breathing volume from 14 liter/min to 9.6 liters/min.
  • 2) Buteyko reduced asthma symptoms by 71%.
  • 3) Buteyko reduced beta2-agonist medication use by 90%.
  • 4) Buteyko showed a trend towards lower inhaled steroid medication use: 49% less.
  • 5) Buteyko showed a trend towards higher quality-of-life scores.
  • 6) The relative reduction in beta2-agonist medication with Buteyko was related to the proportionate reduction in minute volume with Buteyko.
  • 7) Although minute breathing volume went down, no change was observed in end-tidal CO2 (this unexpected result was probably due to a wrong setup of the end-tidal CO2 measurement: just a few minutes after doing the peak-flow test).

Additional results from the trial

As an experienced Buteyko instructor reading this article, I notice several additional results from the trial:

1: Asthma patients have lower CO2 values than the normal population

Even though the end-tidal CO2 measuring setup probably wasn't done correctly, it still showed a big difference between end-tidal CO2 values of asthma patients and people without asthma: the normal group has an average end-tidal CO2 of 43 mmHg whereas the asthma patients have an average end-tidal Co2 of 34 mmHG. That's a big difference in CO2 levels which agrees with Professor Buteyko's claim that asthma is caused by low CO2 values.

2: Asthma patients breathe more than the normal population

Minute breathing volume was higher in asthma patients than in the group of normal people (without asthma). This agrees with Professor Buteyko claim that overbreathing (hyperventilation) causes asthma.

3: Asthma patients who practice Buteyko need less medication as they become better at Buteyko

The finding (number 7 above) that the relative reduction in beta2-agonist medication was related to the proportionate reduction in minute volume with Buteyko is extremely meaningful. This really means that the more progress asthma patients make with Buteyko, the less medication they need. This is such an important finding that the title of the study could well have been: "Asthma patients who practice Buteyko Breathing need less medication as they become better at Buteyko"!

4: Buteyko does what it promises: change breathing habits and reduce disease symptoms

The finding that Buteyko lowers the average minute breathing volume from 14 liter/min to 9.6 liters/min proves that Buteyko Breathing really does significantly change breathing habits. The finding that asthma symptoms went down by 71% proves that Buteyko does improve health and reduces chronic disease symptoms. So these two finding combined together in effect prove that Buteyko Breathing does do what it promises.

5: Buteyko reverts hyperventilation

The finding that Buteyko lowers the average minute breathing volume from 14 liter/min to 9.6 liters/min is also a highly significant finding for people suffering from hyperventilation. Those suffering from hyperventilation can learn and practice Buteyko Breathing to reverse and improve their hyperventilation symptoms.

Article review by drs. Eduard Reuvers

Even though this article's trial results are extremely positive for Buteyko, this article has multiple issues regarding bias, conflicts of interest and sloppiness which all put Buteyko at a disadvantage. This makes it even more remarkable that Buteyko achieved such an extremely positive result. The problematic issues I see with this article are as follows:

Issue 1: Failure to declare multiple conflicts of interest

The authors of the article do not declare their own conflicts of interest. As physicians employed in a hospital, a large part of their own and their hospitals' income is dependent on the prescription of medications to asthma patients. They have a conflict of interest with Buteyko Breathing which claims to revert asthma without any medications. If this were true, it would negatively impact the authors' and their hospitals' business interests (prescribing and selling asthma medications). Also, as researchers making a career in asthma medication research, their career prospects are highly dependent on research grants provided by pharmaceutical companies. The phramaceutical companies have no interest in a competing treatment option (Buteyko) that lowers asthma symptoms and allows patients to take less medications. Asthma patients often take medications on a daily basis for many years or the rest of their lives, making asthma medications a very profitable business for physicians, hospitals and pharmaceutical companies. So the authors of the study do have a double conflict of interest: (1) as physicians employed in hospitals they are dependent on income from prescribing asthma medications and (2) as professional asthma medication researchers they are dependent on research grants from large pharmaceutical companies who wish to sell more asthma medications and would suffer economically if Buteyko breathing was foudn to be an effective treatment for asthma. The failure to declare these two big conflicts of interest is a major ethical issue with this article.

Issue 2: Failure to mention that Buteyko led to a 71% reduction of asthma symptoms

The article mentions that all asthma patients were asked to rate the severity of their asthma symptoms on a daily basis. But the results of this question are completely missing from the results section of the article. Via another source I was able to find out that in this trial, the asthma symptoms did go down by a lot: a 71% reduction (source). But why was this crucial information left out from the published article? Is it just sloppiness or is the effectiveness of Buteyko an inconvenient truth for the authors (with conflicts of interest)?

Issue 3: Author bias regarding peak flow (PEF) test results

In the article, the authors mention several times that the lung function of asthma patients (measured using the Peak Flow (PEF) test) did not improve with Buteyko. And in a 1998 interview with the BBC, Dr. Charles Mitchell again emphasizes how the Peak Flow test showed Buteyko makes no real difference for asthma patients as Buteyko doesn't change lung fucntion (ignoring that patients reported a 71% decrease in asthma symptoms and lowered asthma medications by 90%). I have been a Buteyko instructor for 10 years now and have never asked my Buteyko Breathing students for their Peak Flow test values because the Peak Flow test is useless in a Buteyko setting and irrelevant for reversing asthma with Buteyko. In fact, this study proves that asthma patients doing Buteyko will experience great improvement in symptoms and great reduction in medication use without any change in lung function. This finding should have made the authors reflect on their own bias that peak flow test results absolutely need to improve for asthma patients to recover from asthma. After all, their own study showed them wrong. In a fair and balanced article, the authors would have mentioned that in Buteyko these Peak Flow values are considered quite irrelevant: Buteyko is about the oxyhemoglobin dissociation curve, CO2 values and cell oxygenation. It seems here that the authors of the article (with a double conflict of interest) are closing their eyes to the results of their own trial.

Issue 4: Disregarding the Control Pause test which is essential in Buteyko

The article completely disregards the "Control Pause" test which in Buteyko Breathing is an important indicator of progress for asthma patients. When trying to evaluate whether Buteyko works, it seems strange to leave out this essential breathing test. This oversight makes me wonder to what extend the authors of the article had any real interest in learning more about Buteyko Breathing?

Issue 5: Why are the authors not interested in further research?

In the same year this article was published (1998), one of the authors (Dr. Charles Mitchell) was interviewed by the BBC about the results of his Buteyko trial. Although it was a landmark trial (first Western trial on Buteyko) with extremely positive results for asthma patients which brought the BBC all the way from England to his doorstep in Australia, Dr. Charles Mitchell tells the BBC that he won't be doing any more research on Buteyko. I found this statement quite strange as usually scientists welcome media attention to their work and any discoveries they make. Twenty years later, the statement that he won't do any more research on Buteyko turns out to be very true. But when we check the online research databases, we see that Dr. Charles Mitchell did publish many more research articles on various asthma medications: it even looks as if he made a career out of researching various asthma medications. This perfectly explains Dr. Charles Mitchell's bias against Buteyko: Buteyko is an inconvenient truth.

Issue 6: Wrong setup of the end-tidal CO2 measurements

The fact that the average minute volume went down a lot without any change in end-tidal CO2 was unexpected and strange. This was most likely due to performing the peak-flow breathing test just a few minutes before doing the end-tidal CO2 measurement. Doing a peak-flow test will lead to low end-tidal CO2 values for up to 15 minutes afterwards.

Final Score: Article Rating

I give this article an overall rating of 6.5 out of 10.

Main positive points:

  • (1) This article uses the gold standard of trials (blinded randomised controlled trial).
  • (2) The asthma patients were taught Buteyko the proper way, by actual Buteyko instructors.
  • (3) Quite a large group of asthma patients were taught.

Main negative points:

  • (1) The authors did not declare their obvious multiple conflicts of interest.
  • (2) The authors give a biased interpretation of the results of the trial.
  • (3) The authors fail to report that Buteyko led to a 71% decrease in asthma symptoms (in the result and abstract sections of the article).
  • (4) No details are given on the participants' Buteyko practice and progress.
  • (5) The end-tidal CO2 measurement wasn't setup correctly.

Review by drs. Eduard Reuvers, 2017