Heart Rate Variability Biofeedback Does Not Substitute for Asthma Steroid Controller Medication

Abstract

Despite previous findings of therapeutic effects for heart rate variability biofeedback (HRVB) on asthma, it is not known whether HRVB can substitute either for controller or rescue medication, or whether it affects airway inflammation. Sixty-eight paid volunteer steroid naïve study participants with mild or moderate asthma were given 3 months of HRVB or a comparison condition consisting of EEG alpha biofeedback with relaxing music and relaxed paced breathing (EEG+), in a two-center trial. All participants received a month of intensive asthma education prior to randomization. Both treatment conditions produced similar significant improvements on the methacholine challenge test (MCT), asthma symptoms, and asthma quality of life (AQOL). MCT effects were of similar size to those of enhanced placebo procedures reported elsewhere, and were 65% of those of a course of a high-potency inhaled steroid budesonide given to a sub-group of participants following biofeedback training. Exhaled nitric oxide decreased significantly only in the HRVB group, 81% of the budesonide effect, but with no significant differences between groups. Participants reported becoming more relaxed during practice of both techniques. Administration of albuterol after biofeedback sessions produced a large improvement in pulmonary function test results, indicating that neither treatment normalized pulmonary function as a potent controller medication would have done. Impulse oscillometry showed increased upper airway (vocal cord) resistance during biofeedback periods in both groups. These data suggest that HRVB should not be considered an alternative to asthma controller medications (e.g., inhaled steroids), although both biofeedback conditions produced some beneficial effects, warranting further research, and suggesting potential complementary effects. Various hypotheses are presented to explain why HRVB effects on asthma appeared smaller in this study than in earlier studies. Clinical Trial Registration NCT02766374.

My Life in HRV Biofeedback Research

“…However, lack of effects on inflammatory cytokines suggests that increased vagus nerve activity was not sufficient to decrease inflammation. Perhaps the effects on airway inflammation in our asthma study reported above (Lehrer et al, 2018 ) were specific to the inflammatory cytokine affecting the lung, IL4, which was not measured in the current study, or that the effects of injecting lipopolysaccharide overwhelmed any possible biofeedback effects. Our findings are consistent with the work of others.…”

“… For asthma, replication is needed to determine whether clinical effects are due to changes in inflammation. We did not find such a relationship in one study (Lehrer et al, 2018 ), but this study was done on relatively healthy people where the range for possible clinical improvement was small and the measure of inflammation insensitive. Studies of more severe asthma are warranted with more sensitive measures of airway inflammation, perhaps interleukin levels.…”

“…In a later study (Lehrer et al, 2018 ) we asked the question of whether HRV biofeedback can substitute for asthma controller medication. In this case, we compared HRV biofeedback with real EEG biofeedback to increase frontal-to-occipital EEG alpha rhythms and paced breathing at relaxed baseline rate, usually approximately 15 breaths/min, among steroid naïve asthma patients with mild or moderate asthma.…”

“…Is it possible that breathing slowly but not at resonance frequency would have exactly the same effect as HRVB? This may be the case even for paced breathing at a faster relaxed respiration rate (Feldman et al, 2016 ; Lehrer et al, 2018 ). Our meta-analysis (Lehrer, Kaur, et al, 2020 ) found smaller HRVB effects for fatigue and PTSD than for anxiety and depression.…”

“…Is it possible that breathing slowly but not at resonance frequency would have exactly the same effect as HRVB? This may be the case even for paced breathing at a faster relaxed respiration rate (Feldman et al, 2016 ; Lehrer et al, 2018 ).…”