title: Inspiratory muscle training for asthma.
abstract: BACKGROUND
  In some people with asthma, expiratory airflow limitation, premature closure of small airways, activity of inspiratory muscles at the end of expiration and reduced pulmonary compliance may lead to lung hyperinflation. With the increase in lung volume, chest wall geometry is modified, shortening the inspiratory muscles and leaving them at a sub-optimal position in their length-tension relationship. Thus, the capacity of these muscles to generate tension is reduced. An increase in cross-sectional area of the inspiratory muscles caused by hypertrophy could offset the functional weakening induced by hyperinflation. Previous studies have shown that inspiratory muscle training promotes diaphragm hypertrophy in healthy people and patients with chronic heart failure, and increases the proportion of type I fibres and the size of type II fibres of the external intercostal muscles in patients with chronic obstructive pulmonary disease. However, its effects on clinical outcomes in patients with asthma are unclear.
  
  
  OBJECTIVE
  To evaluate the efficacy of inspiratory muscle training with either an external resistive device or threshold loading in people with asthma.
  
  
  METHODS
  We searched the Cochrane Airways Group Specialised Register of trials, Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov and reference lists of included studies. The latest search was performed in November 2012.
  
  
  METHODS
  We included randomised controlled trials that involved the use of an external inspiratory muscle training device versus a control (sham or no inspiratory training device) in people with stable asthma.
  
  
  METHODS
  We used standard methodological procedures expected by The Cochrane Collaboration.
  
  
  RESULTS
  We included five studies involving 113 adults. Participants in four studies had mild to moderate asthma and the fifth study included participants independent of their asthma severity. There were substantial differences between the studies, including the training protocol, duration of training sessions (10 to 30 minutes) and duration of the intervention (3 to 25 weeks). Three clinical trials were produced by the same research group. Risk of bias in the included studies was difficult to ascertain accurately due to poor reporting of methods.The included studies showed a statistically significant increase in inspiratory muscle strength, measured by maximal inspiratory pressure (PImax) (mean difference (MD) 13.34 cmH2O, 95% CI 4.70 to 21.98, 4 studies, 84 participants, low quality evidence). Our other primary outcome, exacerbations requiring a course of oral or inhaled corticosteroids or emergency department visits, was not reported. For the secondary outcomes, results from one trial showed no statistically significant difference between the inspiratory muscle training group and the control group for maximal expiratory pressure, peak expiratory flow rate, forced expiratory volume in one second, forced vital capacity, sensation of dyspnoea and use of beta2-agonist. There were no studies describing inspiratory muscle endurance, hospital admissions or days off work or school.
  
  
  CONCLUSIONS
  There is no conclusive evidence in this review to support or refute inspiratory muscle training for asthma. The evidence was limited by the small number of trials with few participants together with the risk of bias. More well conducted randomised controlled trials are needed. Future trials should investigate the following outcomes: lung function, exacerbation rate, asthma symptoms, hospital admissions, use of medications and days off work or school. Inspiratory muscle training should also be assessed in people with more severe asthma and conducted in children with asthma.
authors.affiliation: PhD Program in Physical Therapy, Federal University of Rio Grande do Norte, Federal University of Rio Grande do Norte, Avenida Senador Salgado Filho 3000, Lagoa Nova, Natal, Rio Grande do Norte, Brazil, 59072-970.
authors.forename: Ivanizia S
authors.initials: IS
authors.lastname: Silva
authors.forename: Guilherme A F
authors.initials: GA
authors.lastname: Fregonezi
authors.forename: Fernando A L
authors.initials: FA
authors.lastname: Dias
authors.forename: Cibele T D
authors.initials: CT
authors.lastname: Ribeiro
authors.forename: Ricardo O
authors.initials: RO
authors.lastname: Guerra
authors.forename: Gardenia M H
authors.initials: GM
authors.lastname: Ferreira
mesh_terms: D000328:Adult; D001249:Asthma / Q000534:rehabilitation*; D001945:Breathing Exercises / Q000379:methods*; D006801:Humans; D053580:Muscle Strength / Q000502:physiology; D016032:Randomized Controlled Trials as Topic; D012132:Respiratory Muscles / Q000503:physiopathology*; D012138:Respiratory Therapy / Q000295:instrumentation / Q000379:methods*