Asthma is one of the most prevalent respiratory illness effecting the pathways that carry air in and out of the lungs. It is a chronic lung condition that produces recurrent episodes of wheezing, chest tightness, shortness of breath, and coughing by inflaming and narrowing the airway by spastic contraction of smooth muscle in the bronchioles [1,2].

In emerging nations, childhood bronchial asthma and other allergy diseases are more common [3]. The World Health Organisation (WHO) estimates that 300 million individuals suffer from asthma, and 255,000 individuals died from it in 2005; 80% of these deaths take place in low- and lower-middle-income nations. According to earlier estimates, the prevalence of asthma in India is approximately 3% (30 million patients), with a prevalence of 2.4% in adults aged >15 years, and between 4% and 20% in children. In 2004, it was estimated that 57,000 deaths in India were attributed to asthma; it is one of the leading causes of morbidity and mortality in rural India and is projected to increase in the coming decades [4]. In 2016, asthma was a contributing factor in 24.8 million DALYs and 417,918 deaths worldwide [5].

In contrast, yoga was initially practised some 5000 years ago. It is a technique that ties the mind, breath and body together. It helps to reduce asthma by combining physical postures, breathing techniques and meditation into a single, cohesive whole [6].

The anti-asthmatic medications on the market are quite costly and have side effects and tolerance [1]. Inhaled corticosteroids and long-acting beta-agonists are common medications used to treat asthma. Additional controller drugs including oral corticosteroids, anti-leukotrines and anti-immunoglobulin E therapy are advised for severe instances [7-9]

Since bronchial asthma is an important cause of morbidity and mortality especially in resource limited areas where the long-term use of multiple drugs is costly, it is wise to think alternative way to treat such an illness with better economic safety and avoid adverse effect of the drugs. Therefore, this study tries to look into the applicability of yoga as an additional therapeutic approach to asthma. The research aim is to determine the clinical features, peak expiratory flow rate and use of drugs for asthma before and after the yoga practicein asthmatic patients.

This study was conducted at a tertiary care teaching hospital. It was a prospective interventional study conducted between September 2023 to February 2024. The study was conducted among known asthmatic patients attending the outpatient department (OPD) of a tertiary care teaching hospital.

A total of 60 asthmatic patients attending tertiary care teaching hospital were taken, among them 30 were intervened with yoga along with their regular medication and 30 who were only on medication. Patients who were getting treatment for asthma at OPD of tertiary care teaching hospital and willing to participate in the study were included. Known asthmatic patients who were seriously ill and/ or on supplementary support in the past one month, known cases of cardiovascular diseases and those who were suffering from any acute respiratory infection either upper respiratory or lower respiratory tract infections at the time of the study were excluded from the study.

A self-designed, semi-structured questionnaire was used to collect the socio-demographic details, history of illness, treatment history and Asthma control questionnaire was used to collect the details of symptoms related to asthma before and after intervention. Spirometer was used to assess the pulmonary function of the patient. Patients who were attending pulmonology outpatient department and meeting the inclusion and exclusion criteria were selected for the study. They were asked to pick a chit with one and two numbers. Those with odd numbers were intervened with yoga along with their regular medication and those with even numbers were continued only on medication without any respiratory exercises.

Informed written consent was obtained from the study subjects after explaining the purpose and nature of the study in the language they understand. Ethical clearance was acquired from the Institutional Ethics Committee (IEC) before starting the study (IEC/KMCH/2023/23). Patients who were willing to participate in the study, were asked the questionnaire and pulmonary function of all these patients was initially assessed using spirometry. Then these patients were divided into groups with the help of lottery method. In a bowl, 1 and 2 numbers were written on 30 chits each. Patients who pick 1 were intervened with yoga along with asthma medications and those who pick 2 were continued on their regular asthmatic medication. Regular monitoring of yoga (breathing exercises) was done for a period of 4 weeks. Pulmonary function of all the patients was again assessed after 4 weeks and the results between the two groups was compared. Data collected was entered into Microsoft Excel sheets. Results were expressed in frequencies or percentages and chi square test was done using Statistical Package for Social Sciences (SPSS) version 20 software.

Among 60 study subjects, 30 were intervened with yoga and other 30 were not intervened. The age of the study subjects ranges from 21 to 45 years of age. The mean age of the study population was 31 (± 6.1) years. In the study subjects, 34 (56.7%) were males and 26 (43.3%) were females. The history of asthma in the study subjects range from 2 to 17 years. The mean years of history of asthma in study subjects was 14.12 ± 0.7 years. Among the study subjects, 54 (90%) had asthma for more than 10 years and 33 (55%) had family history of asthma.

Asthma Control questionnaire:

Table 1 Sleep disturbances during night due to asthma.

Table 2 Symptoms of asthma in the morning

Table 3 Limitation of daily activities.

Table 4 Shortness of breath.

Table 5 Wheeze due to asthma

Table 6 Number of puffs of bronchodilator per day.

Table 1-6 shows the perception of the symptoms of asthma in both intervention and control group measured by using Asthma control questionnaire. It has been observed that various symptoms of asthma in the morning were improved in the intervention group after 4 weeks of yoga practise when compared to the control group. In the intervention group there was improvement in the sleep, decrease in the wheeze, decrease in number of episodes of shortness of breath after practising yoga. It has also been noted that there was decrease in the number of bronchodilator puffs used per day in the subjects in intervention group. Overall it can be noted that the symptoms have been improved in intervention group than in the control group.

Table 7 Pulmonary function tests among the intervention group.

Table 7 shows that there was increase in the FEV1, FVC, FEV1/FVC and PEFR in the intervention group but statistically highly significant increase (p<0.01) was observed in FEV1, FEV1/FVC and PEFR.

Table 8 Pulmonary function tests among the control group.

Table 8 shows the pulmonary function changes in the control group. It was observed that statistically significant variation was observed only in FEV1, FVC.

Table 9 Comparison of pulmonary function tests between two groups after intervention.

Table 9 shows that there was a highly statistically significant increase in FEV1, FVC and PEFR in the intervention group that were intervened with the practise of yoga exercises for 4 weeks than in the control group (p<0.01).

A cross-sectional study was conducted among 60 asthmatic patients attending a tertiary care teaching hospital. 30 patients were intervened with yoga along with their medication and 30 were selected as controls. In this study, age of the study subjects ranges between 21 to 45 years of age. The mean age of the study population was 31 ± 6.1 years. 56.67% were male and 43.33% were female. Among 60 study subjects, 90% were known asthmatics for more than 10 years. 56.67% subjects use only bronchodilators while 43.33% use both bronchodilators and corticosteroids. Family history of asthma was present in 55% study subjects and 45% had no family history of asthma.

Yoga is a 3000-year-old tradition which is now regarded in the western world as a holistic approach of health and is classified by the National Institutes of Health as a form of Complementary and Alternative Medicine (CAM)[10].

Regular practice of yoga promotes strength, endurance, flexibility and facilitates characteristics of friendliness, compassion, and greater self-control, while cultivating a sense of calmness and well-being [11]. Sustained practice also leads to important outcomes such as changes in life perspective, self-awareness and an improved sense of energy to live life fully and with genuine enjoyment [12]. The practice of yoga produces a physiological state opposite to that of the flight-or-fight stress response and with that interruption in the stress response, a sense of balance and union between the mind and body can be achieved[13].

Yoga is a form of mind-body fitness that involves a combination of muscular activity and an internally directed mindful focus on awareness of the self, the breath, and energy [11].

Yoga is recognized as a form of mind-body medicine that integrates an individual's physical, mental and spiritual components to improve aspects of health, particularly stress related illnesses [12]. Evidence shows that stress contributes to the etiology of heart disease, cancer and stroke as well as other chronic conditions and diseases [14]. The scientific study of yoga has increased substantially in recent years and many clinical trials have been designed to assess its therapeutic effects and benefits.

In our study, the yoga intervention group there was decrease in the number of times they were woken up due to asthma at nights. The daily activities of the individuals were also improved after intervention with yoga when compared to the control group. There was also a decrease in number of puffs of bronchodilator used per day in the study subjects after intervention with yoga than in those not intervened. In the control group, not much improvement was observed and there was an increase in the number of puffs of bronchodilator used and there was increase in limitation of daily activities. Similar results were observed in a study with statistically significant reduction in the day and night asthma attacks in the individuals intervened with yoga [15].

In current study, pulmonary function among the study subjects in the yoga intervention group showed an increase in the FEV1, FVC, FEV1/FVC and PEFR. The increase in FEV1, FVC and FEV1/FVC was statistically significant. Among the control group, pulmonary function has not improved. There was increase in FEV1/FVC in the control group but is not statistically significant. After intervention with yoga for 4 weeks, there was statistically significant increase in FEV1, FVC and PEFR than in the control group. Increase in FEV1/FVC is also observed in the study subjects with yoga intervention than in the control group but was not statistically significant. A preliminary clinical trial conducted among 24 asthmatic patients showed that there was 10% increase in PEFR in yoga group while only 2% increase was seen in control group [15]. A study conducted among 112 asthma patients after a 6 weeks intervention with yoga, respiratory function, Asthma Control Test (AST) and Asthma Quality of Life Scale (AQLQ) were studied. There was statistically significant variation found in these parameters pre-test and post-test in both experimental and control groups. It was also observed that post-test average scores were increased in the experimental group while they were decreased in the control group [16]. It was observed that yoga intervention helps in improvement in pulmonary function like FEV1, FVC, FEV1/FVC and PEFR among the fifteen articles included in the study [17]. A systematic review conducted by Zu-Yao Yang et al., to show effect of yoga on various aspects like quality of life, asthma symptom score, asthma control, lung function measures, asthma medication usage and adverse events showed that yoga moderately improves the quality of life and symptoms in people with asthma. There was uncertainty about the effect of yoga on the lung function and medication usage [18]. Another systematic review showed that there was no significant improvement in the pulmonary function with yoga intervention even after 3 months of intervention except for PEFR at 4-6 weeks, PEF absolute at 3 months and FVC absolute at 3 months [19].

In this study, the study subjects intervened with yoga had decrease in number of awakenings at night, improvement in the daily activities, decrease in the symptoms like wheeze, decrease in shortness of breath and decrease in number of puffs of bronchodilator use per day. There was statistically significant improvement in the pulmonary function among the yoga group before and after intervention for 4 weeks. There was statistically significant increase in the pulmonary functions like FEV1, FVC and PEFR in yoga group when compared to control group. Further research on the long-term benefits that can be obtained by practicing yoga among asthmatic patients has to be studied as it has additional advantage of decreasing the number and dose of drugs and ultimately decreasing the adverse effects caused in them on long term use of those medicines and improving the overall quality of life of the asthmatic patients.

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