National Journal of Physiology, Pharmacy and Pharmacology

RESEARCH ARTICLE
Yoga as a complementary therapy improves pulmonary functions in
patients of bronchial asthma: A randomized controlled trial

Pushpa K1, Divya Sharma2

1
Department of Physiology, Shridevi Institute of Medical Sciences and Research Hospital, Tumakuru, Karnataka, India, 2Department of
Pharmacovigilance, Medical Safety Advisor, IQVIA, Bengaluru, Karnataka, India
Correspondence to: Divya, E-mail: divyabhatap@gmail.com

Received: October 21, 2018; Accepted: November 09, 2018

ABSTRACT

Background: Asthma is one of the major non-communicable diseases affecting mainly urban population worldwide. With
increasing traffic, there is upsurge in air pollution levels in Bengaluru, resulting in increase in number of bronchial asthma
cases. The purpose of the study was to know the effectiveness of yoga on lung functions so as to reduce the disease burden
in bronchial asthma patients. Aims and Objectives: The aim of the study was to record pulmonary function test (PFT) in
(1) Group A - 30 bronchial asthma patients practicing yoga along with pharmacological treatment and (2) Group B - 30
bronchial asthma patients who are only on pharmacological treatment and to compare the results between the two groups
at baseline, after 4 weeks, and after 8 weeks. Materials and Methods: Study included 60 mild-moderate bronchial asthma
patients, divided into Group A and Group B. PFT was done, forced expiratory volume in one second (FEV1), forced vital
capacity (FVC), FEV1/FVC, peak expiratory flow rate (PEFR), and forced expiratory flow rate 25–75% (FEF25-75) were
measured using MEC PFT and airway resistance (RAW) and specific airway conductance (sGAW) were measured using
body plethysmograph at baseline, after 4 weeks and after 8 weeks in both the groups. Results: Group A showed progressive
improvement in FEV1, FVC, FEV1/FVC, PEFR, FEF25-75, and sGAW (P < 0.001) and a significant reduction in RAW after
4th and 8th weeks of yoga training. Group B showed no significant change in FEV1, FVC, FEV1/FVC, PEFR, FEF25-75,
RAW, and sGAW after 4 weeks and 8 weeks. Conclusion: Yoga can be used as adjunctive therapy as it significantly
improves lung functions in mild-to-moderate bronchial asthma. Regular practice of yoga leads to improved quality of life
in bronchial asthmatics.

KEY WORDS: Airway Resistance; Asthma; Pranayama; Pulmonary Functions; Yoga

INTRODUCTION prevalence of asthma had been much lower, there is a rising

prevalence which is associated with increased urbanization.
Bronchial asthma is one of the most common chronic The increasing global prevalence of asthma, the large burden
diseases globally, and currently, it affects approximately 300 it now imposes on patients, and the high health-care costs
million people worldwide. In developing countries where the have led to extensive research into its mechanisms and
treatment.[1] There is a rising incidence of asthma in India.
Access this article online Overall, the prevalence of asthma in major cities of India
Website: www.njppp.com Quick Response code is 2.38%, prevalence in Bengaluru city alone is 3.47%.[2]
Bengaluru is a rapidly growing city in terms of migration,
transportation as well as an industrial sector from past two
DOI: 10.5455/njppp.2018.8.1033009112018 decades. Hence, air pollution level is increasing in Bengaluru
resulting in poor air quality due to the elevated content of
particulate matter which is one of the major risk factors for

National Journal of Physiology, Pharmacy and Pharmacology Online 2018. © 2018 Pushpa K and Divya. This is an Open Access article distributed under the terms of the Creative
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Pushpa and Sharma Effect of yoga on pulmonary functions in bronchial asthmatics

the development of asthma. This leads to increased incidence Bengaluru Medical College and Research Institute. The study
of bronchial asthma cases and acute exacerbations in chronic was a randomized controlled trial conducted in Bengaluru
asthma patients. In developing countries like India, long-term including 60 patients with mild-moderate bronchial asthma.
use of multiple drugs is expensive. Moreover, most of the Subjects were selected from the diagnosed cases of bronchial
asthma-related deaths occur in low and lower-middle income asthma attending Victoria Hospital Outpatient Department
countries. According to the latest WHO estimates, released for treatment, based on inclusion and exclusion criteria.
in December 2016, there were 383,000 deaths due to asthma The study included diagnosed cases of bronchial asthma,
in 2015.[3] As there is a rising rate of bronchial asthma and aged 18–50 years with an established diagnosis for at least
its complications among urban population in Bengaluru city, 6 months, mild-moderate cases meeting[12] National Asthma
measures have to be taken for appropriate management of Education and Prevention Program classification. Subjects
asthma which can reduce the disease burden, health-care cost on Inhaled B-agonist (short-acting and long-acting) with
and also improve the quality of life of bronchial asthmatics. stable medication dose for past 1 month. Study excluded
smokers, patients with concomitant lung disease, those who
Bronchial asthma is a condition characterized by chronic practiced yoga or any other similar discipline during 6 months
airway inflammation and airway hyperresponsiveness leading preceding the study, pregnancy, any chronic medical condition
to symptoms of wheeze, cough, chest tightness, and dyspnea. that required a treatment with oral/systemic steroids in the
Bronchial asthma besides being a chronic inflammatory past months, any medical condition that contraindicated
disease of the airways also has psychosomatic imbalance exercise, history of tuberculosis, diabetes mellitus, renal
and an increased vagal tone as its etiopathogenesis. Yoga failure, coronary artery disease, musculoskeletal deformities,
therapy readjusts the autonomic imbalance, controls the rate and status asthmaticus. The written informed consent
of breathing and thus alters various physiological variables.[4] was obtained from all the subjects, and a general physical
Yoga includes gentle stretching of muscles and breathing examination was done. The procedure was explained, and
exercises with wide range of classical asanas and pranayama the subjects were randomly divided into yoga training group
practices. Pranayama involves regulated breathing exercises (n = 30) and control group (n = 30).
which require a person to hold his breath, maintaining
isometric contraction of respiratory muscles and also requires Yoga training group practiced yoga exercises along with the
forceful respiration. Pranayama helps to strengthen the medication, Yogic exercises used by the patients included
respiratory muscles and increases respiratory endurance.[5] pranayamas (deep breathing exercises), kapalabhati (cleaning
breath), bhastrika (rapid and deep respiratory movements
Effects of yoga on pulmonary functions in bronchial like that of the bellows), ujjayi (loud sound producing
asthmatics have varied across studies. Some studies suggest pranayama) and sukhapurvaka pranayama (easy comfortable
that yoga when adjunctively used with pharmacological breathing), meditation, and shavasana (relaxation technique)
treatment in mild-to-moderate asthmatic patients lead to under the guidance of trained yoga teacher for 45 min a day
improvement in pulmonary functions and reduces the usage for the duration of 2 weeks and instructed to practice at home
of bronchodilators.[4,6-8] Others mention that usefulness of for 45 min twice daily, regularly for remaining 6 weeks and
yoga techniques in asthmatics is limited and should be further were instructed to maintain a dairy record of each day of yoga
investigated.[9-11] Moreover, physicians and pulmonologists practice. Control group was taking only pharmacological
give less attention for yoga in the treatment of bronchial therapy. All patients were remained on their prescribed
asthma. There is a paucity of studies showing the effect treatment during the study. Pulmonary function test (PFT)
of yoga on airway resistance (RAW) and specific airway was done in the morning hours between 9 and 10 am after
conductance in asthma patients. Hence, the purpose of the a light breakfast and 30 min of rest. PFTs were recorded in
study was to assess the effect of yoga training whether it both the groups at baseline, after 4 weeks and 8 weeks using
improves pulmonary functions in bronchial asthma patients M.E.C PFT body plethysmograph station. The results were
as compared to those asthmatics who were only on standard tabulated in the master chart and statistically analyzed. The
pharmacological treatment. The results of this study would statistical software, namely SAS 9.2, SPSS 15.0, Stata 10.1,
emphasize the importance of yoga techniques in improving MedCalc 9.0.1 and Systat 12.0, and R environment ver.2.11.1
pulmonary functions in asthmatics so that yoga can be was used for the analysis of the data and Microsoft Word
included as an adjuvant therapy along with the standard and Excel have been used to generate graphs, tables.[13-15]
pharmacological treatment and asthmatics can lead a good Descriptive statistical analysis was done in our present study.
quality of life. For calculation of results on continuous measurements,
mean ± standard deviation (minimum-maximum) was
MATERIALS AND METHODS applied. Number (%) has been used to present results on
categorical measurements. Assessment of significance
The study was carried out in lifestyle laboratory, Department was done at 5% level of significance. Analysis of variance
of Physiology, BMCRI, Bengaluru. Ethical clearance was test was carried out to analyze the significance of study
taken from Institutional Ethical Clearance Committee of parameters between three or more than three groups of

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Pushpa and Sharma Effect of yoga on pulmonary functions in bronchial asthmatics

patients, student t-test (two-tailed, independent) has been is a significant improvement in pulmonary functions after
applied to assess the significance of study parameters on 8 weeks of yoga training in the study group. FEV1 and FVC
continuous scale between two groups intergroup analysis on in study group has significantly increased from baseline value
metric parameters. Leven1s test for homogeneity of variance of 2.06 ± 0.62 to 2.31 ± 0.66 (P < 0.001), and 2.87 ± 0.83 to
has been carried out to assess the homogeneity of variance. 2.90 ± 0.82, respectively. FEV1/FVC% has increased from
71.74 ± 5.38 to 79.95 ± 5.44 (P < 0.001). Increase in PEFR
from 5.13 ± 1.57 to 5.26 ± 1.56. FEF25-75 improved from a
RESULTS
baseline value of 2.82 ± 0.70 to 2.85 ± 0.70. Reduction of
The present study was a randomized controlled study consisting RAW from baseline value of 0.528 ± 0.19 to 0.512±0.19
of 60 mild-to-moderate cases of asthma, divided randomly (P < 0.001) after yoga sGAW improved from 1.02 ± 0.28 to
into Group A (yoga training along with pharmacological 1.05 ± 0.28 in the study group whereas the control group did
therapy) and Group B (only pharmacological therapy). not show any significant change in FEV1, FVC, FEV1/FVC,
Table 1 shows the anthropometric parameters in both groups. PEFR, FEF25-75, RAW, and sGAW over 8 weeks.
Subjects in both the groups were well matched with respect
to age, height, weight, and Body mass index (BMI). Table 2 Asthma is associated with an increase in RAW, decrease in
shows that gender distribution was matched in both groups. forced respiratory volumes and flow rates, hyperinflation
Table 3 shows the pulmonary parameters recorded at baseline, of the lungs and increased work of breathing. Yoga therapy
after 4 weeks and after 8 weeks. The pulmonary parameters readjusts the autonomic imbalance, controls the rate of
were well matched between both the groups at baseline. breathing, relaxes the voluntary inspiratory and expiratory
There is improvement of forced expiratory volume in one muscles reduces RAW and increases lung compliance.[6]
second (FEV1), forced vital capacity (FVC), FEV1/FVC,
peak expiratory flow rate (PEFR), forced expiratory flow Our study is in agreement with Sodhi et al. and Singh et al.
rate 25–75% (FEF25-75), specific airway conductance (sGAW) who have found similar results on pulmonary functions
(P < 0.001), and significant reduction in RAW (P < 0.001) FEV1, FVC and FEV1/FVC% after the yoga training. Yoga
after 4th and 8th weeks of yoga practice in Group A as therapy relaxes the voluntary inspiratory and expiratory
compared to Group B [Tables 1-3]. muscles increases respiratory efficiency balances activity
of opposing muscle groups and slows dynamic and static
movements.[4] Yoga asanas and pranayama enhances the
DISCUSSION strength and endurance of respiratory muscles, diaphragm and
upper abdominal muscles.[6] Regular practice of pranayama
In this randomized controlled study using MEC PFT and will lead to improvement in vital capacity due to increased
body plethysmograph system, effort has been made to study development of respiratory musculature. Moreover, the
the effect of yoga on PFTs in patients of the mild-to-moderate respiratory apparatus is emptied and filled more completely
severity of bronchial asthma. Study group practiced yoga and efficiently which is recorded in terms of FVC. The
along with pharmacological therapy and control group increase in FEV1 might be due to a significant increase in
followed only pharmacological therapy. As per Table 3, there vital capacity.[16]

Table 1: Anthropometric parameters of the patients This study is in agreement with study done by Nagarathna R
studied et al. and Singh S et al. who studied the effect of yoga on
Anthropometric Group A Group B P value bronchial asthma and found significant improvement in
variable PEFR and FEF25-75 in yoga group. Yoga improves thoracic
Age (years) 32.67±8.69 31.00±9.03 0.553 - pulmonary compliances and leads to bronchodilation.
Height (cm) 160.27±8.93 160.87±9.00 0.796
Stimulation of pulmonary stretch receptors by inflation
of the lung reflexly relaxes smooth muscles of larynx and
Weight (kg) 63.70±11.61 63.27±8.32 0.869
tracheobronchial tree, and this may modulate the airway
BMI (kg/m2) 24.78±4.21 25.51±5.97 0.586
caliber and reduces RAW.[17] Modification of vagal efferent
BMI: Body mass index activity by yoga therapy seems to affect calibre of airways.[7]
Yoga appears to result in somatic muscular relaxation finally
Table 2: Gender distribution of patients studied resulting in a reduction in RAW and increases compliance of
Gender Group A Group B the lung.[6] Yoga with its calming effect on the mind which
n (%) n (%) could reduce the emotional stress and therefore withdrawing
Male 10 (33.3) 10 (33.3)
the bronchoconstrictor effects.[18]
Female 20 (66.7) 20 (66.7)
Our study is in agreement with Lehman et al. who studied
Total 30 (100.0) 30 (100.0) the effect of functional relaxation as complementary therapy

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Pushpa and Sharma Effect of yoga on pulmonary functions in bronchial asthmatics

Table 3: Comparison of study variables in two groups at baseline, after 4 and 8 weeks
Variables Groups Baseline Week 4 Week 8 P value
FEV1(l) A 2.06±0.62 2.16±0.64 2.31±0.66 <0.001**
B 2.07±0.57 2.08±0.57 2.07±0.57 0.557
P Value 0.942 0.599 0.133
FVC (l) A 2.87±0.83 2.88±0.82 2.90±0.82 <0.001**
B 2.93±0.70 2.94±0.70 2.94±0.70 0.324
P Value 0.742 0.748 0.836
FEV1/FVC% A 71.74±5.38 74.84±5.08 79.95±5.44 <0.001**
B 70.28±6.71 70.18±6.7 70.96±6.81 0.227
P Value 0.360 <0.003** <0.001**
PEFR (l/s) A 5.13±1.57 5.18±1.57 5.26±1.56 <0.001**
B 5.03±1.59 5.08±1.61 5.02±1.58 0.405
P Value 0.812 0.807 0.569
FEF25‑75 (l/s) A 2.82±0.70 2.83±0.70 2.85±0.70 <0.001**
B 2.92±0.64 2.94±0.65 2.93±0.65 0.133
P Value 0.556 0.536 0.661
RAW kPa (l/s) A 0.528±0.19 0.516±0.19 0.512±0.19 <0.001**
B 0.577±0.18 0.578±0.18 0.582±0.18 0.195
P Value 0.308 0.193 0.085+
sGAW (l/kPa/s) A 1.02±0.28 1.03±0.28 1.05±0.28 <0.001**
B 0.95±0.25 0.96±0.25 0.95±0.25 0.266
P Value 0.264 0.236 0.163
BMI: Body mass index, FEV1: Forced expiratory volume in 1 second, FVC: Forced vital capacity, PEFR: Peak expiratory flow rate,
FEF25‑75: Forced expiratory flow rate 25–75% of FVC, RAW: Airway resistance, sGAW: Specific airway conductance

in asthma and found that functional relaxation leads to a have psychophysiological benefits by increasing the patient’s
significant decrease in sRAW and significant improvement sense of control over stress and thus helps in reducing their
in FEV1. Psychological treatment methods may influence autonomic arousal factors. Yoga leads to an autonomic
airway caliber by balancing the activity of the autonomous equilibrium with a tendency toward parasympathetic
nervous system. Mitigation of vagal stimulation rebalances dominance rather than sympathetic dominance.[4] Yoga is a
autonomic system and is claimed to be responsible for form of mind-body medicine, which promotes positive affect
bronchodilation and thereby reducing RAW.[8] Reduction and reduces negative affect to improve pulmonary functions
in psychological hyperactivity and emotional instability and reduce usage of bronchodilators in asthma patients.[20]
achieved by yoga reduces efferent vagal reactivity.[7] During Hence, reducing the health-care cost burden and improving
pranayama training, regular inspiration and expiration for the quality of life in bronchial asthma patients. Bronchial
prolonged period will help the lungs to inflate and deflate asthmatics should be motivated to practice yoga on a regular
maximally and that it causes strengthening and increases basis so as to reduce the symptoms and prevent further
the endurance of the respiratory muscles. This maximum complications so that they can lead a better quality of life.
inflation and deflation is an important physiological stimulus The study was conducted on a limited sample over a short
for the release of surfactants and prostaglandins into the duration of time. There is scope for similar large-scale studies
alveolar spaces, which thereby increases the lung compliance. over longer duration so that yoga could be included as a part
The stretch receptors reflexly decrease the tracheobronchial of the standard treatment regimen.
smooth muscle tone activity, which, in turn, causes decreased
airflow resistance and increased airway caliber and reduces CONCLUSION
RAW.[19] This leads to an improvement in specific airway
conductance. Regular practice of yoga improves pulmonary functions
in mild-to-moderate cases of bronchial asthma, when used
Our study shows that there is a significant improvement in adjunctively with standard pharmacological treatment.
all the pulmonary parameters with regular practice of yoga Physicians may emphasize on regular practice of yoga along
techniques along with standard pharmacological treatment. with pharmacological therapy in asthmatics. Awareness has
Yoga reduces the bronchoconstrictor effects, increases lung to be created among asthma patients regarding usefulness
compliance and respiratory endurance. Overall, yoga may yoga in the treatment of bronchial asthma.

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Pushpa and Sharma Effect of yoga on pulmonary functions in bronchial asthmatics

ACKNOWLEDGMENTS 2003;58:674-9.
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Hussong M, et al. Functional relaxation and guided imagery
complementary therapy improves pulmonary functions in
as complementary therapy in asthma: A randomized controlled
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Source of Support: Nil, Conflict of Interest: None declared.
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