Description
Intervention design: This was a pragmatic 3-group, 12-month, observer-blinded, parallel-group randomised trial comparing the use of a DVD and booklet (DVDB) intervention with face-to-face physiotherapy or with a control group receiving usual care, in adults with asthma who were recruited from 34 UK general practices. Participants were randomly assigned to receive either the DVDB intervention, three face-to-face breathing retraining sessions, or standard care, in a 2:1:2 ratio, for 12 months. The research nurse then provided the participant with the appropriate materials and follow-up arrangements for the relevant study group.
The DVDB materials were developed by a multidisciplinary team including physicians, physiotherapists, health psychologists, communications technology specialists, and patient representatives, with extensive iterative qualitative patient input to optimise acceptability and effectiveness, and consisted of three elements. First, the DVDB intervention provided a detailed explanation and illustration of how to complete the breathing exercises, with footage showing a physiotherapist teaching these exercises to patients. The exercises comprised an illustration of, and training in, diaphragmatic breathing, nasal breathing, slow breathing, controlled breath holds, and simple relaxation exercises. Second, the DVDB intervention provided motivational components, explaining the rationale and addressing common concerns. Finally, supportive features (such as a daily planner and progress charts) were included for practicing and implementing the techniques in daily life.
Participants randomly assigned to the usual care group received usual medical care, with no additional attention to the baseline assessment. Participants randomly assigned to the DVDB intervention group were provided with the DVD and the booklet. Participants randomly assigned to the face-to-face group also received the booklet and worked to a standardised intervention schedule and were seen by a respiratory physiotherapist who was trained and skilled in providing breathing retraining for three one-to-one sessions, each of about 40 min duration, approximately once every 2 weeks after randomisation. The same physiotherapist, working to a structured protocol, delivered all the face-to-face sessions for all patients. Fidelity to treatment delivery was identified by use of a physiotherapist-completed checklist at every session, and a direct observation checklist completed by one author (AB) of a random sample of 5% of sessions. Protocol adherence was predefined as conforming to 90% of the checklist, and was 100% on both the physiotherapist and the observation checklists.
People involved: 655 participants.
G1: 261 (DVDB), G2: 132 (face-to face), G3: 262 (usual care)
Age - G1: 56 (45–65), G2: 55 (47–63), G3: 57 (47–65
To be included in the study, participants had to be aged 16–70 years, be registered at a medical practice for at least 12 months, have asthma diagnosed by a physician, have been prescribed at least 1 asthma medication in the previous year, achieve an Asthma Quality of Life Questionnaire (AQLQ)11 score of less than 5•5, and to provide written informed consent. Patients were excluded if they had concomitant chronic obstructive pulmonary disease (COPD) diagnosis with FEV1 less than 60% predicted.
Identified barriers: Since the start of the study, DVD use has declined, accompanied by an increase in online and streaming sources for digital information and entertainment. Therefore, in order to make this intervention accessible to clinicians, researchers and asthma patients, the content of the DVD and accompanying booklet were made available online via the Breathe study website.
A limitation of the study is that of the individuals invited to participate, only 10% were enrolled, with a slightly older age profile than the overall UK adult asthma population, and thus might represent an atypical population that might be more prepared to consider breathing retraining
Current access to breathing retraining therapy within the NHS is limited by the availability of suitably trained physiotherapists and the logistical and economical challenges to providing face-to-face therapy to a wider population.

Sustainability
Transferability: the adult asthma population