The goal for this clinical trial was to compare the effectiveness of Diaphragmatic Breathing and Pursed-Lip Expiration Exercises in improving lung functions {the Peak Expiratory Flow Rate (PEFR) and Forced Expiratory Volume in 1- second (FEV1)} and Chest Expansion in Egyptian outpatient adults with bronchial asthma.

The research questions were:

1. Are Diaphragmatic Breathing Exercises effective in improving lung function parameters?
2. Are Pursed-Lip Expiration Exercises effective in improving lung function parameters?
3. Which of the two studied breathing exercise is more effective in improving lung function parameters?

All the participants were classified into 2 groups:

Group1:

Diaphragmatic Breathing Exercise training was offered for participants to complete the 8-weeks exercise program (each session lasted about 20 minutes twice daily for 5 days per week).

Group2:

Pursed Lip Breathing Exercise training was offered for participants to complete the 8-weeks exercise program (each session lasted about 20 minutes twice daily for 5 days per week).

The two main parameters which were assessed initially and after completion of the 2-month exercise program were:

1. Lung functions {Peak Expiratory Flow Rate (PEFR) and Forced Expiratory Volume in 1-second (FEV1)}
2. The chest expansion

Participants were enrolled from Outpatient Chest Clinic in Ain Shams University Hospitals.

After checking for inclusion and exclusion criteria and signing the informed consent form the following was carried out.

After enrollment of the participants from outpatient chest clinic, their education and interviewing were conducted in a private comfortable room near to chest clinic taking the time for discussion, understanding the 2- month training program and practicing the exercises techniques through first visit, bimonthly visits and the last visit. These visits were the same for the two groups with a difference in the exercise technique (explained in detail in a separate paragraph for each group), these visits included:

A. First visit:

1. Thorough history was carefully taken for proper assessment and exclusion of any patients prone to risks.

2. Spirometry based- diagnosis was reviewed.

3. Measurement of Peak Expiratory Flow Rate (PEFR), Forced Expiratory Volume in 1-second (FEV1) and chest expansion. The techniques and steps of peak flowmeter and chest expansion measurements were explained for participants before assessing these parameters.

4. The whole exercises technique was explained carefully and video demonstration on laptop was shown for participants to make sure of their understanding (See Appendix 1).

5. Every participant practiced the exercise under supervision, and any mistakes were reviewed, and the exercise was repeated till mastering the technique.

6. Encouragement of the participants for adherence to exercise program through:

   • Explanation of the breathing exercises' benefits to participants which included, increased control over breathing, reduced need for medication, feeling more relaxed, improved health and quality of life and non- respiratory psychological benefits such as decreasing anxiety; these benefits were recorded by previous clinical trials. Regarding the down or up stepping of the asthma medications for the participants, this was completely the chest doctor's responsibility toward their patients.
   • Daily self-monitoring sheets regarding days, frequency and duration of exercise should be fulfilled by the participants to improve their compliance motivation, remembering and adherence; the participants were informed about the items in the follow-up sheets to fulfill it properly and were reviewed in the bimonthly follow up visits regularly (See Appendix 2,3).
   • WhatsApp group for each arm of the trial for daily follow up monitoring and reinforcement by videos.

7. The exercise program and follow up plan were discussed with participants.

8. Informed consent was obtained from all the participants.

B- Bimonthly Follow up visits (Three follow up visits along the 2-month exercise program):

1. The exercise technique was reviewed with the participants to ensure mastering the technique and the participants practiced the exercise in front of the investigator.
2. Discussion about the adherence to the training program and any obstacles were reviewed for simplification.
3. Reviewing the printed follow up daily sheets.
4. Reinforcing and encouragement of participants to maintain the exercise program.
5. No measurements were obtained in follow up visits, only in the first visits initially and the last visit after completion of the 2-month exercise program.

C-The last visit:

1. Remeasuring of PEFR, FEV1 and chest expansion after the 2-months exercise program.
2. Thanking the participants about their exercise program engagement.

Inclusion Criteria:

• Egyptian adults aged between 18 and 60 years old, both males and females.
• Pulmonary function-based diagnosis for asthma.
• Mild and moderate cases of asthma.

Exclusion Criteria:

• Recent myocardial infarction or acute coronary syndrome.
• Non-cooperative patients.
• Status asthmatics patients.
• Hypoxic patients.
• Asthmatic patients who were associated with other chest and heart diseases.
• Recent pneumothorax or pulmonary embolism.
• Large thoracic or abdominal aortic aneurysm.
• Acute onset of hemoptysis.
• Retinal detachment.
• Intracranial hypertension.
• Patients with dementia.
• Recent brain, eye, ear, nose, abdominal or thoracic surgery.
• Severe uncontrolled hypertension.
• Patients with urinary incontinence.
• Currently admitted to intensive care unit.