What motivated you to investigate non-drug, non-exercise interventions for breathlessness in people with chronic lung disease? 

Breathlessness is a distressing and debilitating symptom for people with chronic lung disease. 

Pulmonary rehabilitation (PR), and exercise training in particular, is proven to reduce dyspnoea and improve quality of life. 

Research is saturated in this area. 

Despite this, uptake and completion of PR remain low. Given this implementation gap, it was important for us to explore alternative non-pharmacological strategies.

Until now, interventions outside of pharmacotherapy or exercise therapy for dyspnoea had not been systematically reviewed and meta-analysed. 

Our review provides clinicians with evidence for strategies that could support people who are eligible for PR but cannot, or will not, attend. 

Your review highlights breathing techniques such as pursed lip breathing and yoga breathing. What is it about these approaches that seems to help patients? 

In people with chronic obstructive pulmonary disease, strategies like pursed lip breathing and yoga breathing can produce small to moderate short-term reductions in breathlessness and longer-term improvements in quality of life. 

Chronic obstructive pulmonary disease is characterised by expiratory airflow limitation and dynamic hyperinflation. 

Pursed lip breathing slows respiratory rates and elongates exhalation, allowing for a more complete expiration. 

It creates positive expiratory pressure, which may help maintain airway patency and reduce dynamic airway closure. 

Yoga breathing or pranayama combines slow, controlled breathing with relaxation and body awareness. 

Given the strong interaction between anxiety and dyspnoea perception, calm, deliberate breathing improves expiration while simultaneously reducing anxiety, both of which contribute to a reduction in breathlessness. 

You also found that inhaling menthol can reduce the unpleasantness of breathlessness. How does that work and could it be applied in day-to-day care? 

The two crossover trials demonstrated that inhaling L-menthol produced an immediate reduction in the intensity or unpleasantness of dyspnoea. 

The cooling sensation of menthol on the nasal and facial regions stimulates the trigeminal and vagal sensory nerves, altering the cognitive perception of airflow. 

This may reduce the mismatch between respiratory effort and sensory feedback—a key factor in dyspnoea. 

While the patches and/or swabs used in these trials are not routinely available, natural menthol is sourced from peppermint and many over-the-counter products. 

This suggests a simple, cost-effective strategy that could be trialled in day-to-day care. 

Pulmonary rehabilitation is very effective, yet many patients never attend. How might the strategies you reviewed help fill this gap in care? 

There were many non-pharmacological strategies identified. Breathing retraining, in particular, is safe, low-cost and simple. 

It can be practised at home and delivered in rural or resource-limited settings. 

Introducing alternatives early may encourage PR participation. 

Considering the significant distress associated with dyspnoea, many may initially hesitate to participate in exercise-based programs. 

Offering simple treatments can relieve symptoms, challenge unhelpful beliefs and build confidence—potentially enhancing patients’ willingness to engage in PR. 

All of the interventions reviewed were simple, inexpensive and safe. Do you see these being adopted more widely in clinical practice and what might help that happen? 

A crucial first step is raising awareness among patients, many of whom don’t realise that simple techniques like breathing retraining can make a meaningful difference. 

Clinician education and confidence in delivering these strategies are equally important. 

Embedding them into existing care pathways, including primary care, PR and telehealth, can improve accessibility. 

Wider adoption will also depend on more robust research evaluating long-term benefits and cost-effectiveness. 

Looking ahead, what are the biggest research questions that still need answering to strengthen the evidence for non-drug, non-exercise interventions? 

More robust research should be conducted to enhance evidence-based practice for the use of alternative treatments. 

For instance, handheld fans are commonly used to relieve breathlessness, but their effectiveness has not been widely studied. 

Similarly, forward-lean positions are often recommended in practice, yet there are minimal high-quality trials. 

Including qualitative input from individuals with lived experience could provide insight into how and why strategies work, particularly where qualitative evidence is limited. 

Hypotheses from chronic pain research suggest that helping people understand their symptoms and challenging unhelpful beliefs may be crucial in managing noxious stimuli (eg, pain or dyspnoea). 

Approaches like cognitive functional therapy, which combines graded exposure, self-management and lifestyle adaptation, are worth exploring as potential strategies for dyspnoea. 

>>Makayla Pinna APAM is a physiotherapist focused on improving care for people with chronic lung disease. Her research explores practical, non-pharmacological, non-exercise strategies that support patients who experience dyspnoea and are unable to access pulmonary rehabilitation programs.

Email inmotion@australian.physio for references.