Applied Psychophysiology and Biofeedback

, Volume 29, Issue 2, pp 121–133 | Cite as

Combined Heart Rate Variability and Pulse Oximetry Biofeedback for Chronic Obstructive Pulmonary Disease: Preliminary Findings

  • Nicholas D. Giardino
  • Leighton Chan
  • Soo Borson


The purpose of this study was to examine the feasibility of an intervention that included heart rate variability (HRV) biofeedback and walking with pulse oximetry feedback to improve functioning and quality of life for patients with chronic obstructive pulmonary disease (COPD). Twenty patients with COPD participated in 5 weekly sessions of HRV biofeedback and 4 weekly sessions of walking practice with oximetry feedback, with instructions for daily home practice. Primary outcomes measures were the distance walked in 6 min (6MWD) and overall quality of life, as measured by the St. George's Respiratory Questionnaire (SGRQ). Secondary outcomes included measures of self-efficacy, self-reported disability, anxiety, depression, dyspnea before and after the 6MWD, and HRV at the frequency of respiration during spontaneous and paced breathing. After 10 weeks of training, participants showed statistically and clinically significant improvements in 6MWD and quality of life. Significant changes were also seen in self-efficacy, disability, dyspnea before and after the 6MWD, and HRV amplitude during spontaneous breathing. We conclude that our intervention is feasible for patients with COPD and that further research using a randomized controlled design is warranted.

heart rate variability respiratory sinus arrhythmia pulse oximetry biofeedback chronic obstructive pulmonary disease 


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  1. American Thoracic Society. (1995a). Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease. American Journal of Respiratory and Critical Care Medicine, 152, S77-S121.Google Scholar
  2. American Thoracic Society. (1995b). Standardization of spirometry, 1994 update. American Journal of Respiratory and Critical Care Medicine, 152, 1107-1136.Google Scholar
  3. American Thoracic Society. (2002). ATS statement: Guidelines for the six-minute walk test. American Journal of Respiratory and Critical Care Medicine, 166, 111-117.Google Scholar
  4. Arias, E., & Smith, B. L. (2003). Deaths: Preliminary data for 2001. In National vital statistics report (Vol. 51, Issue 5). Hyattsville, MD: National Center for Health Statistics.Google Scholar
  5. Barach, A. L. (1973). Physiologic advantages of grunting, groaning, and pursed-lip breathing: Adaptive symptoms related to the development of continuous positive pressure breathing. Bulletin of the New York Academy of Medicine, 49, 666-673.Google Scholar
  6. Bernardi, L., Gabutti, A., Porta, C., & Spicuzza, L. (2001). Slow breathing reduces chemoreflex response to hypoxia and hypercapnia, and increases baroreflex sensitivity. Journal of Hypertension, 19, 2221-2229.Google Scholar
  7. Berntson, G. G., Bigger, J. T., Eckberg, D. L., Grossman, P., Kaufmann, P. G., Malik, M., et al. (1997). Heart rate variability: Origins, methods, and interpretive caveats. Psychophysiology, 34, 623-648.Google Scholar
  8. Breslin, E. H. (1995). Breathing retraining in chronic obstructive pulmonary disease. Journal of Cardiopulmonary Rehabilitation, 15, 25-33.Google Scholar
  9. Brown, T. E., Beightol, L. A., Koh, J., & Eckberg, D. L. (1993). Important influence of respiration on human R-R interval power spectra is largely ignored. Journal of Applied Physiology, 75, 2310-2317.Google Scholar
  10. Casciari, R. J., Fairshter, R. D., Harrison, A., Morrison, J. T., Blackburn, C., & Wilson, A. F. (1981). Effects of breathing retraining in patients with chronic obstructive pulmonary disease. Chest, 79, 393-398.Google Scholar
  11. Challapalli, S., Kadish, A. H., Horvath, G., & Goldberger, J. J. (1999). Differential effects of parasympathetic blockade and parasympathetic withdrawal on heart rate variability. Journal of Cardiovascular Electrophysiology, 10, 1192-1199.Google Scholar
  12. Delk, K. K., Gevirtz, R., Hicks, D. A., Carden, F., & Rucker, R. (1994). The effects of biofeedback assisted breathing retraining on lung functions in patients with cystic fibrosis. Chest, 105, 23-28.Google Scholar
  13. Dowson, C., Laing, R., Barraclough, R., Town, I., Mulder, R., Norris, K., et al. (2001). The use of the Hospital Anxiety and Depression Scale (HADS) in patients with chronic obstructive pulmonary disease: A pilot study.New Zealand Medical Journal, 114, 447-449.Google Scholar
  14. Esteve, F., Blanc-Gras, N., Gallego, J., & Benchetrit, G. (1996). The effects of breathing pattern training on ventilatory function in patients with COPD. Biofeedback and Self Regulation, 21, 311-321.Google Scholar
  15. Faling, L. J. (1986). Pulmonary rehabilitation-physical modalities. Clinics in ChestMedicine, 7, 599-618.Google Scholar
  16. Giardino, N. D., Chan, L., & Borson, S. (2003). Respiratory sinus arrhythmia is associated with pulmonary gas exchange efficiency in chronic obstructive pulmonary disease. Manuscript submitted for publication.Google Scholar
  17. Giardino, N. D., Glenny, R. W., Borson, S., & Chan, L. (2003). Respiratory sinus arrhythmia is associated with efficiency of pulmonary gas exchange in healthy humans. American Journal of Physiology: Heart and Circulatory Physiology, 284, H1585-H1591.Google Scholar
  18. Goldberger, J. J., Ahmed, M. W., Parker, M. A., & Kadish, A. H. (1994). Dissociation of heart rate variability from parasympathetic tone. American Journal of Physiology, 266, H2152-H2157.Google Scholar
  19. Goldberger, J. J., Challapalli, S., Tung, R., Parker, M. A., & Kadish, A. H. (2001). Relationship of heart rate variability to parasympathetic effect. Circulation, 103, 1977-1983.Google Scholar
  20. Grossman, P., Karemaker, J., & Wieling, W. (1991). Prediction of tonic parasympathetic cardiac control using respiratory sinus arrhythmia: The need for respiratory control. Psychophysiology, 28, 201-216.Google Scholar
  21. Hayano, J., & Yasuma, F. (2003). Hypothesis: Respiratory sinus arrhythmia is an intrinsic resting function of cardiopulmonary system. Cardiovascular Research, 58, 1-9.Google Scholar
  22. Hayano, J., Yasuma, F., Okada, A., Mukai, S., & Fujinami, T. (1996). Respiratory sinus arrhythmia.Aphenomenon improving pulmonary gas exchange and circulatory efficiency. Circulation, 94, 842-847.Google Scholar
  23. Hirsch, J. A., & Bishop, B. (1981). Respiratory sinus arrhythmia in humans: How breathing pattern modulates heart rate. American Journal of Physiology, 241, 620-629.Google Scholar
  24. Iellamo, F., Legramante, J. M., Pigozzi, F., Spataro, A., Norbiato, G., Lucini, D., et al. (2002). Conversion from vagal to sympathetic predominance with strenuous training in high-performance world class athletes. Circulation, 105, 2719-2724.Google Scholar
  25. Jones, P. W. (1998). Testing health status (“quality of life”) questionnaires for asthma andCOPD. European Respiratory Journal, 11, 5-6.Google Scholar
  26. Jones, P. W., Quirk, F. H., Baveystock, C. M., & Littlejohns, P. (1992). A self-complete measure of health status for chronic airflow limitation. The St. George's Respiratory Questionnaire. American Review Respiratory Disease, 145, 1321-1327.Google Scholar
  27. Lareau, S. C., Meek, P. M., & Roos, P. J. (1998). Development and testing of the modified version of the pulmonary functional status and dyspnea questionnaire (PFSDQ-M). Heart and Lung, 27, 159-168.Google Scholar
  28. Lehrer, P., Carr, R. E., Smetankine, A., Vaschillo, E., Peper, E., Porges, S., et al. (1997). Respiratory sinus arrhythmia versus neck/trapezius EMG and incentive inspirometry biofeedback for asthma: A pilot study.Applied Psychophysiology and Biofeedback, 22, 95-109.Google Scholar
  29. Lehrer, P., Smetankin, A., & Potapova, T. (2000). Respiratory sinus arrhythmia biofeedback therapy for asthma: A report of 20 unmedicated pediatric cases using the Smetankin method. Applied Psychophysiology and Biofeedback, 25, 193-200.Google Scholar
  30. Lehrer, P. M., Vaschillo, E., & Vaschillo, B. (2000). Resonant frequency biofeedback training to increase cardiac variability: Rationale and manual for training. Applied Psychophysiology and Biofeedback, 25, 177-191.Google Scholar
  31. Mezzacappa, E. S., Kelsey, R. M., Katkin, E. S., & Sloan, R. P. (2001). Vagal rebound and recovery from psychological stress. Psychosomatic Medicine, 63, 650-657.Google Scholar
  32. Miller, W. F. (1954). A physiologic evaluation of the effects of diaphragmatic breathing training in patients with chronic pulmonary emphysema. American Journal of Medicine, 17, 471-477.Google Scholar
  33. Motley, H. L. (1963). The effects of slow deep breathing on the blood gas exchange in emphysema. American Review Respiratory Disease, 88, 485-492.Google Scholar
  34. Mueller, R. E., Petty, T. L., & Filley, G. F. (1970). Ventilation and arterial blood gas changes induced by pursed-lips breathing. Journal of Applied Physiology, 28, 784-789.Google Scholar
  35. Murray, C. J. L., & Lopez, A. D. (1996). The global burden of disease: A comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Cambridge, MA: Harvard School of Public Health on behalf of the World Health Organization and the World Bank.Google Scholar
  36. Nelesen, R. A., Yu, H., Ziegler, M. G., Mills, P. J., Clausen, J. L., & Dimsdale, J. E. (2001). Continuous positive airway pressure normalizes cardiac autonomic and hemodynamic responses to a laboratory stressor in apneic patients. Chest, 119, 1092-1101.Google Scholar
  37. Pagani, M., Lucini, D., Pizzinelli, P., Sergi, M., Bosisio, E., Mela, G. S., et al. (1996). Effects of aging and of chronic obstructive pulmonary disease on RR interval variability. Journal of the Autonomic Nervous System, 59, 125-132.Google Scholar
  38. Paul, G., Eldridge, F., Mitchell, J., & Fiene, T. (1966). Some effects of slowing respiration rate in chronic emphysema and bronchitis. Journal of Applied Physiology, 21, 877-882.Google Scholar
  39. Salman, G. F., Mosier, M. C., Beasley, B. W., & Calkins, D. R. (2003). Rehabilitation for patients with chronic obstructive pulmonary disease: Meta-analysis of randomized controlled trials. Journal of General Internal Medicine, 18, 213-221.Google Scholar
  40. Sargunaraj, D., Lehrer, P. M., Hochron, S. M., Rausch, L., Edelberg, R., & Porges, S. W. (1996). Cardiac rhythm effects of.125-Hz paced breathing through a resistive load: Implications for paced breathing therapy and the polyvagal theory. Biofeedback and Self Regulation, 21, 131-147.Google Scholar
  41. Saul, J. P., Berger, R. D., Chen, M. H., & Cohen, R. J. (1989). Transfer function analysis of autonomic regulation. II. Respiratory sinus arrhythmia. American Journal of Physiology, 256, 153-161.Google Scholar
  42. Silverman, E. K., & Speizer, F. E. (1996). Risk factors for the development of chronic obstructive pulmonary disease. Medical Clinics of North America, 80, 501-522.Google Scholar
  43. Stein, P. K., Nelson, P., Rottman, J. N., Howard, D., Ward, S. M., Kleiger, R. E., et al. (1998). Heart rate variability reflects severity of COPD in PiZ alpha1-antitrypsin deficiency. Chest, 113, 327-333.Google Scholar
  44. Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. (1996). Heart rate variability. Standards of measurement, physiological interpretation, and clinical use. European Heart Journal, 17, 354-381.Google Scholar
  45. Tiep, B. L., Burns, M., Kao, D., Madison, R., & Herrera, J. (1986). Pursed-lips breathing training using ear oximetry. Chest, 90, 218-221.Google Scholar
  46. Vaschillo, E. G. (1984). Dynamics of slow-wave cardiac rhythm structure as an index of the functional state of an operant. Unpublished doctoral dissertation, Leningrad State University, Russia.Google Scholar
  47. Vaschillo, E., Lehrer, P., Rishe, N., & Konstantinov, M. (2002). Heart rate variability biofeedback as a method for assessing baroreflex function: A preliminary study of resonance in the cardiovascular system. Applied Psychophysiology and Biofeedback, 27, 1-27.Google Scholar
  48. Volterrani, M., Scalvini, S., Mazzuero, G., Lanfranchi, P., Colombo, R., Clark, A. L., et al. (1994). Decreased heart rate variability in patients with chronic obstructive pulmonary disease. Chest, 106, 1432-1437.Google Scholar
  49. Wigal, J. K., Creer, T. L., & Kotses, H. (1991). The COPD Self-Efficacy Scale. Chest, 99, 1193-1196.Google Scholar
  50. Yasuma, F., & Hayano, J. (2001). Augmentation of respiratory sinus arrhythmia in response to progressive hypercapnia in conscious dogs. American Journal of Physiology: Heart and Circulatory Physiology, 280, H2336-H2341.Google Scholar
  51. Zigmond, A. S., & Snaith, R. P. (1983). The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica, 67, 361-370.Google Scholar

Copyright information

© Plenum Publishing Corporation 2004

Authors and Affiliations

  • Nicholas D. Giardino
    • 1
    • 2
  • Leighton Chan
    • 1
  • Soo Borson
    • 3
  1. 1.Department of Rehabilitation MedicineUniversity of WashingtonSeattle
  2. 2.Department of PsychologyUniversity of CincinnatiCincinnatiUSA
  3. 3.Department of Psychiatry and Behavioral SciencesUniversity of WashingtonSeattle

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