International Journal of Nursing Studies 46 (2009) 1061–1070

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International Journal of Nursing Studies

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Effect of relaxation-breathing training on anxiety and asthma

signs/symptoms of children with moderate-to-severe asthma:
A randomized controlled trial
Li-Chi Chiang a,*, Wei-Fen Ma a, Jing-Long Huang b, Li-Feng Tseng c, Kai-Chung Hsueh d
a
School of Nursing, China Medical University and China Medical University Hospital, Taichung 40402, Taiwan, ROC
b
Division of Allergy, Asthma and Rheumatology, Department of Pediatrics, Chang Gung Children’s Hospital and Chang Gung University,
Taoyuan, Taiwan, ROC
c
National Taichung Institute of Technology, Department of General Education, Taichung, Taiwan, ROC
d
Department of Pediatrics, China Medical University Hospital, Taichung, Taiwan, ROC

A R T I C L E I N F O A B S T R A C T

Article history: Background: Emotional stress triggers and exacerbates asthma in children. Reducing
Received 14 August 2008 anxiety in adults by relaxation-breathing techniques has been shown in clinical trials to
Received in revised form 12 January 2009 produce good asthma outcomes. However, more evidence is needed on using this
Accepted 24 January 2009
intervention with asthmatic children.
Objective: To evaluate the effectiveness of combined self-management and relaxation-
Keywords: breathing training for children with moderate-to-severe asthma compared to self-
Anxiety
management-only training.
Children
Design: Two-group experimental design.
Asthma
Relaxation-breathing training Setting and participants: Pediatric outpatient clinic of a medical center in central Taiwan.
Chronic illness Participants were 48 children, ages 6–14 years, with moderate-to-severe asthma and their
parents.
Methods: Participants were randomly assigned to an experimental or comparison group
and matched by gender, age, and asthma severity. Both groups participated in an asthma
self-management program. Children in the experimental group were also given 30 min of
training in a relaxation-breathing technique and a CD for home practice. Data on anxiety
levels, self-perceived health status, asthma signs/symptoms, peak expiratory flow rate,
and medication use were collected at baseline and at the end of the 12-week intervention.
Effects of group, time, and group–time interaction were analyzed using the Mixed Model
in SPSS (12.0).
Results: Anxiety (especially state anxiety) was significantly lower for children in the
experimental group than in the comparison group. Differences in the other four
physiological variables were also noted between pre- and post-intervention, but these
changes did not differ significantly between groups.
Conclusions: A combination of self-management and relaxation-breathing training can
reduce anxiety, thus improving asthmatic children’s health. These results can serve as an
evidence base for psychological nursing practice with asthmatic children.
ß 2009 Elsevier Ltd. All rights reserved.

What is already known about the topic?

* Corresponding author. Tel.: +886 4 22053366x7119;

 Self-management programs can reduce asthma signs/
fax: +886 426310776. symptoms, school absenteeism, number of days of
E-mail address: lichi514@seed.net.tw (L.-C. Chiang). restricted activity, and can improve lung function.

0020-7489/$ – see front matter ß 2009 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijnurstu.2009.01.013
1062 L.-C. Chiang et al. / International Journal of Nursing Studies 46 (2009) 1061–1070
 Relaxation-breathing training has been suggested to
increase asthmatic children’s immunologic function and
improve asthma signs/symptoms and health status, yet
previous studies had inconsistent results and did not
include psychological effects.
 Relaxation-breathing training could be used in children
to reduce their anxiety but no reports could be found for
its use in children with asthma.
What this paper adds
 Relaxation-breathing training combined with a self-
management program for children with asthma did not
significantly change their self-perceived health status,
asthma signs/symptoms, lung function, and medication
usage compared to the self-management group.
 Relaxation-breathing training combined with a self-
management program lowered children’s anxiety, which
in turn might help children maintain good psychological
health.
1. Introduction
Asthma’s increasing prevalence, severity, and asso-
ciated medical costs have triggered interest in new
physiological and psychological intervention strategies,
including self-management (Guevara et al., 2003; Smith
et al., 2005; Wolf et al., 2003), breathing-exercise
techniques (Dennis, 2000; Ernst, 2000; Holloway and
West, 2007), group and family therapy (Deter and Allert,
1983), and hypnosis (Kohen and Wynne, 1997). Educa-
tional and self-management programs have shown posi-
tive results in terms of reducing asthma signs/symptoms,
school absenteeism, number of days of restricted activity,
and improved lung function (Guevara et al., 2003).
However, many studies have focused just on physiological
health even when an intervention has both physiological
and psychological components. Few studies have focused
on treating children’s psychological problems during the
chronic illness period.
Stress and psychological factors have been shown by a
growing body of evidence to trigger and exacerbate
asthmatic conditions (for example, see Lehrer, 1998;
Mathe and Knappe, 1971; Sandberg et al., 2000). Studies
on the links between socio-environmental stressors,
personality, and asthma attacks have shown that, regard-
less of the trigger, anxiety is a common reaction to
asthmatic episodes. For example, asthmatic children have
been described as reacting to stressful situations and
emotional distress in terms of anxiety, depression, and
irritability (Chiang, 2005; Juniper et al., 1996; Rydstrom
et al., 1999). Recurring asthma attacks and asthma signs/
symptoms have been shown to impact on children’s
psychosocial functions (Stores et al., 1997). Furthermore,
almost one-third of all children with asthma meet the
criteria for comorbid anxiety disorders (Katon et al., 2004),
meaning that stress should be viewed as both a trigger and
a consequence of this chronic disease. Asthma patients
experience shortness of breath and a sensation of
asphyxiation due to bronchial constriction, with simulta-
neously enhanced vagal drive, leading to an imbalance of
sympathetic/parasympathetic influences. Various emo-
tional states and stress increase oscillatory resistance.
Stress can also exacerbate airway hyperactivity and airway
inflammation in bronchial asthma. Parasympathetic nerve
impulses lead to a slower heart rate, more regular
respiration, and general relaxation (Lehrer, 1998).
Accordingly, Smith et al. (2005) argue that future
research on psycho-educational interventions must con-
sider the interaction of asthma and psychosocial factors.
Similarly, more psychological intervention studies have
been suggested, with outcome measurements including
severity of asthma signs/symptoms, medication usage, and
psychological indicators, such as anxiety (Pagliari et al.,
2002). In clinical practice, the most popular psychological
nursing intervention for all diseases is teaching relaxation-
breathing techniques that emphasize using the mind–body
connection for sign/symptom control (Kemper, 2000). This
trend is based on empirical validation of the idea that
changes in a patient’s emotional status can influence
immunological performance (Castes et al., 1999; Kern-
Buell et al., 2000). For example, an intervention that
combined relaxation teaching, guided imagery, and self-
esteem techniques reduced the IgE response to primary
allergens, increased the number of natural killer cells, and
led to other positive changes in cell surface markers so
that they resembled those of non-asthmatic children in
identical environments (Castes et al., 1999). In one
relaxation-training study involving 16 non-smoking and
non-steroid-dependent asthma patients between the ages
of 13 and 30, patients in the experimental group showed
significant improvements in lung function (FEV1/FVC) but
not in immunologic function (Kern-Buell et al., 2000).
These results provide inconsistent support for the effect of
relaxation techniques on immunologic function. Moreover,
the effects of relaxation training on psychological indica-
tors for asthmatic children remain unknown.
Relaxation-based behavioral therapy was found in a
meta-analysis of 31 psycho-educational programs con-
ducted between 1972 and 1993 to exert moderately strong
effects (effect size >0.35) on psychological health, attacks,
lung function, and medication dosage of adult asthmatics
(Devine, 1996). The effects of relaxation and disease-
management techniques in clinical trials have been incon-
sistent in asthmatic adults (Davis et al., 1973; Devine, 1996;
Erskine-Milliss and Schonell, 1981; Lehrer et al., 1992;
Richter and Dahme, 1982) and in children (Alexander et al.,
1979; Kotses et al., 1978; McQuaid and Nassau, 1999; Scherr
et al., 1975; Vazquez and Buceta, 1993a,b). Relaxation
training has been shown to make positive contributions to
asthma management, but Ritz (2001) suggested that studies
in this area have generally been poorly designed. On the
other hand, others (Huntley et al., 2002) concluded that
insufficient evidence supports a role for relaxation therapies
in assisting asthma management, but acknowledged
positive effects in terms of muscular relaxation and
improved lung function. Furthermore, a combined self-
management and relaxation-training program for asthmatic
children did not significantly change pulmonary function
variables (Vazquez and Buceta, 1993a,b). Relaxation tech-
niques have a positive effect on autonomic balance
(Lehrer, 1998). Thus, relaxation techniques might stimulate
 L.-C. Chiang et al. / International Journal of Nursing Studies 46 (2009) 1061–1070
parasympathetic nerve impulses and lead to a slower heart
rate, more regular respiration, and general relaxation
(Lehrer, 1998).
It is important to note that the efficacy of asthma-
management techniques has been measured by a sig-
nificant number of researchers using only physiological
indicators—that is, their results do not directly address
psychological indicators. When studying asthma manage-
ment in children and adolescents, psychosocial interven-
tions should be emphasized (Malhi, 2001), and
intervention studies that address physiological, beha-
vioral, and psychological variables provide evidence in
support of holistic nursing approaches to this chronic
disease. Indeed, relaxation training of 46 school-aged
children successfully reduced levels of anxiety (Lamon-
tagne et al., 1985). Furthermore, levels of dysphasia were
reduced in 17 children and adolescents (ages 8–18) who
were taught a relaxation technique based on self-induced
hypnosis (Ran, 2001).
Based on this background, the purpose of the present
study was to examine the effectiveness of teaching a
combination of self-management and relaxation-breath-
ing techniques to children with moderate-to-severe
asthma. The results from an experimental intervention
(self-management plus relaxation training) were com-
pared with results from the self-management-only pro-
gram currently favored by Taiwanese asthma clinics.
Outcome measures were anxiety, perceived health status,
asthma signs/symptoms, peak expiratory flow rate (PEFR),
and asthma medication usage. The two hypotheses tested
were as follows:
1. Changes in physiological and psychological outcome
measures between pre- and post-intervention are the
same for both the experimental and comparison groups
(i.e., the group  time interaction is not significant).
2. Physiological and psychological outcome measures do
not change in either group from pre- to post-interven-
tion (i.e., the self-management program does not have a
significant time effect).
2. Methods
2.1. Design
A two-group experimental design was used to evaluate
the effectiveness of relaxation-breathing training com-
bined with a self-management program in children with
asthma. Children in both the experimental and comparison
groups received explanations of asthma disease, asthma
medication, and monitoring with peak flow meters, but
only those in the experimental group received relaxation-
breathing training. Interventions lasted for 12 weeks per
participant, with data for five outcome indicators collected
at the beginning and end of each intervention.
2.2. Participants
All asthmatic children who participated in this study
were recruited from the pediatric asthma clinic of a
medical center in central Taiwan. Potential participants
1063
were recruited from patients at the asthma clinic by a well-
trained research assistant (RA). Children were included in
the study if they met these criteria: (1) diagnosed with
moderate-to-severe asthma by a physician at least 6
months before the study, (2) had >5 asthmatic episodes
per year, with an Aas score of 2 (Aas, 1981), and (3)
regularly treated with asthma medication in a pediatric
clinic. Children were excluded if they had participated in
any other clinical trials. Potential participants were given a
complete description of the study. Those who agreed to
participate provided written informed consent.
The Aas asthma severity score is a 5-step clinical score
that assesses the frequency and duration of asthma attacks
during the previous year (Aas, 1981). A score of 1 (mild
asthma) indicates <5 asthma attacks, each lasting <7 days,
and no functional limitation. A score of 2 (moderate
asthma) indicates <10 attacks, each lasting <7 days, and
no functional limitation. A score of 3 (moderate asthma)
indicates >10 attacks, each lasting <7 days, and no
functional limitation. A score of 4 (severe asthma)
indicates >5 attacks, chronic cough, and hospitalization.
A score of 5 indicates chronic malfunctioning asthma,
acute exacerbation, and the need for continuous medica-
tion treatment. Therefore, an asthmatic child with an Aas
asthma severity score >2 has had >5 attacks in the
previous year.
To provide high quality care, all participating children
and parents received the medical center’s routine asthma
self-management program and an asthma-management
teaching booklet. After receiving the asthma self-manage-
ment program, children and parents in the experimental
group also received relaxation training in a separate room.
In general, matching is used to make sure that
participants in various research groups are equivalent on
one or more characteristics (Polit and Beck, 2005). The
characteristics previously found to influence asthma self-
management, physical activity, and quality of life were
gender (Chiang et al., 2006a,b), age (young children or pre-
adolescents) (Miles et al., 1995), and asthma severity
(Chiang et al., 2006a,b). Therefore, children were randomly
assigned to the experimental or comparison groups using a
2  2  3 randomized block design (2 genders, 2 age ranges
(6–10 and 11–14 years old), and 3 asthma severity scores (2,
3, 4) (Aas, 1981)). This randomization procedure was
confidentially conducted by an administrator in the clinic.
The first eligible child was assigned by a coin toss to the
experimental or comparison group using the block
randomization scheme. If the first child was a girl, aged
6–10 with an Aas score of 3, she would be randomly
assigned by coin toss into the experimental or comparison
group. Then the next girl, aged 6–10 with an Aas score of 3,
would be assigned to the other group. The assignment
continued until all participants were assigned to each
group. This procedure removed the variance due to gender,
age, and asthma severity from the error term, increasing
the power of the study. A list of treatment assignments
linked with case number was generated and kept by the
first author and the study statistician. The codes and
treatment assignments were not released to any subjects,
staff, and pediatric physicians other than those mentioned
until the completion of data analysis.
1064 L.-C. Chiang et al. / International Journal of Nursing Studies 46 (2009) 1061–1070
Of the 65 families who met the inclusion criteria, 3
families refused to participate or their questionnaires were
incomplete at pre-test. From the remaining 62 families, 29
children were randomly assigned to the experimental
group and 33 children to the comparison group. Another
three families in the experimental group did not complete
the asthma self-management program and relaxation
training. Unfortunately, four families in the experimental
group and seven families in the comparison group were
lost to the 3-month follow-up. Thus, the final sample
included 22 children in the experimental group and 26 in
the comparison group (Fig. 1).
Our power analysis, based on Cohen (1992) suggested
criteria for comparing the means of two groups with a large
effect size and a = 0.05, indicated that the necessary
sample size was 26 for each group. Although 59 children
were recruited for the study, 11 families dropped out. The
sample size was then re-calculated using the following
parameter values: Type I error of 5% (z1 = 1.96), power of
80% (z2 = 0.842), mean values (m1 = 17.00 and m2 = 11.00),
and standard deviations (s1 = 7.0 and s2 = 6.8). The means
Fig. 1. The flowchart of recruiting.
and SDs were obtained from a small pilot study. Placing
these values into the following formula (Muellner, 2002):
ðz1 þ z2 Þ2 ðs21 þ s22 Þ
nðper groupÞ ¼
ðm1  m2 Þ2
produced an overall sample size of 40, with 20 in each
group.
The children who dropped out and participating
children were not significantly different in terms of gender
(x2 = 0.677, p = 0.513), age (x2 = 0.250, p = 0.720), and Aas
score (x2 = 2.471, p = 0.291). Because of dropouts, it was
necessary to check the homogeneity of the two groups in
terms of gender, age, and asthma severity. This analysis
showed no significant differences between the experi-
mental and comparison groups (Table 1).
2.3. Interventions
The comparison and experimental groups received
different interventions: only the routine self-management
program offered by a graduate nurse student after medical
 L.-C. Chiang et al. / International Journal of Nursing Studies 46 (2009) 1061–1070 1065

Table 1 relaxation were recorded in a relaxation CD and one-page

Demographic characteristics of the experimental and comparison groups.
instruction sheet provided to parents, who were taught
Experimental Comparison x2 p how to coach their child to practice relaxation at home. The
group (n = 22) group asthmatic children easily followed directions on the CD
(n = 26)
and practiced every day at home.
n % n % To ensure that the participating children were capable
Gender of achieving a state of relaxation, the entire sequence of
Male 15 68.2 15 57.7 0.559 0.328 muscle contraction–relaxation was recorded using bio-
Female 7 31.8 11 42.3 physiological (biofeedback) software. Children’s relaxation
Asthma severitya was scored by the research assistant using the Behavioral
2 5 22.7 5 19.2 Relaxation Scale (Raymer and Poppen, 1985) and frontal
3 9 40.9 12 46.2 0.155 0.545 electromyogram. All children were also requested to self-
4 8 36.4 9 34.6
report their level of relaxation on the Relaxation Visual
Age (years) Analogue Scale (Norton et al., 1997). Parents and children
6–10 16 72.7 20 76.9 0.112 0.498 were contacted once per week by telephone to encourage
11–14 6 27.3 6 23.1
regular practice. During the 12-week intervention, parti-
Emotion-induced asthma cipants practiced relaxation for 30 min at least three times
Yes 5 22.7 4 15.4 0.422 0.389 per week. Some of the pre-adolescents practiced relaxation
No 17 77.3 22 84.6
by themselves, but most young children practiced with
a
Asthma severity in the previous year determined by Aas score (Aas,
their parents.
1981): 2 indicates moderate asthma with <10 attacks, each lasting <7
days, and no functional limitation; 3 indicates moderate asthma with >10
attacks, each lasting <7 days, and no functional limitation; 4 indicates 2.4. Ethical considerations
severe asthma with >5 attacks, chronic cough, and hospitalization.
This study was approved by the Institutional Review
center’s asthma clinic, and the routine self-management Board of China Medical University Hospital (DMR92-IRB-
program plus relaxation-breathing training, respectively. 027). Parents were also given an informed consent
agreement emphasizing the voluntary nature of their
2.3.1. Self-management program participation, explaining their right to leave the study at
After collecting baseline data, the first author and a any time, and giving study details. Copies of signed
nursing graduate student used a case-management model agreements were retained by the research assistant and
(Tzeng and Chiang, 2005) to implement the self-manage- parents.
ment education program to children in both groups. This
program has five units: (a) reforming asthma cognition, (b) 2.5. Data collection
correct usage of asthma drugs, (c) establishing a safe home
environment, (d) monitoring with a peak flow meter, and Data were collected on anxiety, self-perceived health
(e) keeping an asthma diary. Parents were given an status, asthma signs/symptoms, PEFR, and asthma medica-
educational booklet on personal care plans, peak flow tion with instruments commonly used in Taiwan to measure
meter records (with one meter given to each family), and children’s anxiety and associated health indicators.
using a diary to record asthma signs/symptoms.
2.5.1. Anxiety
2.3.2. Relaxation-breathing training Anxiety was measured using the Chinese Children’s
At the end of the self-management program for all Anxiety Scale (CCAS; Lin et al., 1973), which has been used
participants, children and their parents in the experi- in several studies involving Chinese children and adoles-
mental group received 30 min of relaxation-breathing cents (ages 6–19). The CCAS has 66 dichotomous items
training. In this training, which is based on a technique divided into the 37-item Chinese Children’s Manifest
developed by Jacobson (Titlebaum, 1988), children were Anxiety Scale (CCMAS) and the 29-item General Anxiety
coached to relax 15 muscle groups in progression, with Scale for Chinese Children (GASCC). Total anxiety scores
regular deep breathing. The researcher directs children to range from 0 to 66, with higher scores indicating greater
sit comfortably in a quiet room for 5 min, tense a group of anxiety. The CCMAS is based on the Children’s Manifest
muscles, such as those in the right arm, hold the Anxiety Scale (Castaneda et al., 1956), which was originally
contraction for about 8 s, and relax the muscle group for designed to assess the level and nature of anxiety in
about 30 s while breathing out. After a short rest, this children and adolescents ages 6–19 years. The CCMAS is
sequence is repeated with another set of muscles. The used to measure children’s general tendency to anxiety.
muscle sequence was right foot, right lower leg and foot, The GASCC is based on the General Anxiety Scale for
entire right leg, left foot, left lower leg and foot, entire left Children (Sarason et al., 1960), which was originally
leg, right hand, right forearm and hand, entire right arm, designed to measure trait anxiety. The current Chinese
left hand, left forearm and hand, entire left arm, abdomen, version was designed to measure emotional responses to
chest, neck and shoulders, and face. Through repetitive specific situations. The overall CCAS has been shown to
practice, patients learn to recognize the feelings associated have adequate internal consistency, content validity, and
with a tensed muscle and a completely relaxed muscle. construct validity when used with Taiwanese children (Lin
This process and the sequence of progressive muscle et al., 1973). In a re-examination of the reliability and
1066 L.-C. Chiang et al. / International Journal of Nursing Studies 46 (2009) 1061–1070

validity of the CCAS (Tseng, 1993) the test–retest reliability
for the CCMAS was 0.78 and for the GASCC was 0.72 for
boys and 0.76 for girls.
2.5.2. Self-perceived health status
Self-perceived health status was measured by four
items adapted from the Perceived Health Status Scale
(Kaplan and Camacho, 1988). Responses to items were
measured on a 5-point Likert scale from 1 (very bad) to 5
(very good). In this study, internal consistency (Cronbach’s
a) was 0.71.
2.5.3. Asthma signs/symptoms
The signs/symptoms checklist used in this study was
modified from an asthma symptom diary (Santanello et al.,
1999). The checklist includes four items: ability to sleep at
night (1 item) and daytime symptoms of persistent
coughing, wheezing, and dyspnea (3 items). Responses
to items were recorded by parents on a 4-point scale
according to the frequency of asthma signs/symptoms.
Lower scores indicate better control of asthma signs/
symptoms. In this study, internal consistency (Cronbach’s
a) was 0.71.
2.5.4. Peak expiratory flow rate (PEFR)
PEFR was measured in participating children twice each
day using Astech1 peak flow meters (Dey, L.P., Napa, CA),
which are used in Taiwanese asthma clinics. PEFR is
recorded as the best of three trials. Results from spirometric
measures indicated a Pearson correlation r = 0.313
(p < 0.05) between PEFR and the score on the asthma
signs/symptoms checklist used in this study and r = 0.682
(p < 0.001) between PEFR and FEV1 by Micro-Medical Super
Spiro CE120, SN1141. The children were trained in the self-
management program to correctly use the PEF meter.
2.5.5. Asthma medication usage
Use of asthma medications was assessed by the Asthma
Medication score, based on a treatment ladder established
according to Global Initiative for Asthma guidelines
(National Heart, Lung and Blood Institute, 2007). Higher
scores indicate greater dosage and/or stronger asthma
medications. Scores for participants in this study ranged
from 0 to 14, with scoring methods focused on monthly
drug dose. Use of a prophylactic medication in the
preceding month received 1 point, use of a beta-agonist
medication once per week over 4 weeks received 1 point
and more than twice per week 2 points, 2 use theophylline
or Singullair1 received 2 points, and use of an oral steroid
received between 3 and 5 points (3 for <3–5 days/4 weeks,
4 for 6–10 days, and 5 for >10 days).
2.6. Data analysis
All data were analyzed (descriptive and inferential
statistics) using SPSS (12.0) for Windows. Demographic data
of the experimental and comparison groups were compared
using Chi-Square analysis. The SPSS Mixed Model was used to
analyze scores for anxiety, self-perceived health status,
asthma signs/symptom, medication usage, and PEFR for
differences between the two groups and within each group
over the 12-week intervention. To reduce problems in
repeated measurements, the mixed model technique is
better than the General Linear Model in overcoming missing
data in some variables at follow-up and limited availability of
variance–covariance structures (Chan, 2004). These types of
designs are called mixed-model ANOVAs, since they involve
a mixture of one between-groups factor and one within-
groups factor. This type of analysis is better than traditional
analysis, i.e., a two-way ANOVA, which combines one
independent-sample factor and one correlated-group factor.
3. Results
3.1. Participant characteristics
In the final sample of 48 children and their parents, 22
were in the experimental group, and 26 were in the
comparison group. Both groups had a majority of boys
(experimental: 68.2%; comparison: 57.7%), consistent with
the high prevalence of boys having asthma (Chiang et al.,
2007). Each group also had a majority (experimental:
72.7%; comparison: 76.9%) of young children (6–10 years
old) and a minority (experimental: 22.7%; comparison:
15.4%) of children with emotion-induced asthma (Table 1).
3.2. Outcome variables
Data for each variable at the beginning and end of the
12-week intervention are presented in Table 2. Psycholo-
gical indicators (total anxiety) for the experimental group
decreased on average over the 12-week intervention (from

Table 2
Descriptive statistics for pre- and post-intervention outcomes for asthmatic children.

Variable Pre-intervention Post-intervention

Experimental group Comparison group Experimental group Comparison group

n Mean (SD) n Mean (SD) n Mean (SD) n Mean (SD)

Children’s anxiety 22 31.73 (12.27) 23 29.96 (11.96) 18 26.11 (11.41) 19 32.21 (17.76)
CCMASa 22 16.64 (6.86) 23 14.74 (7.37) 18 12.67 (7.15) 19 15.77 (10.45)
GASCCb 22 15.09 (6.57) 23 15.22 (6.02) 16 13.88 (6.08) 19 16.21 (8.64)
Health status 22 15.19 (3.20) 26 15.43 (3.80) 20 18.55 (3.39) 17 17.82 (4.02)
Asthma signs/symptoms 22 9.46 (2.11) 26 10.44 (1.95) 20 6.93 (1.51) 17 7.24 (1.71)
PEFR 22 227.05 (71.69) 26 186.73 (46.80) 20 282.50 (76.72) 17 240.12 (63.62)
Asthma medication 20 5.10 (3.34) 18 4.17 (2.68) 20 2.75 (2.84) 18 1.94 (2.18)
a
CCMAS: Chinese Children’s Manifest Anxiety Scale.
b
GASCC: General Anxiety Scale for Chinese Children.
 L.-C. Chiang et al. / International Journal of Nursing Studies 46 (2009) 1061–1070 1067

a score of 31.73–26.11), but increased on average for the
comparison group (29.96–32.21). Tendency to anxiety
(CCMAS scores) in the experimental group was decreased
on average (16.64–12.67), but increased in the comparison
group (14.74–15.77).
Physiological indicators improved for both groups
over the 12-week interventions. Specifically, health status
improved (15.19–18.55 in the experimental group; 15.43–
17.82 in the comparison group), asthma signs/symptoms
were reduced (9.46–6.93 in the experimental group;
10.44–7.24 in the comparison group), PEFR increased
(227.05–282.50 in the experimental group; 186.73–240.12
in the comparison group), and less asthma medication was
used (5.10–2.75 in the experimental group; 4.17–1.94 in
the comparison group).
The results from Mixed Model analyses are shown in
Table 3. Total anxiety and general tendency to anxiety
(CCMAS) scores changed significantly more from pre- to
post-intervention in the experimental group than in the
comparison group (by 5.62/2.25 and 3.97/1.03, respec-
tively). However, trait anxiety (GASCC) scores did not differ
significantly between groups. The results indicate that
children in the experimental group had significantly less
total anxiety than their comparison group counterparts
(t = 2.27, p < 0.05). Therefore, relaxation-breathing train-
ing appears to have exerted a positive effect on general
tendency to anxiety but not on trait anxiety.
Physiological indicators improved after the 12-week
interventions in both groups (health status: t = 2.70,
p < 0.01; asthma signs/symptoms: t = 5.84, p < 0.001;
PEFR: t = 4.00, p < 0.001; asthma medication usage:
t = 3.03, p < 0.01). However, the group  time interaction
was not significant for any of the four physiological
variables (health status, asthma signs/symptoms, PEFR,
asthma medication) although improvement over time was
evident for both groups (Table 4).

Table 3
Mixed Model evaluation of the effect of relaxation-breathing technique on anxiety.

Outcome variable b SE t p 95% confidence interval

Upper Lower

Children’s anxiety
Experimental group (comparison group) 7.44 4.33 1.72 0.091 16.10 1.22
Pre-intervention (post-intervention) 2.68 2.83 0.95 0.347 8.34 2.98
Group  time interaction 9.21 4.05 2.27 0.027 1.11 17.32

CCMAS
Experimental group (comparison group) 4.07 2.52 1.62 0.111 9.10 0.97
Pre-intervention (post-intervention) 1.55 1.61 0.96 0.340 4.78 1.67
Group  time interaction 5.96 2.51 2.58 0.012 1.34 10.59

GASCC
Experimental group (comparison group) 3.44 2.15 1.60 0.115 7.74 0.86
Pre-intervention (post-intervention) 1.08 1.50 0.72 0.475 4.07 1.92
Group  time interaction 3.31 2.13 1.56 0.124 0.93 7.56

Mixed model with fixed gender effect as covariance.

Experimental group = 0, comparison group = 1, pre-intervention = 1, post-intervention = 2.
CCMAS: Chinese Children’s Manifest Anxiety Scale.
GASCC: General Anxiety Scale for Chinese Children.

Table 4
Mixed Model evaluation of the effect of relaxation-breathing technique on physiological outcomes.

Outcome variable b SE t p 95% confidence interval

Upper Lower

Health status
Experimental group (comparison group) 0.52 1.18 0.45 0.657 1.83 2.88
Pre-intervention (post-intervention) 2.59 0.95 2.70 0.009 4.50 0.68
Group  time interaction 0.77 1.33 0.58 0.567 3.42 1.89

Asthma signs/symptoms
Experimental group (comparison group) 0.28 0.61 0.46 0.644 1.50 0.93
Pre-intervention (post-intervention) 3.23 0.55 5.84 <0.000 2.13 4.33
Group  time interaction 0.70 0.77 0.90 0.369 2.24 0.84

PEFR
Experimental group (comparison group) 39.14 20.35 1.92 0.059 1.51 79.78
Pre-intervention (post-intervention) 55.07 13.77 4.00 <0.000 82.57 27.57
Group  time interaction 1.18 18.97 0.06 0.951 36.72 39.07

Asthma medication
Experimental group (comparison group) 0.81 0.91 0.88 0.381 1.02 2.63
Pre-intervention (post-intervention) 2.22 0.73 3.03 0.004 0.75 3.69
Group  time interaction 0.13 1.01 0.13 0.900 1.90 2.15

Mixed model with fixed gender effect as covariance.

Experimental group = 0, comparison group = 1, pre-intervention = 1, post-intervention = 2.
1068 L.-C. Chiang et al. / International Journal of Nursing Studies 46 (2009) 1061–1070
4. Discussion
Our study results indicate that relaxation-breathing
training combined with a self-management program can
improve both physiological indicators (self-perceived
health status, asthma signs/symptoms, PEFR, and reliance
on asthma medications) and psychological indicators
(anxiety) for children with moderate-to-severe asthma.
Health care providers rightly emphasize the physiological
aspects of asthma, but in this disease, as with all chronic
diseases, it is important to acknowledge the potential for
long-term psychological influences. For children with
moderate and severe asthma, high-quality nursing care
needs to include efforts to promote psychological adapta-
tion to the disease. Our findings are consistent with those
reported in other studies of the effects of self-management
interventions in children with asthma (Guevara et al.,
2003; Smith et al., 2005; Wolf et al., 2003). The data also
indicate that children in the experimental group received
not only the benefit of improved physiological health but
also reduced anxiety.
The high prevalence of anxiety in the participating
children is consistent with previous findings (Katon et al.,
2004). The data suggest that children’s anxiety increases
over time if not treated by a health care provider.
Specifically, the results indicate a change in general
tendency to anxiety but not in trait anxiety, which is
thought to be a relatively stable personality disposition
and a predictor of state anxiety (Li and Lopez, 2005). In the
present study, the nursing intervention of relaxation-
breathing training affected children’s perceived anxiety.
Over time, the practice of relaxation breathing might
change trait anxiety more than transitory emotional
reactions. For children with moderate or severe asthma,
much more time and effort are required to teach them self-
management and relaxation strategies that will mitigate
emotional distress (Rydstrom et al., 1999). Proper training
of asthmatic children and their parents may also require
overcoming psychological barriers that can negatively
influence disease management (Pagliari et al., 2002).
Therefore, future studies should extend relaxation training
for asthmatic children and assess long-term effects on
psychological and physiological outcomes.
The results from the present study are inconsistent with
previous reports that relaxation-breathing training posi-
tively affected physiologic-immunological interactions
and physiological indicators. Specifically, the lack of a
positive effect of the combined self-management and
relaxation-breathing training on signs/symptoms or lung
function is consistent with the findings of Vazquez and
Buceta (1993a,b) and Kohen and Wynne (1997), but not
with those of Kern-Buell et al. (2000). Accordingly, the
effects of relaxation-breathing techniques on psychologi-
cal and physiological indicators among asthma patients
require further clarification.
Although not part of the study, some of the qualitative
data from interviews with parents and asthmatic children
give insights into their perceptions of practicing relaxation
techniques. Many children claimed that practicing relaxa-
tion every night enabled them to feel very relaxed, calm,
and to fall asleep easily. The deep breathing exercises were
very comfortable, especially following the directions on
the relaxation CD. One 10-year-old girl mentioned, ‘‘My
mother’s presence during my relaxation practice allowed
me to feel my parents’ love and care, and that really helped
me to remain calm.’’ Previous nursing interventions or
relaxation-training programs were conducted in hospital
or in a laboratory (Vazquez and Buceta, 1993a,b). To
translate the practice into the routine of life, we trained
parents to coach their children in using the relaxation
technique at home and telephoned to remind them to
practice regularly every night. The results revealed that
relaxation-breathing could reduce children’s anxiety and
prevent further psychological problems. This improved
psychological status may lead to better nursing care and
improve outcomes for children with asthma.
Future nurse-led psycho-education interventions for
children with asthma require more investigation to
promote high quality care in biological, psychological,
and sociological health for children with a chronic disease.
4.1. Limitations
This study and its findings have at least three
limitations. First, the sample was limited in terms of
recruiting children from a single hospital, although doing
so reduced the potential for contaminated data and
supported internal validity. Cooperation of the parents
and children was required for training in the relaxation
technique. Everyday practice depended on the total
cooperation of participants, making the study difficult to
implement. For example, over the 12-week intervention,
some parents did not think that recording data in their
diaries was necessary because their children went through
a period of few or mild asthma attacks. Other parents
stated that they were too tired at night to encourage their
children to practice relaxation, and a few families started
visiting other clinics for their health care needs. Despite
these difficulties, which resulted in some drop-out, most
participants in this study adhered to the study protocol.
Furthermore, guidelines for sample size (Green, 1990)
suggest that similarity in dropout rates for the two groups
did not necessitate canceling the entire study, and the
added factor of relaxation-breathing training for the
experimental group did not influence decisions to drop
out of the study. Second, to make data collection
convenient for nurses, laboratory measures of IgE and
pulmonary function (spirometries for FEV1/FVC) were not
determined. Third, the data collection instruments were
long, requiring a great deal of time and effort from the
participating children. This raises not only the issue of
participant burden, but also questions regarding socially
desirable responses.
4.2. Conclusion and clinical implications
The results suggest that a combination of asthma self-
management and relaxation-breathing training can posi-
tively affect the physiological and psychological health of
children with moderate-to-severe asthma. Relaxation-
breathing training is a simple intervention that pediatric
nurses can implement independently. However, guidelines
 L.-C. Chiang et al. / International Journal of Nursing Studies 46 (2009) 1061–1070
and procedures must be established to ensure that the
intervention actually affects anxiety levels in asthmatic
children over time. Parents or other caretakers need to be
involved in the training to improve chances of success.
Training programs can include (but are not limited to) the
distribution of asthma care booklets and a CD containing
information on relaxation techniques for practice at
home—a low-cost strategy for improving children’s
physiological and psychological health. Further monitor-
ing is required to measure the long-term effects of such a
strategy.
Acknowledgements
This study was supported by grants from the National
Science Council (No. NSC-92-2314-B039-019 and NSC-93-
2314-B039-005) and China Medical University (No. CMU-
92-NS02), both of Taiwan, Republic of China.
Conflict of interest
None declared.
Funding
This research was supported by grants from China
Medical University (No. CMU-92-NS02), National Science
Council (NSC-92-2314-B039-019 and NSC-93-2314-B039-
005), Taiwan, Republic of China.
Ethical approval
This study was proved by the Institute of Review Board
in China Medical University Hospital.
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