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Little is known about the opinions or perceived benefits of an inspiratory muscle training intervention in patients with cystic fibrosis and their multidisciplinary team.
The aim of this qualitative study was to examine patients' and multidisciplinary teams' views on inspiratory muscle training to inform and tailor future interventions.
Individual, semistructured interviews were conducted to evaluate participants’ perspectives of a 4-week inspiratory muscle training intervention. In this study, 8 of 13 individuals involved in the inspiratory muscle training program (5 children aged 11-14 years; 2 physiotherapists; and 1 respiratory physician) participated. Interviews were transcribed verbatim, analyzed using thematic analyses, and then coded into relevant themes.
Four key themes emerged: acceptability, facilitators, barriers, and recommendations. While fun, enjoyment, and improved perceived physical ability were reported by children and their multidisciplinary team following the inspiratory muscle training program, the multidisciplinary team identified factors such as time and cost as key barriers.
A short inspiratory muscle training program was perceived to have positive effects on the physical ability and psychosocial health of children with cystic fibrosis. These findings highlight the importance of obtaining participants’ and multidisciplinary teams' perceptions and recommendations to ensure the efficacy and optimal design of future inspiratory muscle training protocols.
Cystic fibrosis (CF) is the most common inherited, life-shortening condition in the United Kingdom [
Inspiratory muscle training (IMT), which utilizes restricted airflow breathing exercises to increase the mechanical load on the external intercostal muscles and diaphragm, is a subject of research interest. The increased muscular load engendered by IMT provides a stimulus to elicit a hypertrophic response [
In this study, 5 children (age, 11-14 years) were included if they met the following criteria: (1) took part in the pilot study of IMT conducted by Swansea University; (2) had a confirmed diagnosis of CF or were a matched control; (3) had no additional non-CF illness or disease; and (4) voluntarily participated and provided written informed parental consent and child assent. MDT participants (2 physiotherapists and 1 respiratory physician) were eligible for inclusion if they provided clinical care for children with CF and had been involved in the same IMT pilot study.
The IMT intervention consisted of participants undertaking 30 inspirations, twice a day, for 28 consecutive days using a POWERbreathe Plus device (POWERbreathe Plus LF Level 1, Gaiam Ltd E & OE, UK). A progressive approach was adopted, whereby participants initially trained at a load of 40% of their baseline maximal inspiratory pressure, increasing to 50% during weeks 3 and 4 [
Children and MDT members took part in individual semistructured interviews with follow-up questions. A semistructured interview includes a series of predetermined but open-ended questions, thereby allowing the interviewer to follow topical trajectories in the conversation, as well as providing interviewees freedom to express their views in their own terms [
Example interview questions.
Interview and topic | Examples | |
Inspiratory muscle training |
What did you like and dislike about the training device? What made it easy or difficult to do the training program? |
|
Future |
How would you react if you were asked to do this training again? |
|
Inspiratory muscle training |
What is your opinion of the IMT device? How did the patients respond to the IMT device? |
|
Future |
What do you think about the National Health Service adopting an IMT intervention as a treatment? What recommendations do you have for interventions you would like to see for CF patients? |
All interviews were transcribed verbatim by one author (JLM) and analyzed thematically [
Five children (n=3 boys) and 3 MDTs (2 physiotherapists and 1 respiratory physician) completed the interviews. All interviews were semistructured and lasted between 30 and 40 minutes. Example verbatim quotes are provided to support the points raised with a frequency count (in brackets) to indicate the number of times the particular theme was raised. The following 4 themes emerged from the interviews: (1) acceptability; (2) facilitators; (3) barrier; and (4) recommendations.
Feedback from all participants was very positive regarding the acceptability of the intervention. The MDT noted children’s enthusiasm, and all children reported enjoying the IMT intervention:
I felt really excited [to do IMT] I just wanted to have a go at it.
Some patients even suggested they would like to take part in future interventions:
I was pretty sad I didn’t have to do it again. I’d happily do it again.
Children reported good participation and adherence to the IMT intervention due to the ease of implementation:
Like it was easy you just do it [IMT] at home. You don’t have to go anywhere specific or special. You could just do it in your bedroom if you wanted.
In addition, the ease of integration into daily routine:
I got into it…I feel like I’ve always done it. When you get up in the morning, you normally eat your breakfast, get ready for school, do IMT and then quickly leave the house for the bus.
Most importantly, children expressed enthusiasm and enjoyment:
I really enjoyed it, I got into it…I feel like I’ve always done it.
Furthermore, all children perceived IMT to have a positive effect on their ability when partaking in a physical activity (PA):
For some reason, I don’t know how, but they [lungs] almost felt like, almost got stronger. You could just breathe more freely…I could keep running for longer, I didn’t have to stop and take deep breaths as much as normal.
Children also indicated reduced embarrassment associated with completing the treatment at home:
I like it [using the device at home] cause of not having all the constant questions. I don’t like, well, I don’t mind answering questions when people do ask [about CF], but like I am not getting caught up in it all the time in school with my friends.
Moreover, the CF care team reported positive feedback from their patients and high adherence:
They would have all liked to have kept the IMT device and carried on. In fact, one of the patients subsequently went out and bought one and uses it as part of their routine.
Akin to the children’s perceptions, CF care team members believe that the IMT training schedule fit well around children’s home and school schedules:
From a practical point of view, I think that fitted well. All feedback seemed to confirm that.
Unsurprisingly, the MDT highlighted the importance of family, specifically parental influence, with “sporty families” being labeled as easier to motivate to undertake an intervention and exercise:
If you’ve a sporty family its easier…Families will support them [children] most of the families were very keen on IMT. You have to get the families on board.”
Not only are family facilitators influential, but peer facilitators are key, especially for children. The MDT highlighting the importance of children with CF being seen as equal to their peers:
It is very important to both keep them healthy and also to keep them in their peer group, you know at school and during sports activities. They need to be able to keep up with the rest of their class, so it is very, very important…A psychological benefit of being able to keep up with their peer group.
Although it seemed the intervention was well adhered to and enjoyed thoroughly by all participants, barriers were nonetheless highlighted, although predominantly by the MDT rather than the children. The MDT highlighted the following main barriers to the implementation of IMT:
The clinical care team highlighted cost to be a major barrier in implementing IMT within the local NHS framework:
Obviously there is a cost implication as there is no money in the NHS for any of these things.
Furthermore, there is a reliance on charitable income to fund airway clearance equipment:
Cost would be a big thing and whether it was a benefit to patients.
However, it was accentuated that if IMT proved to be successful, the cost should be met:
If it is proven to be beneficial they [the NHS] are more likely to get it. If it’s proven to be beneficial and improve lung function compared to the cost of some of the drugs they [the NHS] might pay for it.
Patients with CF have a high treatment burden involving daily physical therapy coupled with medication. Incorporating IMT into an already busy treatment schedule was a concern raised by the MDT:
It’s yet another thing for us to ask them to do because they do have quite a large treatment burden…so that would be the biggest con, a time thing.
This concern was also echoed by one of the children:
It was extra work to do with everything else that I have to do.
Yet, one of the MDT had a solution, whereby an IMT program could be viable within the treatment schedule of a patient with CF:
Obviously you don’t want it to be too much of a burden. Deciding whether it is better than other parts of their treatment and other part of their Physio and then substitute it [IMT] in could be an option.
Converse to families being deemed as facilitators, a physiotherapist reflected on previous cases, whereby children’s divorced parents have had a negative impact on children’s participation levels in activities:
The parents have divorced, and the girl lives with mum. The mum has a full-time job and mum didn’t push any after-school clubs, dad was the one that did it previously. So that created a big barrier.
Participants were requested to comment on any changes they would make to the device and protocol. The children reported no changes, whereas the care team had numerous suggestions to improve future interventions. One of the main changes the care team suggested was the importance of knowing whether participants were adhering to the intervention:
I don’t know if you can measure compliance, but it would be good if it [IMT] can tell us how much they actually did.
To ensure future would adherence to IMT protocols and make the intervention attractive to children, the following was suggested:
Young people like to have their smartphones and apps, visual feedback in a piece of electrical equipment, that is probably the way forwards.
In addition, implementing a competitive element was highlighted as important additions in future interventions:
Feedback so they know how well they are doing. They are quite competitive, so if they know the others are doing it, they’ll be more motivated.
Contrastingly, despite reporting that a three times-a-day intervention fitted well into a child’s routine, the MDT suggested a more time-efficient intervention to reduce the burden on patients:
Three times a day would be a problem, it [IMT] would have to be something regular to get them into a routine.
The aim of this study was to ascertain the views of children and the CF care team in relation to an IMT intervention, thereby providing population-specific evidence to inform future interventions. Results indicate that all children enjoyed the home-based intervention, while the CF care team raised concerns regarding cost and treatment burden. Overall, these results provide important insights regarding future IMT interventions, building upon the limited literature available regarding the opinions of patients, respiratory physicians, and physiotherapists.
IMT in patients with CF has been reported to improve endurance and strength of the inspiratory muscles, as well as exercise capacity [
The perceived improvement in physical ability reported by participants could be attributed to the good adherence to the IMT program. This is in contrast to previous reports that adherence to treatment in CF is suboptimal [
With a reduced exercise capacity and low daily PA levels potentially impacting psychological and physiological health of patients with CF, parental and family involvement in PA is extremely important when encouraging children to meet recommended PA and exercise guidelines [
In addition to families, peer support is influential in determining activity-related self-esteem and, therefore, treatment behaviors[
Despite the ease of implementation, good adherence, and enjoyment reported by participants, the MDT was more reserved with regards to their enthusiasm for an IMT intervention, with reservations relating to cost and treatment burden. Nevertheless, the team expressed an interest in investigating the potential of a longer-term IMT intervention to provide a clearer evidence-base on the impact on psychological and physiological health in patients with CF. The main concern voiced by the care team, as well as children with CF, was the potential burden it may have on patients in terms of their time and current treatments. Reports that a patient with CF can spend a mean of 108 minutes per day on a wide range of CF therapies, regardless of age or disease severity [
In conclusion, the data revealed consistent themes relating to IMT among children with CF and their MDT. This preliminary study highlights the ease of incorporating an IMT program into the lives of patients with CF, who reported noticeable perceived improvements to their physical ability after only 4 weeks of IMT. These preliminary results suggest that an IMT intervention may be well accepted by young patients with CF. Furthermore, this study emphasizes the importance of gathering views and opinions of patients and their care teams to ensure good adherence and enjoyment to future interventions.
cystic fibrosis
inspiratory muscle training
multidisciplinary team
moderate-to-vigorous physical activity
National Health Service
physical activity
quality of life
We would like to thank Laura Morris and Nicholas Wade for helping to run the IMT intervention.
MAM and KAM conceived the study, JLM acquired the data, and all authors were involved in the interpretation and manuscript preparation.
None declared.