Review Article

Exploring the Therapeutic Benefits of Pranayama (Yogic Breathing):

A Systematic Review

Abstract Ranil
Background: Pranayama (yogic breathing) has demonstrated numerous beneficial health effects. At Jayawardena1,2,
present, there are no systematic reviews evaluating the beneficial health effects of pranayama alone Priyanga
as a practice. Aim: The aim of this study is to perform a systematic review about the beneficial
health effects of pranayama. Methods: Data were obtained using a stepwise search process by Ranasinghe3,
searching the online PubMed, Web of Science, and SciVerse Scopus databases using keywords. Himansa
Controlled clinical trials in humans, using “Pranayama” as an intervention with an appropriate Ranawaka1,
control group and evaluating health‑related outcomes were selected for inclusion. Results: Initial Nishadi Gamage3,
database searching indicated 669 potentially eligible articles, of which 18 studies satisfying the Dilshani
inclusion/exclusion criteria were selected. All were controlled trials, of which 13 were randomized
and 1 was a crossover study. Number of participants ranged from 16 to 160, and the duration Dissanayake1,
of pranayama practice varied from 4 days to 6 months. Studies demonstrated a significant effect Anoop Misra4
on cardiorespiratory functions, in patients with bronchial asthma, with the improvement of pulse Departments of 1Physiology
rate, systolic blood pressure, and respiratory function measurements. Furthermore, reduction in the and 3Pharmacology, Faculty
frequency of attacks, severity, and medication requirement was also observed, with improved quality of Medicine, University of
of life (QOL). In patients with chronic obstructive pulmonary disease, symptom, activity, and impact Colombo, Colombo, Sri
Lanka, 2Institute of Health
scores were improved. QOL improvement was also noted in cancer patients. Conclusions: Available and Biomedical Innovation,
evidence on pranayama indicates physiological and psychological benefits. Beneficial effects were Queensland University
mostly observed in patients with respiratory diseases such as bronchial asthma. It also helped those of Technology, Brisbane,
with cancer and cardiovascular disease. However, further high‑quality randomized trials are required Australia, 4Fortis‑C‑DOC
to provide definitive evidence. Centre of Excellence for
Diabetes, Metabolic Diseases
Keywords: Pranayama, therapeutic benefit, yogic breathing and Endocrinology, Diabetes
Foundation and National
Diabetes Obesity and
Introduction harmony to the physical, mental, emotional, Cholesterol Foundation,
and spiritual health of an individual. New Delhi, India
Complementary and alternative medicine
Therapeutic Yoga is defined as the
(CAM) is defined by the World Health
application of Yoga postures and practice
Organization as the broad set of health‑care
to the treatment of health conditions to
practices that are not part of that country’s
prevent, reduce, or alleviate structural,
own tradition and are not integrated into
physiological, emotional and spiritual pain,
the dominant health‑care system.[1] Over
suffering, or limitations.[5] Hatha Yoga, the
the years, the popularity of CAMs has
most widely practiced and studied form of
increased globally, with 70%–80% of the
Yoga in the modern world, emphasizes two
population in developed countries having
main aspects, “asana” (physical postures)
used some form of CAM during their
and “pranayama” (breathing exercises).[6] Address for correspondence:
lifetime.[2] CAMs can be grouped into two Dr. Ranil Jayawardena,
broad categories, natural products (herbs, Pranayama is a Sanskrit word formed by Department of Physiology,
etc.,) and mind‑body practices. Mind and the conjunction of two words, namely Faculty of Medicine, University
of Colombo, Colombo,
body practices are a group of techniques “prana,” meaning breath of life/vital Sri Lanka.
that are administered or taught by a trained energy, and “ayama,” meaning expansion/ E‑mail: [email protected]
practitioner and Yoga is a practice that fall regulation/control.[7] It is the yogic art
under this domain.[3] Yoga is a 3000‑year‑old of breathing, consisting of the deliberate
spiritual and ascetic discipline, which has modifications of the breathing process, such Access this article online

gained wider popularity in the recent past as rapid diaphragmatic breathing, slow/deep Website: www.ijoy.org.in
as a CAM.[4] It has been designed to bring breathing, alternate nostril breathing, and DOI: 10.4103/ijoy.IJOY_37_19
How to cite this article: Jayawardena R, Quick Response Code:
This is an open access journal, and articles are Ranasinghe P, Ranawaka H, Gamage N,
distributed under the terms of the Creative Commons Dissanayake D, Misra A. Exploring the therapeutic
Attribution‑NonCommercial‑ShareAlike 4.0 License, which benefits of Pranayama (yogic breathing):
allows others to remix, tweak, and build upon the work
A systematic review. Int J Yoga 2020;13:99-110.
non‑commercially, as long as appropriate credit is given and
the new creations are licensed under the identical terms. Submitted: 26-Apr-2019 Revised: 14-May-2019.
For reprints contact: [email protected] Accepted: 31-Aug-2019 Published: 01-May-2020.

© 2020 International Journal of Yoga | Published by Wolters Kluwer ‑ Medknow 99

 Jayawardena, et al.: Therapeutic benefits of yogic breathing

breath holding/retention, which are usually done in a seated Inclusion/exclusion criteria, data extraction, and
posture.[8] Pranayama practices four important aspects of analysis
breathing such as Pūraka (inhalation), Recaka (exhalation),
The following inclusion criteria were applied: (a)
Antaḥ kumbhaka (internal breath retention), and Bahiḥ
controlled clinical trials involving human subjects, (b)
kumbhaka (external breath retention).[7] According to the
using “Pranayama” as an intervention with an appropriate
Yoga‑Sutra of Patanjali, which is the most authoritative non‑yoga control group, and (c) evaluating health‑related
book on Yoga in India, pranayama is the fourth limb of the outcomes between the intervention and control groups
eight‑fold holistic process defined as Yoga.[9] using either clinical and/or biochemical measurements.
Although Yoga has been practiced for 1000s of years in Results were limited to studies conducted in humans,
India, its recent popularity has led to much speculation published in English. Data were extracted from the
on their effects on the health of individuals, leading to included studies by one reviewer (HR) using a standardized
a multitude of studies investigating the impact of these form and checked for accuracy by a second reviewer (RJ).
practices on various diseases.[5] Majority of the research The data extracted from each study were as follows: (a)
studies and reviews evaluating the health benefits of Yoga study details (first author, year of publication, country), (b)
have considered Yoga “asana” and “pranayama” as a whole, methods (sample size, age, duration of diabetes, male/
without focusing on pranayama solely.[10‑13] Pranayama female ratio of intervention and control groups), (c)
alone has demonstrated numerous beneficial health study design (randomization, blinding, duration of the
effects, including stress relief,[14] beneficial cardiovascular study), (d) details of intervention and control (method
effect,[14] improved respiratory function,[15] and enhanced and type of yoga breathing exercise, its frequency and
cognition.[16] However, at present, there are no systematic duration), and (e) outcome measurements (clinical and
reviews evaluating the beneficial health effects of biochemical parameters). Discrepancies in the extracted
pranayama alone as a practice. Therefore, the present study data were resolved by discussion, with the involvement of
a third reviewer when necessary (PR). Additional data not
aims to perform a systematic review of the studies done
available in the published manuscript were obtained from
about the beneficial health effects of pranayama.
corresponding authors or calculated using the published
Methods data.

The present systematic review was performed following Quality assessment

the Preferred Reporting Items for Systematic Reviews and The PEDro scale was used to assess the methodological
Meta‑Analyses (PRISMA) guidelines. quality of the trials included in the systematic
Literature search review.[17] Each study was scored from 0 to 10 according
to the following criteria: (1) random allocation, (2)
Data were obtained using a stepwise search process concealed allocation, (3) similarity at baseline, (4) subject
by searching the online PubMed® (U. S. National blinding, (5) therapist blinding, (6) assessor blinding, (7)
Library of Medicine, USA), Web of Science® (Thomson more than 85% follow‑up for at least one key outcome, (8)
Reuters, USA), and SciVerse Scopus® (Elsevier intention‑to‑treat analysis, (9) between‑group statistical
Properties S. A, USA) databases using keywords comparison for at least one key outcome, and (10)
“Pranayama,” “Pranayam,” “Pranayamas,” “Yogic point and variability measures for at least one key
Breathing Exercise,” and “Yoga Breathing Exercise.” outcome.[17] The PEDro scale categorizes studies as “good”
The search was restricted to studies on humans with quality (score 6–10), “fair” quality (score 4–5), and “poor”
articles published in English before June 31, 2017, while quality (score <4).
conference proceedings, editorials, commentaries, case
reports, qualitative studies, and book chapters/book Results
reviews were excluded. In the second stage, the total hits The initial database (PubMed, Web of Science, and SciVerse
obtained from searching the above databases were pooled Scopus) searching indicated 669 potentially eligible articles,
together, and duplicates were removed. Subsequently, the of which 401 remained after pooling the articles from the
studies were screened by reading the “title,” “abstract,” three databases and removing the duplicate article (four
and “full‑text” of the manuscripts. Studies not satisfying additional articles were included from other sources). Of
the inclusion criteria were excluded at this stage. To obtain these, 295 were excluded by screening the title and the
additional data, a manual search was performed using the abstract for failure to meet the inclusion criteria. Of the
reference lists of articles selected in the final stage. This remaining 106 articles a full‑text review yielded, 18 studies
stepwise search process was conducted by two independent satisfying the inclusion/exclusion criteria. Of these, eight
reviewers (RJ and HR), and the final group of articles to studies were conducted on respiratory diseases (including
be included in the review was determined after an iterative asthma, chronic obstructive pulmonary disease [COPD],
consensus process among the reviewers. and pleural effusion), five studies in patient with malignant

100 International Journal of Yoga | Volume 13 | Issue 2 | May-August 2020

 Jayawardena, et al.: Therapeutic benefits of yogic breathing

diseases and four studies in patients with hypertension and group followed Pranayama in addition to medication for
cardiovascular diseases. The search strategy is summarized 3 months. Pulse rate (PR), systolic blood pressure (SBP),
in Figure 1, and description of the characteristics of each diastolic blood pressure (DBP), respiratory rate, peak
study is provided in Table 1. expiratory flow rate (PEFR), forced expiratory volume
All were controlled trials, of which 13 were randomized in the 1st s (FEV1), and forced vital capacity (FVC) were
and 1 was a cross‑over study. Most studies were conducted determined in all participants. Test results revealed a
in India (n = 14). The number of participants ranged from significant improvement in PR (P < 0.05), SBP (P < 0.05),
16 to 160, and the duration of pranayama practice varied FVC (P < 0.05), PEFR (P < 0.05), and FEV1 (P < 0.001)
from 4 days to 6 months. Most studies included participants in posttest values compared to pretest values in the
from both genders (n = 10), whereas only females were intervention group. However, no significant changes were
included four studies and only males were included in one reported in the control group. A similar study by Saxena
study. The PEDro scale analysis of the methodological and Saxena evaluated the effect of pranayama in patients
quality of the trials included in the systematic review and mild‑to‑moderate bronchial asthma (n = 50) for 12 weeks.[15]
identified six studies with “poor” quality (score 0–4), 7 FEV1 and PEFR were measured in all participants at the
studies with “fair” quality (score 4–5), and five studies initial stage and after 12 weeks. A significant reduction in
with “good” quality (score 6–19). symptoms, improvement in FEV1 and PEFR was observed
Pranayama in patients with respiratory disease in the intervention group (P < 0.001) as compared to the
control group after the practice of pranayama.
There were six studies comparing the effects of pranayama
in patients with bronchial asthma, whereas one study A randomized controlled trial (RCT) conducted by
each included patients with COPD and pleural effusion, Sodhi et al. in patients with bronchial asthma (n = 120)
respectively. Bhatt and Rampallivar evaluated the effects for 2 months, demonstrated a statistically significant
of Pranayama on ventilatory functions in patients with increase (P < 0.01) in percentage of predicted PEFR,
bronchial asthma.[19] Patients with asthma (n = 80) were FEV1, FEF25‑75, FVC, and FEV1/FVC% ratio at 4 and
divided equally into two groups and the intervention 8 weeks in the intervention group who practiced yoga

Records identified through Additional records identified

Identification

database searching through other sources

(n =669) (n =4)

Records after duplicates removed

(n = 401)
Screening

Records screened by Title

and Abstract
(n =401)

Records excluded
(n =295)
Eligibility

Full-text articles assessed

for eligibility
(n =106)

Full-text articles excluded

(n =88)

Studies included in
Included

qualitative synthesis
(n =18)

Figure 1: Summarized search strategy (Preferred Reporting Items for Systematic Reviews and Meta‑Analyses flow diagram)

International Journal of Yoga | Volume 13 | Issue 2 | May-August 2020 101

 Jayawardena, et al.: Therapeutic benefits of yogic breathing

Table 1: Summary of included studies

Author, Year Objective/s Study Duration Participants Gender Details of Outcome Result
of publication, design of n Age intervention measure (s)
Country Pranayama intervention*
(referebce) n control*
Anitha 2016, Effects of C 5 days 30 30 NM NM 10 min of Speilberger Significantly
India[18] Pranayama Pranayama once a State Anxiety lower posttest
on the level day in the morning Inventory anxiety in
of anxiety in for 5 consecutive (pre‑ and intervention
patients with days post‑test score)
group compared
myocardial to pretest anxiety
infarction of IG (P<0.01)
with no significant
pre‑post change
in CG
Bhatt and Effect of R, C 3 months 40 40 NM 18-72 Different types PR, SBP, DBP, Significant
Rampallivar Pranayama years of Pranayama RR FVC, reduction in PR
2016, India[19] on ventilator (Bhastrika, FEV1, FEV1/ (P<0.05), SBP
functions Kapalbhati, FVC %, PEFR (P<0.05) and
in asthma Anuloma‑Viloma, increase in FVC
patients Bhramri and (P<0.05), PEFR
Ujjayi) (P<0.05) and
Few days of expert FEV1 (P<0.001)
supervised sessions, in the IG posttest
followed by home compared to
continuation pretest. No
significant change
in CG
Mobini Bidgoli Effect of R, C 5 min 40 40 Both 59.1 Sukha Pranayama Spielberger Significant
et al., 2016, Pranayama DB years for 5 min under the State Anxiety reduction in
Iran[20] on anxiety supervision Inventory mean anxiety
in patients before, 0.5 score (P<0.0001)
undergoing and 1 h in IG at 0.5
coronary postintervention and 1 h compared
angiography to pretest anxiety
of IG. Significant
difference in
postintervention
mean anxiety
scores between
groups
(P<0.01). No
significant pre‑post
change in CG
Chakrabarty Effect of R, C 1.5 months 80 80 Female Pranayama (Nadi Cancer fatigue Significant
et al., 2015, Pranayama on >18 years shodana, Sheethali, scale reduction in
India[21] cancer‑related Brahmari) for 30 cancer‑related
fatigue in min twice daily for fatigue in
breast cancer 5 days a week, for IG posttest
patients 6 weeks compared to
undergoing pretest (P<0.001).
radiotherapy Significantly
lower posttest
cancer related
fatigue in IG
compared to CG
(P<0.01)

Contd...

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 Jayawardena, et al.: Therapeutic benefits of yogic breathing

Table 1: Contd....
Author, Year Objective/s Study Duration Participants Gender Details of Outcome Result
of publication, design of n Age intervention measure (s)
Country Pranayama intervention*
(referebce) n control*
Chakrabarty Effect of R, C 1.5 months 80 80 Female Pranayama (Nadi Serum protein Significantly
et al., 2013, Pranayama >18 years shodana, Sheethali, thiols and higher levels of
India[22] on the Brahmari) for glutathione serum protein
antioxidant 30 min twice daily thiols (P=0.001)
levels in for 5 days a week, and glutathione
breast for 6 weeks (P=0.002) posttest
cancer patients in the IG compared
undergoing to CG
radiation
therapy
Chakrabarty Effect of R, C 1.5 months 80 80 Female Performance of Emotions Significantly less
et al., 2016, Pranayama >18 years pranayama (Nadi according to an posttest negative
India[23] on Emotional shodana, Sheethali, expert‑validated emotions in the IG
changes in Brahmari) for scale devised compared to CG
breast cancer 30 min twice daily by the (P=0.001)
patients for 5 days a week, investigators
undergoing for 6 weeks
radiation
therapy
Dhruva et al., Effect of R, C Intervention 8 8 Both 54.2 Weekly Pranayama Revised Piper Significantly
2012, USA[24] Pranayama between years session lasting Fatigue Scale, improved sleep
on cancer two therapy for 60 min General Sleep disturbance
chemotherapy cycles (inclusive of Disturbance (P=0.04), anxiety
associated breath observation, Scale, Hospital (P=0.04), and
symptoms and Ujjayi, Kaplabhati, Anxiety and mental component
QOL and Nadi shodana Depression of QOL (P=0.05) in
pranayama) taught Scale, the IG posttest. No
by instructors, Perceived significant change
and practice Stress Scale in CG
of pranayama and QOL
techniques for (SF‑12)
10-15 min,
twice daily at
home, during
two consecutive
cycles of
chemotherapy
Franzblau et al., Effects of R, C 4 days 20 20 Female Division of BDI‑II Significant
2008, USA[25] Pranayama 18-45 participants reduction in
on depression years into 4 groups. BDI‑II score
in abused Intervention types posttest in groups
women are: practice of yogic who underwent
breathing (45 min yogic breathing
per day); giving (P<0.005),
testimony (45 min giving testimony
per day); practice (P<0.005) and the
of yogic breathing combination of
and giving both (P<0.005), but
testimony (90 min not in the CG
per day).
CG group had no
intervention

Contd...

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 Jayawardena, et al.: Therapeutic benefits of yogic breathing

Table 1: Contd....
Author, Year Objective/s Study Duration Participants Gender Details of Outcome Result
of publication, design of n Age intervention measure (s)
Country Pranayama intervention*
(referebce) n control*
Goyal et al., Effect of C 1.5 months 25 25 Both Practice of PR, BP, RPP PR decreased
2014, India[26] Pranayama in 20-50 pranayama (Nadi (HR*SBP) significantly in
patients with years shodana: 2-10 min, both the groups
hypertension Chandar bhedi: as compared
(Stage 1) 2-10 min, to baseline.
Brahmari: RPP decreased
10 cycles, Omkar significantly in both
chanting: 10 cycles) groups compared to
daily for 6 weeks baseline, however
the decrease was
significantly more
(P<0.01) in IG in
comparison to CG
Katiyar and Effect of R, C 3 months 24 24 Both 52.2 Performance FVC, FEV1, Significant posttest
Bihari 2006, Pranayama in SB ears of pranayama PEFR, 6 min increase of PEF
India[27] patients with (Bhastika, walk test, PO2, (P<0.05), distance
COPD Kapalabhati, Vhasya, pCO2 and walked in 6 min
Anulom‑Vilom, (SGRQ) score test (P<0.05) and
Bhramid and significant decrease
Udgeedh in SGRQ score
pranayama) for at (P<0.02) in IG
least 30 min daily, compared to CG
6 days a week, for 3
months
Kochupillai Effect of C 6 months 21 6 NM 22-65 Pranayama (Ujjayi Immune Significant increase
et al., 2005, Pranayam years and Bhastrika) functions: of NK cell count at
India[28] on Immune followed by SK CD3+, CD4+, 12 (P=0.001) and 24
Functions (taught at 6 a day CD8+, and NK weeks (P=0.0001)
in cancer workshop) daily at cell count at compared to baseline
patients home for 6 months baseline, week in IG. Significant
1, 12 and 24 increase in NK cell
count in IG at week
24 compared to CG
(P<0.05)
Mourya et al., Effect of R, C 3 months 20, 20 20 Both Practice of BP and Significant reduction
2009, India[29] Pranayama in 20-60 breathing exercises autonomic in posttest SBP
patients with years (fast [n=20] or slow function and DBP in
hypertension [n=20]) for 15 min tests (SLR, slow‑breathing
(Stage 1) twice daily 10-12 h immediate group and
apart, for 3 months HR response fast‑breathing
to standing group with a
[30:15 ratio], greater reduction
Valsalva ratio, in slow‑breathing
HR variation group. Significant
with respiration increase in SLR,
[EIR], 30:15 ratio, EIR,
hand‑grip DBP response
test and in hand grip test,
cold presser and rise in both
response) SBP and DBP in
cold pressor test in
patients practicing
the slow‑breathing
exercise compared to
baseline (P<0.001)
and CG (P<0.001)
Contd...
104 International Journal of Yoga | Volume 13 | Issue 2 | May-August 2020
 Jayawardena, et al.: Therapeutic benefits of yogic breathing

Table 1: Contd....
Author, Year Objective/s Study Duration Participants Gender Details of Outcome Result
of publication, design of n Age intervention measure (s)
Country Pranayama intervention*
(referebce) n control*
Prakasamma Effect of C 20 days 10 10 Male Anuloma‑viloma FVC, FEV1, Significant increase
and Bhaduri Pranayama 16-50 Pranayama for 30 MVV, PEFR, in posttest FVC,
1984, India[30] as a nursing years min daily for 20 CE and RS CE in IG (P<0.1)
intervention days after aspiration compared to CG
in the care of pleural fluid
of patients
with pleural
effusion
Prem et al., Effect of R, 3 months 40 40 Both Patients trained AQLQ score, IG showed
2013, India[31] Pranayama CSB 18-60 to perform Asthma Control a significant
on QOL and years diaphragmatic Questionnaire improvement
pulmonary breathing, thoracic and FEV1, (P=0.042) in
function in breathing, upper FEV1/FVC total asthma QOL
patients with lobe breathing Questionnaire score
bronchial and full yogic The study also
asthma breathing included a parallel
progressing to 3rd group who
right nostril practiced Buteyko
breathing, left techniques as an
nostril breathing intervention (n=40)
and alternate
nostril breathing
for 3-5 days with a
session of 60 min
each day. They
were instructed
to practice the
exercise at home
for 15 min twice
daily for 3 months
Saxena and Effect of R, C 3 months 25 25 Both Practice of Symptoms Significant
Saxena 2009, Pranayama 18-45 breathing exercises score, FEV1%, improvement in
India[15] in patients years (deep breathing, PEFR posttest symptoms
with mild Sasankasana (P<0.01), FEV
to moderate breathing, 1
% (P<0.001) and
bronchial Anuloma‑viloma, PEFR (P<0.001) in
asthma Bhramari, IG compared to CG
Omkara) for
20 min twice daily
for 3 months
Singh et al., Effect of C 0.5 months 22 22 Both Practice of slow FEV1, FVC, PD20 increased
1990, UK[32] Pranayama CO 19-54 deep breathing PEFR, significantly in IG
on airway years through the Pink symptom score, compared to CG
reactivity City Lung Exerciser inhaler use, (P=0.013)
in subjects for 15 min, twice a PD20 histamine
with bronchial day, for 2 weeks level
asthma
Sodhi et al., Effect of R, C 8 weeks 60 60 Both Pranayama AQLQ score, Significant
2014, India[33] Pranayama 17-50 (deep breathing, number and improvement
Yoga on years Kaplabhati, severity of in total score of
the QOL in Bhastrika, Ujjayi asthmatic AQLQ compared to
patients with and Sukha purvaka attacks, dosage baseline (P<0.01)
bronchial pranayama) of medication in IG, but not in
asthma required CG. Significant

Contd...

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 Jayawardena, et al.: Therapeutic benefits of yogic breathing

Table 1: Contd....
Author, Year Objective/s Study Duration Participants Gender Details of Outcome Result
of publication, design of n Age intervention measure (s)
Country Pranayama intervention*
(referebce) n control*
for 45 min, twice reduction in
daily on all days daily number and
of the week for severity of attacks
8 weeks in the IG posttest
compared to
baseline (P<0.01)
and compared
to CG (P<0.05).
Significant
reduction in
the dosage of
medication required
in the IG compared
to baseline
(P<0.05), but not in
the CG
Sodhi et al., Effect of R, C 8 weeks 60 60 Both IG Yoga breathing PEFR, FVC, Significant increase
2009, India[34] Pranayama ‑ 20-50 exercises (deep FEV1, FEF25-75, in PEFR, FVC,
on pulmonary years CG breathing, FEV1/FVC % FEV1, FEF25-75,
functions in ‑ 17-50 Kaplabhati, FEV1/FVC %
patients with years Bhastrika, Ujjayi at 4 weeks and
bronchial and Sukha purvaka 8 weeks in the
asthma pranayama) for 45 IG compared to
min, twice daily on baseline (P<0.01),
all days of the week but not in the CG
for 8 weeks
PEF=Peak expiratory flow, AQLQ=Asthma QOL Questionnaire, BP: Blood pressure, BDI‑II=Beck depression inventory‑II, C=Controlled,
CE=Chest expansion, CG=Control group, CO=Cross‑over, COPD=Chronic Obstructive Pulmonary Disease, DB=Double blind, DBP=Diastolic BP,
FEV1=Forced expiratory volume in 1 s, FVC=Forced vital capacity, IG=Intervention group, NM=Not mentioned, PEFR=PEF rate, PR=Pulse rate,
R=Randomized, RPP=Rate pressure product, RR=Respiratory rate, RS=Radiological score, SB=Single blind, SBP=Systolic BP, SGRQ=St. George’s
Respiratory Questionnaire, SLR=Standing‑to‑lying ratio, NK=Natural killer, SLR=Standing‑to‑lying ratio, QOL=Quality of life, SK=Sudharshan
Kriya, HR=Heart rate, SF=Short form, EIR=End inspiratory rate, MVV=Maximal voluntary ventilation, FEF25-75=Forced Expiratory Flow

breathing compared to control group.[34] Singh et al., equal groups. The control group (n = 40) underwent
studied the effects of slow‑deep breathing through routine pharmacological management. Considering
the Pink City Lung (PCL) exerciser, in patients with the two intervention groups, one group performed
bronchial asthma.[32] Patients were asked to breathe pranayama (n = 40), whereas the other group performed
through a matched placebo device during the control Buteyko (n = 40) for a training period of 3 months.
period. Mean FEV1 PEFR, Symptom score, and inhaler Pre‑ and post‑training values of the Asthma Quality of Life
use over the past 3 days of each treatment period were Questionnaire (AQLQ), Asthma Control Questionnaire, and
assessed. All values improved more with the PCL pulmonary function tests were noted in all participants. In
exerciser than with the placebo device; however, these comparison between the pranayama and control groups,
differences were not significant. A significant increase pranayama showed a significant improvement (P = 0.042)
in the dose of histamine needed to provoke a 20% in total AQLQ score. However, Buteyko group showed
reduction in FEV1 (PD20) during pranayama breathing better improvement in total AQLQ score than the
was reported with the PCL exerciser (P = 0.013) but not pranayama (P = 0.056). Similar results were observed
with the placebo device. in the study conducted by Sodhi et al., who reported a
significant improvement in “symptoms,” “activities,” and
Several controlled trials have evaluated the effects of “environmental” domains of AQLQ at 8 weeks (P < 0.01)
Pranayama on quality of life (QOL) in patients with in the yoga group than the control group. They also
bronchial asthma. An RCT was carried out in India observed a significant reduction in daily number and
by Prem et al. to compare the effects of Buteyko and severity of attacks, and the dosage of medication required
pranayama breathing techniques on QOL in patients at 4 and 8 weeks (P < 0.01) in the yoga group compared to
with asthma (n = 120).[31] Patients were assigned to three the baseline.[33]

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 Jayawardena, et al.: Therapeutic benefits of yogic breathing

An RCT conducted by Katiyar and Bihari evaluated usual care during cycle A and pranayama along with
the role of pranayama (3 months) in the rehabilitation usual care in cycle B. The symptom and QOL measures
of patients with COPD (n = 48).[27] The St. George’s were self‑administered. Fatigue level was measured
Respiratory Questionnaire (SGRQ) was used to measure using the revised Piper Fatigue Scale. Sleep disturbance
the overall health status of the participants, while of the participants was measured using the General
spirometry tests, 6‑min walk test (6‑MWT), and arterial Sleep Disturbance Scale. Anxiety and depression were
blood gas (ABG) analysis were done in all participants. measured by means of the 14‑item Hospital Anxiety and
The study results indicated statistical significant decrease in Depression Scale. Stress was measured using the Perceived
the symptom score (P = 0.03), activity score (P < 0.005), Stress Scale. The Short Form‑12 version one was used
impact score (P < 0.008), and total SGRQ score (P = 0.02) to measure QOL. The study results indicated significant
in the interventional group, but not in the control group. improvements in sleep disturbance (P = 0.04), level of
The increase in FVC and FEV1 in the interventional anxiety (P = 0.04), and mental QOL (P = 0.05) of the
group was insignificant, but the increase in the PEF was participants who followed yoga breathing between the two
statistically significant (P = 0.05) only in the interventional consecutive cycles of chemotherapy (interventional group).
group. No significant changes were reported in either group Effect of pranayama on immune function of cancer patients
in ABG analysis values. Considering the 6‑MWT results, in remission was assessed by Kochupillai et al.[28] Cancer
a small but significant increase in the distance (P = 0.05) patients (n = 21) who had completed the standard treatment
were reported in the interventional group. Pranayama had statistically significant (P < 0.001) increase in natural
has also demonstrated beneficial effects on respiratory killer cells at 12 and 24 weeks of practice of pranayama
function (FVC) and chest expansion postpleural aspiration and Sudarshan Kriya, with no similar effect observed in the
in patients with pleural effusions.[30] control group.
Pranayama in patients with malignant diseases Pranayama in patients with cardiovascular diseases
A total of five studies assessed the short‑term effects of Anitha conducted a hospital‑based study to evaluate the effect
pranayama in patients with malignancy and evaluated of pranayama on the level of anxiety in patients presenting
cancer‑related fatigue, emotional changes, QOL, with myocardial infarction (n = 60).[18] Standardized
anti‑oxidant status, and immune functions. Three studies Spielberger State Anxiety Rating Scale (self‑administered)
were reported in patients with breast carcinoma, whereas was used to assess the level of anxiety. The study reported
the other studies involved patients with different types of a statistically significant (P < 0.01) improvement in
malignant diseases undergoing chemoradiotherapy.[21,23] posttest anxiety in the interventional group compared to the
Chakrabarty et al. assessed the effect of pranayama control group. Similar beneficial results on anxiety were
on cancer‑related fatigue and emotional aspects of observed in another study on patients undergoing coronary
breast cancer patients (n = 160) undergoing radiation angiography, where the mean anxiety score (Spielberger
therapy.[21,23] Fatigue level was assessed using the cancer State Anxiety Rating Scale) of the interventional group
fatigue scale, and emotional aspects were assessed using was significantly decreased (P = 0.0001) after performing
five items as part of the assessment of cancer‑related pranayama, but not in the control group.[20]
fatigue. The study results indicated a significant Goyal et al. carried out a study to evaluate the effect
difference (P < 0.001) in the pre‑ and post‑test scores of pranayama on PR, blood pressure and rate pressure
cancer‑related fatigue in the interventional group compared product (RPP ) (SBP * PR) in mild hypertensive
to the control group (P < 0.001). Furthermore, a significant patients (n = 50).[26] SBP decreased significantly in the
reduction (P < 0.01) in emotions such as worry, anxiety, intervention group and the decrease was significant as
and frustration was reported in breast cancer patients who compared to control group. PR decreased significantly
performed pranayama compared to the control group. in both the groups as compared to baseline; however,
The effect of pranayama on anti‑oxidant status was also the decrease was similar in both groups. RPP decreased
evaluated in the same group of patients.[22] The results significantly in both groups as compared to baseline;
revealed that the interventional group had significantly however, the decrease was significantly more (P < 0.01) in
higher posttest levels (P < 0.001) of serum protein thiols interventional group when compared to the control group.
compared to the control group. A hospital‑based RCT by Mourya et al. investigated the
Dhruva et al. tested the effects of pranayama effect of slow and fast yogic breathing exercises on blood
on QOL in patients receiving cancer pressure and autonomic function in patients with essential
chemotherapy (n = 16).[24] Patients receiving two hypertension.[29] Patients with Stage 1 hypertension (n = 60)
consecutive cycles of cancer chemotherapy (cycle were equally divided into three groups: Group 1 (control
A and B) were randomized to receive pranayama group), whereas Group 2 and Group 3 followed slow and
immediately (interventional group) or after a waiting fast breathing exercises, respectively, for 3 months. The
period (control group). The control group received only study results revealed a significant decrease in SBP and

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 Jayawardena, et al.: Therapeutic benefits of yogic breathing

DBP in both Group 2 (P < 0.001) and Group 3 (P < 0.01). from bronchial tree and the alveoli, making room for
However, the decrease was greater in Group 2, with no more air.[37] Lung inflation near to total lung capacity
significant changes observed in control group. is known to be a major stimulus for the release of lung
surfactant into alveolar spaces, leading to increased lung
Pranayama in other groups of patients
compliance.[39] The slow and gentle breathing in some of
Franzblau et al. tested the short‑term effects of the Pranayama techniques reduces frictional stress, thereby
having battered women’s provide testimony about stabilizing the mast cell degranulation, thereby reducing
their abuse and/or the effects of yogic breathing on airway inflammation and airway obstruction.[38] The deep
depression which measured by the Beck Depression inspiration, retention of air, and slow expiration increases
Inventory (BDI)‑II.[25] Participants (n = 40) who the overall capacity of the lungs and gradually improves the
self‑identified as verbally, emotionally, physically, and/ pulmonary functions.[38] This improved pulmonary function
or sexually abused within the past 2 years were assigned is likely to be responsible for the observed reduction in
into four groups as: testimony only, yogic breathing severity, frequency, and medication requirement in patients
only, testimony and yogic breathing, and control. with bronchial asthma, which ultimately is responsible for
The study results indicated a significant reduction in the enhanced QOL in these patients. The improvements
posttest BDI‑II score in groups who underwent yogic observed in COPD are also likely to be due to similar
breathing (P < 0.005), giving testimony (P < 0.005), and mechanisms. However, it is important to note that there
the combination of both (P < 0.005), but not in the control has been a case report of occurrence of pneumothorax with
group. practice of Kapalabhati Pranayama.[40] Hence, appropriate
selection of the most suitable Pranayama methods, careful
Discussion supervision, and training may be required in patients with
The present systematic review is the first to systematically already compromised respiratory functions.
evaluate the literature on the beneficial health effects Another long‑term effect of pranayamic breathing is the
of Pranayama yoga practice. We observed a significant improvement in autonomic function.[41] Recent controlled
effect on the cardio‑respiratory functions, in patients with trials suggest that yoga training programs can reduce
bronchial asthma, with the improvement of PR, SBP, FVC, perceived stress, improve mood, and lower catecholamine
FEV1, and PEFR. Furthermore, reduction in the frequency and cortisol levels, cardiovascular response to stress, blood
of attacks, severity, and medication requirement was pressure, and other indices of sympathetic activation in
also observed, in addition to improved QOL. In patients both healthy and clinical populations.[42] Yogic practices
with COPD, symptom, activity, and impact scores were shift the autonomic nervous system balance from
improved with Pranayama practice. QOL improvement has primarily sympathetic to parasympathetic, by directly
been noted in cancer patients, with improved emotions, enhancing parasympathetic output, possibly through vagal
fatigue, sleep, and reduced anxiety. Reduction in anxiety stimulation, resulting in positive changes in cardiovagal
has also been observed in patients with cardiovascular function and associated neuroendocrine, hemodynamic, and
diseases. In patients with hypertension, both SBP and inflammatory profiles, in sleep and affect, and in related
DBP were reduced with Pranayama practices. Hence, the downstream metabolic parameters.[42] Slow pranayamic
available evidence from controlled studies indicates both breathing generates inhibitory signals and hyperpolarizing
physiological and psychological benefits of Pranayama. current within neural and nonneural tissue by mechanically
The predominant beneficial effect of Pranayama practice stretching tissues during breath inhalation and retention.[43]
was observed in patients with respiratory illnesses such It is likely that these inhibitory impulses in cooperation
as bronchial asthma. Several mechanisms are thought with hyperpolarization current initiate the synchronization
to be responsible for the beneficial respiratory effects of of neural elements in the central nervous system, peripheral
nervous system, and surrounding tissues ultimately causing
Pranayama. Pranayama may allow bronchio‑dilatation
shifts in the autonomic balance toward parasympathetic
by correcting abnormal breathing patterns and reducing
dominance.[43] This shift toward parasympathetic dominance
muscle tone of respiratory muscles.[35] Furthermore, yoga
is likely to be responsible for the observed cardiovascular
training is likely to improve the strength of expiratory as
effects of Pranayama practice, such as reduced heart rate,
well as inspiratory muscles, with resultant improvement
SBP, and DBP in patients with hypertension.
in pulmonary function.[36] For example, “Bhastrika”
Pranayama is a type of breathing, in which one breath Our results also indicate several psychological benefits
rapidly and forcefully, exercising both inspiratory and of Pranayama practice, including improved emotional
expiratory muscles.[37] Furthermore, breathing exercises responses, fatigue, stress, and reduced anxiety in cancer
like Kapalbhati, which utilizes the abdominal and patients, as well as in patients with cardiovascular disease.
diaphragmatic muscles train the subject to make full use Increased melatonin production after a regimen of slow
of the diaphragm and abdominal muscles in breathing.[38] breathing pranayamic exercises has been attributed to
This is also likely to help in the removal of secretions pranayama’s tendency to create a sense of relaxation and

108 International Journal of Yoga | Volume 13 | Issue 2 | May-August 2020

 Jayawardena, et al.: Therapeutic benefits of yogic breathing

well‑being in the subject.[44] Breath‑holding, an essential Financial support and sponsorship

part of pranayama, is known to induce theta waves in
Nil.
the electroencephalography.[43] The particular contribution
of pranayama to stress/anxiety reduction might also be Conflicts of interest
contributed by the sympathetic‑parasympathetic shift.
There are no conflicts of interest.
Vagal afferents from peripheral receptors are connected
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