Sauna for chronic obstructive pulmonary disease
Evidence review
Overview
Small Japanese studies of 4 weeks of daily far-infrared (Waon) therapy added to conventional COPD care reported improvements in exercise pulmonary artery pressure, exercise time, quality of life and some airflow measures. Older Dutch studies found a transient improvement in lung function after a sauna session without bronchoconstriction, but no improvement in mucus clearance, and a Russian comparison found sauna less effective than inhaled expectorants at restoring mucociliary clearance. Uncontrolled Russian health-resort series reported symptom and bronchodilator benefits with sauna (107 patients with asthma or chronic bronchitis) and with contrast baths (91 patients with obstructive chronic bronchitis). In a Finnish cohort, frequent sauna use was associated with lower incidence of respiratory disease. Older Japanese uncontrolled studies of 2-month exercise or breathing programs in 100.4 F hot-spring pools (in groups that included many patients with asthma) reported higher FEV1/FVC and lower PaCO2, and one reported a higher ejection fraction. In severe COPD on home oxygen, ordinary bath immersion caused oxygen desaturation with movement, which instruction reduced. None of these studies was randomized.
Key findings
- Waon therapy in severe COPD: exercise pulmonary artery pressure 64 to 51 mmHg (p=0.028); SGRQ 59.7 to 55.3 (p=0.002); exercise time 360 to 392 s (p=0.032) (Umehara 2008, n=13)
- Waon added to usual care vs usual care: FEF50 change 0.08 vs -0.01 L/s (p=0.019); no 6-minute walk difference (Kikuchi 2014, n=20)
- Single sauna session: FVC 3.22 to 3.6 L with no bronchoconstriction (Cox 1989, n=12); no improvement in tracheobronchial clearance (van Hengstum 1991, n=5)
- Sauna less effective than inhaled expectorants for restoring mucociliary clearance (Lunichkina 1989)
- Uncontrolled spa series: 'good results' in 80.3% with contrast baths (Rychkova 1994, n=91); bronchodilator effect reported with sauna (Kholopov 1985, n=107, no figures)
- Frequent sauna and incident respiratory disease (COPD, asthma or pneumonia): HR 0.59 (95% CI 0.37-0.94) for >=4 vs <=1 session/week (Kunutsor 2017, n=1,935)
- Warm-pool (100.4 F) breathing or exercise programs for 2 months, uncontrolled: FEV1/FVC rose and PaCO2 fell (Kurabayashi 1997, n=22 and n=25); LVEF rose in emphysema (Kurabayashi 1998, n=12)
- Severe COPD on home oxygen, bath immersion to the shoulders: significant oxygen desaturation with movement, reduced after instruction (Nakahiro 1998, n=16)
Every study we reviewed
8 found benefit · 2 mixed results · 1 found no effect · 1 found harm
Each study was checked on PubMed. The colored edge shows the direction of the result. The research library lists 23 studies on copd and chronic bronchitis, across all heat and cold therapies, including case reports and older work not graded here.
Repeated waon therapy improves pulmonary hypertension during exercise in patients with severe chronic obstructive pulmonary disease.
Umehara M et al. J Cardiol. 2008. PubMed 18522783 · DOI · Free full text
- Who
- patients with COPD (GOLD criteria) breathless despite conventional treatment
- What
- Waon therapy daily for 4 weeks
- Protocol
- 140 °F · 15 (plus 30 min warm rest) min · daily/wk · 4 wk
- Measured
- right ventricular function, pulmonary hypertension during exercise, exercise time, SGRQ
- Result
- PH during exercise 64 +/- 18 to 51 +/- 13 mmHg (p=0.028); RV dP/dt 397 to 512 mmHg/s (p=0.024); exercise time 360 to 392 s (p=0.032); SGRQ 59.7 to 55.3 (p=0.002); resting PH not changed; no adverse effects.
- Limitations
- uncontrolled before-after; small
Effect of repeated Waon therapy on exercise tolerance and pulmonary function in patients with chronic obstructive pulmonary disease: a pilot controlled clinical trial.
Kikuchi H et al. Int J Chron Obstruct Pulmon Dis. 2014. PubMed 24363555 · DOI · Free full text
- Who
- consecutive COPD patients, GOLD stages 1-4
- What
- Waon therapy plus conventional therapy (including pulmonary rehabilitation) vs conventional therapy alone
- Protocol
- 140 °F · 15 (plus 30 min warm rest) min · 5/wk · 4 wk
- Measured
- pulmonary function, 6-minute walk test
- Result
- Vital capacity change 0.30 vs 0.02 L (P=0.077); PEF 0.48 vs -0.11 L/s (P=0.095); FEF50 0.08 vs -0.01 L/s (P=0.019); no significant 6-minute walk differences.
- Limitations
- non-randomized controlled pilot; small; most outcomes not significant
Sauna to transiently improve pulmonary function in patients with obstructive lung disease.
Cox NJ et al. Arch Phys Med Rehabil. 1989. PubMed 2596966
- Who
- men with obstructive pulmonary disease
- What
- single-day sauna program
- Protocol
- single session/wk
- Measured
- FVC, FEV1
- Result
- FVC 3.22 +/- 0.89 L before vs 3.6 +/- 0.99 L after sauna; no bronchoconstriction elicited.
- Limitations
- acute, transient effect only; uncontrolled
Measurement of tracheobronchial clearance after sauna in subjects with chronic bronchitis.
van Hengstum M et al. Thorax. 1991. PubMed 1750021 · DOI · Free full text
- Who
- men with chronic bronchitis
- What
- sauna exposure
- Protocol
- single session/wk
- Measured
- tracheobronchial clearance (radioaerosol)
- Result
- No enhancement of tracheobronchial clearance detected.
- Limitations
- n=5
Sauna bathing reduces the risk of respiratory diseases: a long-term prospective cohort study.
Kunutsor SK et al. Eur J Epidemiol. 2017. PubMed 28905164 · DOI · Free full text
- Who
- Finnish men aged 42-61 (KIHD)
- What
- self-reported sauna frequency, 2-3 or >=4 vs <=1 session/week
- Protocol
- <=1 vs 2-3 vs >=4/wk
- Measured
- incident hospital-diagnosed respiratory disease (COPD, asthma or pneumonia)
- Result
- HR 0.73 (95% CI 0.58-0.92) for 2-3 and 0.59 (0.37-0.94) for >=4 sessions/week; 379 cases over median 25.6 years.
- Limitations
- observational; composite outcome; men only; prevention rather than treatment of COPD
[Use of the sauna in the complex health resort treatment of patients with nonspecific bronchopulmonary diseases].
Kholopov AP et al. Ter Arkh. 1985. PubMed 2934844
- Who
- health-resort patients with asthma or chronic bronchitis (obstructive bronchopulmonary disease)
- What
- therapeutic sauna hyperthermia as one part of multimodal health-resort treatment
- Measured
- clinical symptoms, adaptation period, bronchial patency, cardiodynamics
- Result
- Authors report faster regression of clinical symptoms, a shorter adaptation period at the resort, a bronchodilator effect and normalization of cardiodynamics; no figures given in abstract.
- Limitations
- no control group described in abstract; sauna was one component of multimodal treatment; asthma and chronic bronchitis not reported separately; no numbers in abstract
[Contrast baths in the rehabilitation of patients with chronic bronchitis].
Rychkova MA et al. Vopr Kurortol Fizioter Lech Fiz Kult. 1994. PubMed 7941472
- Who
- patients with chronic bronchitis with obstructive syndrome
- What
- contrast baths (alternating hot- and cold-water immersion) during rehabilitation
- Measured
- clinical efficacy, external respiration, right-heart hemodynamics, inflammatory activity, immune measures
- Result
- Good results reported in 80.3% of patients; principal contraindications were defined (not listed in abstract).
- Limitations
- uncontrolled; outcome definition of 'good result' not given in abstract; alternating hot and cold water, not sauna
[Effectiveness of pharmacologic and non-pharmacologic methods of restoring bronchial patency].
Lunichkina IV et al. Klin Med (Mosk). 1989. PubMed 2779144
- Who
- patients with impaired mucociliary transport (underlying diagnosis not stated in abstract)
- What
- sauna vs oral expectorants vs inhaled expectorants
- Measured
- mucociliary clearance (time to expectorate an inhaled marker)
- Result
- Inhaled expectorants were the most effective method of restoring bronchial drainage; sauna was less effective. No figures given in abstract.
- Limitations
- allocation and sample size not given in abstract; population diagnosis not specified; no numbers in abstract
Improvement in ejection fraction by hydrotherapy as rehabilitation in patients with chronic pulmonary emphysema.
Kurabayashi H et al. Physiother Res Int. 1998. PubMed 9859136 · DOI
- Who
- Stable chronic pulmonary emphysema, mean age 70.9 (Japan)
- What
- Breathing exercise while standing in a 100.4 F (38 C) pool (inhaling, then exhaling through the mouth with the nose under water), 30 min/day, 6 days/week for 2 months
- Protocol
- 100.4 °F · 30 min · 6/wk · 8 wk
- Measured
- Echocardiographic LVEF, lung function, arterial blood gases
- Result
- LVEF increased after each 30-min session (p<0.01) and after 2 months (p<0.05); LV end-diastolic and end-systolic dimensions fell (p<0.01); FEV1/FVC rose and PaCO2 fell (p<0.05).
- Limitations
- Uncontrolled; 12 patients; warm water combined with breathing exercise and hydrostatic pressure, so heat is not isolated.
Effective physical therapy for chronic obstructive pulmonary disease. Pilot study of exercise in hot spring water.
Kurabayashi H et al. Am J Phys Med Rehabil. 1997. PubMed 9207705 · DOI
- Who
- Stable COPD as defined by the authors (12 bronchial asthma, 10 pulmonary emphysema), mean age 70.9 (Japan)
- What
- Two-month exercise program in a hot-spring water pool (water temperature not given in the abstract)
- Protocol
- 8 wk
- Measured
- Lung function and arterial blood gases
- Result
- FEV1/FVC increased (P<0.05) while %FVC did not change; peak flow tended to rise; PaCO2 fell (P<0.05) and PaO2 did not change.
- Limitations
- Uncontrolled; more than half had bronchial asthma; exercise in water, so heat is not isolated; possible patient overlap with the authors' other reports.
[Physical therapy in a pool as rehabilitation for chronic obstructive pulmonary disease in the elderly].
Kurabayashi H et al. Nihon Ronen Igakkai Zasshi. 1997. PubMed 9455125 · DOI
- Who
- Stable COPD as defined by the authors: 15 older (mean age 75.7) and 10 younger (mean 56.4) patients; 10 emphysema, 15 bronchial asthma (Japan)
- What
- Two-month rehabilitation program in a 100.4 F (38 C) hot-spring water pool
- Protocol
- 100.4 °F · 8 wk
- Measured
- Lung function and arterial blood gases
- Result
- FEV1/FVC increased in both age groups (p<0.05) with no change in %VC; PaO2 rose in both groups and PaCO2 fell in the younger group (p<0.05); effects were clearer in asthma than in emphysema.
- Limitations
- Uncontrolled (two treated age groups); most had asthma; pool exercise, so heat is not isolated; article in Japanese.
[Effects of bathing on lung mechanics in patients with severe COPD].
Nakahiro K et al. Nihon Kokyuki Gakkai Zasshi. 1998. PubMed 9617142
- Who
- 16 patients with severe COPD on home oxygen therapy and 10 healthy subjects (Japan)
- What
- Seated immersion to the navel and to the shoulders in a Japanese-style bath (water temperature not given in the abstract)
- Measured
- Lung volumes and arterial oxygen saturation during bathing
- Result
- Expiratory reserve volume fell (p<0.05) and inspiratory capacity rose with deeper immersion, with smaller changes as obstruction worsened; significant oxygen desaturation occurred with movement during bathing and was reduced after instruction in posture, slow movement and pursed-lip breathing.
- Limitations
- Acute single immersion; small; article in Japanese; figures for desaturation not given in the abstract.
Protocols used in the studies
Waon studies used a 140 F (60 C) far-infrared sauna for 15 minutes followed by 30 minutes of blanket rest, daily or 5 days per week for 4 weeks. The Dutch and Russian studies did not report sauna temperature or session length in their abstracts; the contrast-bath series alternated hot and cold water with temperatures not stated. Cohort exposures were ordinary Finnish sauna sessions per week. The Japanese pool programs used breathing or exercise in 100.4 F (38 C) hot-spring water, 30 minutes a day, 6 days a week for 2 months.
What is still unknown
Randomized trials with exacerbation, dyspnea and exercise outcomes; whether any benefit adds to pulmonary rehabilitation and inhaled therapy; safety in hypoxemic or hypercapnic patients; whether frequent sauna use is associated with COPD incidence independently of socioeconomic status.
Safety
Cautions for sauna in this condition
- Severe COPD with pulmonary hypertension or cor pulmonale warrants cardiopulmonary review before heat exposure; unstable cardiac disease is a contraindication (PMID 11165553).
- Sauna should be avoided during acute respiratory infection, and sympathomimetic drugs may provoke tachycardia and arrhythmias in the sauna (review, PMID 3218895).
- Cold air or cold water after the sauna can trigger bronchospasm in reactive airways (a child with asthma had an attack while using a cold shower, PMID 2281065; cold-shower body cooling lowered FEV1 in asthmatic adults, PMID 653323).
- Patients on supplemental oxygen should keep equipment out of the hot room.
- In severe COPD on home oxygen, immersion in a Japanese-style bath caused significant oxygen desaturation with movement; instruction in posture, slow movement and pursed-lip breathing reduced it (PMID 9617142). Hydrostatic pressure on the chest during deep immersion is an added load that dry sauna does not impose.
- See general-safety.
For clinicians
Suggested rationale
Small studies of far-infrared Waon therapy in COPD (Umehara 2008; Kikuchi 2014) reported improved exercise pulmonary pressures, exercise time and quality-of-life scores over 4 weeks without adverse effects, and a sauna session transiently increased FVC without bronchoconstriction (Cox 1989); no randomized trial has confirmed clinical benefit, and sauna did not improve mucus clearance.
Suggested wording only. The treating clinician decides whether it reflects their clinical judgment for this patient.
Typical ICD-10 codes: J44.9, J44.1. Examples only; the clinician assigns the code.
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