Dysfunctional Breathing

Breathing distress (dyspnoea) can be a symptom of several different diseases. However, there are times when a person’s breathing pattern and/or their sensation of breathing difficulty can be the main cause of their breathing distress. This situation is termed ‘Dysfunctional breathing’. There is no universally agreed definition for dysfunctional breathing, as the condition remains poorly characterised.

Suggestions have however been proposed and include:

• Inappropriate breathing which is persistent enough to cause symptoms, with no apparent organic cause (Clifton-Smith et al. 2011).
• Change in the normal biomechanical breathing patterns that result in intermittent or chronic symptoms, which may be both respiratory and non-respiratory. This alteration may be due to structural causes, or much more commonly, be functional ( that is, a disorder of breathing function without an accompanying structural abnormality) (Depiazzi et al. 2016).

Dysfunctional breathing may, and often does, coexist with organic lung disease. Conversely, the lack of an organic lung disease to explain breathlessness does not always imply a diagnosis of dysfunctional breathing. A diagnosis of dysfunctional breathing should be made only after exclusion or adequate treatment of any organic disease (Boulding et al. 2016).

It is particularly challenging to diagnose dysfunctional breathing in the presence of physiological or structural lung disease. In such cases, dysfunctional breathing may be present if the symptoms are disproportionate to the severity of lung disease.

As with the definition, there are also different proposed classifications, with significant overlap between these. Classifications emphasise the alteration of breathing pattern that can occur with dysfunctional breathing. Further research is needed to clarify the optimal classification for clinical use.

1. (Boulding et al. 2016) Dysfunctional breathing with:
   • Hyperventilation syndrome
   • Periodic deep sighing
   • Thoracic dominant breathing
   • Forced abdominal expiration
   • Thoraco-abdominal asynchrony
2. (Lum 1975) Dysfunctional breathing with:
   • Rapid breathing
   • Irregular amplitude of breaths
   • Irregular rhythm
   • Frequent sighs and yawns
   • Habitual sniffing and coughing
   • Fast breathless talking
   • General tension in the whole body

A variety of symptoms have been proposed to indicate dysfunctional breathing. These symptoms can be respiratory, symptoms of neuronal excitability, or symptoms of vasoconstriction.

• Dyspnoea
• Chest tightness
• Chest pain
• Deep sighing
• Exercise-induced dyspnoea
• Frequent yawning
• Hyperventilation

• Paraesthesia (tingling sensation in the fingertips and around the mouth)
• Spontaneous Electromyogram (EMG) activity

• Headache
• Light headedness
• Visual disturbance
• Ataxia
• Tremor
• Tinnitus
• Loss of consciousness
• Increased cardiac output and heart rate
• Chest pain, rarely arrhythmias

*These symptoms occur with hyperventilation

References relating to signs & symptoms: (Saltzman et al. 1963, Rafferty et al. 1992, Gardner 1996, Howell 1997, Folgering 1999, Depiazzi et al. 2016)

The figure ‘Dimensions of Dysfunctional Breathing’ shows the scope of the different changes than can occur with this condition.  The problem is complex, having several different dimensions. It is also heterogeneous, since not all dimensions are present in the same person or in all people at the same time. This complexity poses a challenge for the recognition and management of dysfunctional breathing.

Used with permission of the author Dr Rosalba Courtney.

The prevalence of dysfunctional breathing is uncertain due to lack of a gold standard diagnosis. The following estimates have been reported:

• General practice population: 8% have hyperventilation based on elevated Nijmegen questionnaire results (Thomas et al. 2005).
• Asthma patients: the percentage of patients with comorbid dysfunctional breathing has been estimated between 29%-80% in different studies (Demeter et al. 1986, Saisch et al. 1996, Thomas et al. 2001, Martínez-Moragón et al. 2005, Grammatopoulou et al. 2014).
• Difficult asthma: 20% of patients attending a difficult asthma clinic were found to have dysfunctional breathing as a major factor in their illness (Heaney et al. 2005). In an Australian difficult asthma clinic, the prevalence based on an elevated Nijmegen score was 30% (Radhakrishna et al. 2016). The presence of dysfunctional breathing had not been detected by the treating specialist in the majority of these patients (Radhakrishna et al. 2017).

Diagnosis incorporates clinical history, physical examination with a focus on observing the pattern of breathing and investigations, including exercise testing in some patients.

A common method of assessing dysfunctional breathing includes that administration of the Nijmegen Questionnaire.

• Nijmegen Questionnaire:
  • The questionnaire provides a subjective assessment of “functional respiratory complaints”, which should be complemented with objective assessment (van Dixhoorn et al. 2015).
  • Validated to detect hyperventilation syndrome in a mild-to-moderate asthma population using a modified 11-item questionnaire (Grammatopoulou et al. 2014). Hyperventilation syndrome may be present as one aspect of dysfunctional breathing. This version of the questionnaire has not been validated in children, adolescents or a severe asthma population (Barker et al. 2015).
  • Higher scores found in females, moderate (versus mild) asthma, uncontrolled asthma, breath hold <30s, end-tidal CO₂ <35 mmHg (Grammatopoulou et al. 2014).
  • Clinically a Nijmegen cut-off score of >23 is often used to screen for the presence of hyperventilation syndrome amongst adults (Garssen et al. 1984; van Doorn et al. 1983; Vansteenkiste et al. 1991) Grammatopoulou suggests a cut off of >17 (using an 11-item questionnaire) (Grammatopoulou et al. 2014) and Van Dixhoorn ≥19 (van Dixhoorn et al. 2015).
• Clinical Observations:
  • Respiratory rate
  • Pattern – chest / abdomen ratio (%)
  • Mouth breathing
  • Inspiratory: Expiratory ratio
  • Breathing pattern while performing tasks that produce symptoms e.g. Exercise
  • Posture, rib cage/thoracic spine abnormalities and movement
• Assessments:
  • Breathing pattern assessment tool (BPAT): a semi-quantitative screening tool that collates data obtained from a respiratory physiotherapy assessment, with demonstrated utility in a severe asthma population (Todd et al. 2018).
  • Oximetry: Pulse oximetry saturations (SpO₂) of 100%, that in the correct clinical circumstances may be consistent with hyperventilation. The normal resting SpO₂ (oxygen saturation) levels are between 95% and 98% (West 2000)
  • Reduced end tidal CO₂
  • Breath hold test <30 seconds
  • Spirometry with a full expiratory and inspiratory maneuvere (Boulding et al. 2016)
  • Disproportionate increase in ventilatory response from supine to standing (Malmberg et al. 2000)
  • Arterial blood gas (ABG) measurement and blood electrolytes: For determination of hypocapnia and respiratory alkalosis
  • Optoelectronic plethysmography: Evaluates breathing pattern through external measurement of the chest wall (Parreira et al. 2012)

• Field walking test – standardised to assess exercise capacity, breathing pattern with exertion, and evaluate treatment responses (e.g. 6-Minute Walk Test (6MWT)).
• Cardiopulmonary exercise testing – used to determine exercise-limiting factors and pathophysiologic mechanisms. May help to identify the underlying cause of unexplained dyspnoea after other testing
• Diaphragm screening/SNIFF test with ultrasound – to evaluate for diaphragmatic palsy
• Maximal inspiratory and expiratory pressures – for potential muscle weakness
• Full lung function +/- bronchial provocation test to identify underlying organic cause of dyspnoea
• Echocardiography to identify cardiac dysfunction and screen for pulmonary hypertension
• Chest imaging such as high resolution computed tomography of the chest may be indicated in certain patients based on history or examination findings

Breathing retraining is delivered by a qualified professional such as a respiratory physiotherapist (Weiss 1994, Bruton et al. 2011, Jones et al. 2013, Bruton et al. 2018). The aim is to deliver a multicomponent intervention that focuses on normalising the ventilatory pattern at rest and with activity. Specific techniques include the Papworth and the BradCliff methods. Physiotherapy breathing retraining improved quality of life in patients with incompletely controlled asthma, in a recent RCT with over 600 patients (Bruton et al. 2018). More research is needed, as the evidence base is limited (Jones et al. 2013).

General principles of breathing retraining include educating the patient to:

• Decrease respiratory rate
• Promote complete expiration
• Reduce overall ventilation
• Promote nose breathing
• Establish an abdominal/diaphragm pattern
• Asthma education, and exercise prescription
• Address musculoskeletal causes
• Posture correction, trigger point therapy, massage and mobilisation
• May involve nutritional advice and sleep hygiene advice
• Use biofeedback – capnometry, breathing rate, weight on abdomen, oximetry
• Inspiratory muscle training

The following video provides guidance on breathing re-training to optimise breathing patterns in chronic lung disease. The techniques are adapted from Papworth and BradCliff methods. Specific exercises for individual patients should be prescribed by a respiratory physiotherapist.

Dysfunctional breathing is frequent among patients with asthma and should be considered in those with difficult-to-treat asthma, or whose symptoms are disproportionate to the degree of airflow obstruction.

Dysfunctional breathing is poorly defined, and difficult to diagnose. No consensus classification exists. Diagnosis relies on a high index of suspicion, and clinical assessment by experienced physiotherapists and physicians.  Referral to a specialist centre should be considered if dysfunctional breathing is suspected. Treatment with breathing re-training is often effective.

• Breathing Freely – Developed by an experienced multidisciplinary team at the University of Southhampton for the Breathe study, this freely available online resource provides guidance on breathing retraining for asthma
• Comorbidity Assessment Resources