Dysfunctional Breathing

Dysfunctional Breathing Key Points

Chronic changes in breathing pattern

Deviations in normal biomechanical patterns of breathing

Irregular breathing patterns

Estimated Prevalence of DB

10% GP

30% asthma

20-48% in long COVID

50% in COPD

60% difficult to treat asthma

More prevalent in women with higher BMI

Often poorly diagnosed and treated - leads to increased ineffective pharmacological treatments

DB Pathophysiology

Normally diaphragm function replaced by upper chest wall and accessory muscle use

Associated with:

• Mild hyperinflation 

• Irregular respiratory rate and volume 

• Frequent sighing 

• May lead to hypocapnia (hyperventilation)

When do DB symptoms occur? 

When abnormal patterns become habitual or happen intermittently (ie. provoked by stress) (ie. 24/7 or triggered)

Can co-exist with respiratory disease, or stand alone as own disorder 

Potential Causes- Biomechanical Factors

Posture

Mouth breather

Movement patterns

Potential Causes- Psychological Factors

Anxiety 

Stress

Pain

Depression

Potential Causes- Medical Factors

Pulmonary disease

Cardiovascular disease

Chronic rhinitis

Metabolic disorders 

Inducible Laryngeal Obstruction 

Occurs when an event, situation or specific irritant causes laryngeal structures to impede passage of air in/out of trachea

Usually occurs during inspiratory phase of cycle (vocal cords partially or completely adducted during inspiration) 

Could also occur when other forms of supraglottic collapse during inspiration

Signs & Symptoms- Inducible Laryngeal Obstruction

Inspiratory stridor

Dyspnoea

Throat or chest discomfort

Subjective Assessment

HPC

Body chart

Onset - when? (often years)

Investigations

Aggs/Eases

Resp. symptoms

• Cough, SOB, sputum, wheeze, ex tolerance

Nose- easily? Sinus infection history?

Cough - Dry? Productive? Pattern?

Vocal cord/speech (EILO-husky sound)
PHMx

Medications 

Social Hx

• Work, daily routine

• Sleep

• Diet

• Hobbies

• Stimulants 

When to consider DB?

Disproportionate symptoms - are symptoms disproportionately severe in the context of clinical examination, recent radiology and pulmonary function tests

Treatment failure- do asthma treatments fail to control symptoms or make them worse?

Location- does the individual identify that symptoms originate in the throat or upper chest?

Marked alterations to pattern/rate- is there a rapid resting respiratory rate or frequent large sighs?

Noise- does the individual report noisy breathing or stridor when they are symptomatic? Is there noisy breathing at rest or during speech? Is the individuals voice affected?

Concomitant factors- is there evidence of significant stress anxiety or pressure either current or historical particularly around time of onset of symptoms 

EILO- Symptoms

Dyspnoea, wheeze, stridor, cough, throat/chest tightness, dysphnoia 

EILO- Onset

Onset- rapid (within seconds) during peak exercise

EILO- Duration

Duration - regresses within minutes of rest 

EILO- Inhaled Drug Therapy

Inhaled Drug Therapy- largely ineffective, inhaled anti-cholinergic may reduce symptoms 

EILO- Breathing Characteristics

Breathing Characteristics- monophonic inspiratory wheeze, prolonged inspiratory phase

Signs and Symptoms of DB

Headache

Air hunger

Sighing/yawning

Tight chest

Asthma

Panic attacks

Excess wind

Cramps / tremors

Dizziness / fainting

Cough

Dry throat

Palpitations (noticeable heartbeats)

Chest pain

Anxiety

Weakness

Unreal feelings

Pins and needles in fingers and toes

EILO- Regional Limitations

Regional Limitations- upper airways, neck 

EILO- Precipitating Factors

Precipitating Factors- exercise, emotional stress, cold air, strong odours 

EILO

Exercise Induced Laryngeal Obstruction

EIB

Exercise Induced Bronchoconstriction

EIB- Onset

Rapid (within minutes) shortly following the termination of exercise 

EIB- Duration

Resolves typically within 30 minutes

EIB- Inhaled Drug Therapy

Beta-2 agonists usually effective

EIB- Regional Limitations

Lower airways, chest

EIB- Symptoms

Dyspnoea, wheeze, cough, chest tightness

EIB- Precipitating Factors

Exercise, infections, cold air, allergens

Objective Assessment

BPAT

Breath hold test

Nijmegen Questionnaire- recommended patient reported assessment 

As required: spirometry, measures of inflammation, psychosocial assessment, investigation of co-morbidities

BPAT

Assessed for one minute

Patient at rest (have sat still for 5 minutes prior to assessment

Supported sitting - back rest against seat back

Breath hold test

Hold at end of exhalation as long as able (<15 seconds indicative of potential DB)

Nijmegen Questionnaire 

Exercise testing as indicated:

• if symptoms are exercise induced - exercise induced bronchoconstriction test, bronchoprovocation test  (not physio) 

Breathing Pattern Assessment Tool

Abdominal or upper chest movement

Inspiratory flow

Expiratory flow

Channel of breath

Air hunger

Respiratory rate

Rhythm

Score 0, 1, 2

Respiratory Physio Treatment Techniques for DB

Positioning

Resting positions 

Breathing retraining 

Relaxation and decrease anxiety 

Pacing strategies 

IMT 

Exercise training 

Walking aid prescription 

Medical management to treat underlying cause 

Physio Treatment Can Include

Physiotherapy - education and reassurance (conditions, anatomy, physiology, mechanics, goals, differentiate symptoms)

Breathing retraining- nose priority, diaphragmatic breathing, commence crook lying, then minute volume

Posture- cause of poor posture (awareness, stretch/strength)

Activity specific- help patient achieve goals

Other- nasal rinsing, airway clearance, inhaler technique, sleep and relaxation education

Mechanism for improvement

1. Hypoventilation increases PaCO2- acts as bronchodilator

2. Regular tidal breathing with slow inspiration relaxes smooth muscle tone

3. Prolonged expiration reduced hyperinflation

4. Reduce anxiety and depression

5. Reduce medication used by distraction

6. Empowerment of patient