Review
Getting to grips with ‘dysfunctional breathing’

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Summary

Dysfunctional breathing (DB) is common, frequently unrecognised and responsible for a substantial burden of morbidity. Previously lack of clarity in the use of the term and the use of multiple terms to describe the same condition has hampered our understanding.

DB can be defined as an alteration in the normal biomechanical patterns of breathing that result in intermittent or chronic symptoms. It can be subdivided into thoracic and extra thoracic forms. Thoracic DB is characterised by breathing patterns involving relatively inefficient, excessive upper chest wall activity with or without accessory muscle activity. This is frequently associated with increased residual volume, frequent sighing and an irregular pattern of respiratory effort. It may be accompanied by true hyperventilation in the minority of subjects. Extra thoracic forms include paradoxical vocal cord dysfunction and the increasingly recognised supra-glottic ‘laryngomalacia’ commonly seen in young sportsmen and women.

While the two forms would appear to be two discreet entities they often share common factors in aetiology and respond to similar interventions. Hence both forms are considered in this review which aims to generate a more coherent approach to understanding, diagnosing and treating these conditions.

Introduction

Dysfunctional breathing is clearly important as demonstrated by its inclusion in the British Thoracic Society/Scottish Intercollegiate Guidelines network (BTS/SIGN) asthma guidelines [1] and the Global Initiative for Asthma (GINA) guideline [2]. Unfortunately, however, neither offers insight into the nature, diagnosis or treatment of the condition. In addition, the importance of dealing with the impacts of dysfunctional breathing was highlighted at the London 2012 Olympic Games, at which Physiotherapists were employed solely to treat athletes with DB [3]. It has also received attention in an increasing number of publications during the past decade, where it has been associated with various specialist areas and in reviews of specific problems such as ‘the breathless athlete’ or ‘pseudo asthma’ [4], [5], [6], [7], [8], [9], [10], [11].

However, ambiguity in the use of the term, and the use of multiple terms to describe the same condition, has hampered our understanding of DB and created difficulties in objectively identifying it. Terms such as dysfunctional breathing [12], [13], [14], [15], [16], hyperventilation syndrome [17], [18], [19], [20], [21], [22], [23], [24], [25], disproportionate breathlessness [24], [26], behavioural breathlessness [27], anxiety related breathlessness [28], sighing dyspnoea [26], [29], psychogenic functional breathing disorders [30] and somatoform respiratory disorders [31] have all been used to describe what appears to be essentially the same problem. Many of the terms imply a significant psychological component, and this perceived link between psychological dysfunction and DB is one of the reasons physicians often avoid this area. Similarly, the relatively well characterised form of DB known as paradoxical vocal cord dysfunction (pVCD) [32], [33], [34], [35], [36], [37] has been labelled factitious asthma, functional stridor, episodic laryngeal dyskinesia, hysterical croup and psychogenic stridor [33].

Consequently, lack of clarity regarding aspects such as aetiology, diagnosis and management means that many clinicians do not have a clear perceptual model on which to diagnose and manage the condition. Failure to diagnose DB not only deprives patients of effective therapy but also places them at risk of adverse events arising from mis-diagnosis.

Section snippets

A new definition for DB

A clear definition of DB is required and we propose it to be defined as:

‘an alteration in the normal biomechanical patterns of breathing that result in intermittent or chronic symptoms which may be respiratory and/or non-respiratory’.

On review of the literature it would appear that the multitude of existing terms are describing, in essence, two forms of DB:

  • Thoracic DB (T-DB) - alterations in the pattern of respiratory muscle activity (pattern disordered breathing), which may or may not be

Pathophysiology of functional DB

It appears that a central component of DB is pattern disordered breathing (PDB), in which the normal relaxed diaphragmatic breathing is replaced by a situation where the respiratory pump is largely being driven by upper chest wall and accessory muscles [15], [18], [39], [40]. This is generally associated with mild hyperinflation, irregular rate and volume of respiration, and frequent sighing, and may be accompanied by an increase in rate (though this may not be dramatic). In some patients the

Diagnosis

Both over- and under-diagnosis are likely and there is the potential for DB to swing from the current position of under-diagnosis to over-diagnosis if the true nature of the condition is not understood. It is important to be clear about an individual's particular problem if the appropriate therapy is to be offered, and a simple referral to the physiotherapist or speech therapist should not be seen as the ‘easy option’.

Thoracic dysfunctional breathing

The lack of tools to objectively quantify the pattern of breathing has

Co-morbidities and differential diagnosis

It is important to recognise that dysfunctional breathing is often associated with, and can exacerbate, symptoms of respiratory diseases such as asthma, chronic obstructive pulmonary disease (COPD) and obliterative bronchiolitis, and that introduction of appropriate therapy often produces significant benefits in terms of function and quality of life.

Recent studies using dynamic CT scans have confirmed that pVCD can be present during expiration amongst asthmatic subjects, and can contribute to

Conclusion

The literature reviewed above clearly demonstrates that there is little evidence available to health professionals on how to diagnose and manage dysfunctional breathing in children. The majority of the evidence that is available is drawn from adult studies, and is not necessarily applicable to children. This lack of appropriate evidence is at odds with the level of morbidity observed and the significant impact the condition has on these children and their families.

Educational aims

  • Understand the spectrum and nature of conditions referred to as ‘dysfunctional breathing’

  • Understand the differences between exercised induced asthma and limitation of exercise due to dysfunctional patterns of breathing

  • Be able to describe how a careful history might identify patients in who dysfunctional breathing is probably contributing to symptoms

  • Be able to explain how breathing retraining addresses the functional imitations

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