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Breathing Pattern Disorders
Breathing Pattern Disorders
Background: Breathing pattern disorders (BPDs), historically known as hyperventilation syndrome, are
being increasingly recognized as an entity of their own. Breathing patterns reflect the functioning of the
respiratory system and the biomechanical system as well as the cognitive state.
Clinical relevance: It is essential, therefore, that physiotherapists from all areas of specialty consider the
assessment and treatment of a patients breathing pattern. New literature is emerging which underpins the
relevance of BPD in patients with lung disease, anxiety, and also in the comparatively new area of sport
performance. Physiotherapists are well placed to treat people with disordered breathing because of their
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clinical skills and comprehensive knowledge base. Current treatment is briefly reviewed in this paper, and
trends for future treatment are also addressed.
Conclusion: The potential for improving the patients state, by optimizing their breathing pattern in all their
activities, is an important development in physiotherapy. It is a developing area of knowledge which is
pertinent to physiotherapy practice as it develops in a biopsychosocial model.
Keywords: Breathing dysfunction, Breathing exercises, Breathing pattern disorders, Breathing retraining, Hyperventilation syndrome
medical, biological framework, and subsequently, tasks, e.g. elite athletes and their performance, singers
research has focused on the phenomena of hyperven- and voice production, or the child playing Saturday
tilation, hypocapnia and symptoms.1719 morning sport.
The term hyperventilation was first used by Kerr
et al. 18 and has been frequently used since this time, Mechanisms Underlying Breathing Pattern
and more recently defined as, breathing in excess of Disorders
metabolic demands, resulting in hypocapnia.20,21 The mechanisms underlying disordered breathing
Although the syndrome was given various names, involve physiological, psychological and biomecha-
the term inferred an anxiety state concurrent with nical components, and these cannot be completely
cardiovascular and emotional symptoms, hence separated.27 At a physiological level, hyperventilation
patients were considered neurotic and their condition has been thought to be driven by central and
not appropriate for serious medical consideration.22 peripheral chemoreceptors, and cortical drive.19,31,32
More recent psychology literature, however, focuses Physiologically every cell in the body requires oxygen
on the symptoms relating to a broad range of to survive yet the bodys need to rid itself of carbon
psychological influences on breathing, including dioxide is the most important stimulus for breathing
anticipation, suppressed emotion, association and in a healthy person. CO2 is the most potent chemical
conditioned responses.23,24 Another recent develop- affecting respiration.33
Hyperventilation results in altered (CO2) levels,
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plays a major factor in panic attacks. Anxiety is the Breathing patterns and the musculo-skeletal
commonest factor thought to influence breathing, implications
and it has been noted to cause increased inspiratory If breathing is not normalized no other movement
flow rate, breathing to become faster and shallower, pattern can be.54,55
and/or involve breath holding.23,42 Subjects with Respiration and stability
BPD have been observed to have higher anxiety Respiratory mechanics play a key role in both
levels than the normal population.43 Tasks involving posture and spinal stability. Research by Hodges
prolonged or intense concentration have also been et al.5658 examines the relationship between trunk
shown to alter breathing patterns.44 stability and low back pain. It supports the vital role
the diaphragm plays with respect to truck stability
Aetiological Factors in Breathing Pattern
Disorders and locomotor control. The diaphragm has the
There is an extensive, perhaps exhaustive list of ability to perform the dual role of respiration and
factors thought to trigger disordered breathing. The postural stability. When all systems are challenged,
broad range of triggers is due to both the variable however, breathing will remain as the final driving
nature of BPD, and the variation in an individuals force.59
response to environmental and psychological factors. In other words Breathing always wins.60
Factors that initially cause a BPD may be different Respiration is integral to movement as well as
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from the factors that perpetuate it.38 Once a pattern is stability.56,57 The diaphragm, transversus abdominus,
established, however,21,45 the breathing pattern dis- multifidius and the pelvic floor muscles work in
order becomes habituated, and thus a disorder of its
own.19
Table 1 Aetiological factors in breathing pattern
Table 1 shows a list produced from a range of disorders
sources.8,1821,23,32,38,4649
Biomechanical factors
Postural maladaptations
Common Symptoms of Breathing Pattern Upper limb movement
Chronic mouth breathing
Disorders Cultural, for example, tummy in, chest out, tight waisted
The symptoms most commonly reported are respira- clothing
tory. These include dyspnoea, frequent yawning and Congenital
Overuse, misuse or abuse of musculo-skeletal system
sighing, unable to get a deep enough breath, and air Abnormal movement patterns
hunger.50 The irregularity of the breathing pattern is Braced posture, for example, post-operative
a common feature, and ironically breathing may Occupational, for example, divers, singers, swimmers,
dancers, musicians, equestrians
appear normal at times, which makes diagnosis and
observation difficult.51 Other common symptoms are Physiological/biochemical factors
Lung disease
dizziness, chest pain, altered vision, feelings of Metabolic disorders
depersonalization and panic attacks, nausea and Allergies post-nasal drip, rhinitis, sinusitis
reflux, general fatigue and difficulty concentrating. Diet
Exaggerated response to decreased CO2
A large range of neurological, psychological, gastro- Drugs, including recreational drugs, caffeine, aspirin, alcohol
intestinal and musculoskeletal changes can occur, Hormonal, including progesterone
Exercise
and over 30 possible symptoms have been Speech/laughter
described.52 Assessment of BPD needs to consider Chronic low grade fever
this range of manifestations. Heat
Humidity/heat
Altitude
Breathing Patterns
Faulty breathing patterns present differently, depend- Psychological factors
Anxiety
ing on the individual. Some patients are more Stress
inclined to mental distress, fear, anxiety and co- Panic disorders
existing loss of self-confidence. Others may exhibit Personality traits, including perfectionist, high achiever,
obsessive
musculoskeletal and more physical symptoms such as Suppressed emotions, for example anger
neck and shoulder problems, chronic pain and Conditioning/learnt response
Action projection/anticipation
fatigue. Many are a combination of both mental History of abuse
and physical factors.53 The key focus of this paper is Mental tasks involving sustained concentration
the musculo-skeletal aspect of BPD. Lung disease Sustained boredom
Pain
and anxiety will be covered, but to a lesser degree as Depression
these have been covered in previous physiotherapy Phobic avoidance
Fear of symptoms/misattribution of symptoms
literature reviews.
unison to establish intra-abdominal pressure. All in residual air adding to the volume of the next
structures add to stability and allow efficient respira- inhalation with eventual over-inflation of the
tion, movement and continence control. Should there lungs. Airflow can become limited and the amount
be a deviation away from a normal recruitment of O2 reaching the alveoli decreases as dead
pattern, then pressure, ventilation volumes and space volume increases. Inefficient ventilation
ultimately work of breathing is affected.59 Research and dyspnoea are the end result.65 The suppor-
by OSullivan60 and Falla et al.61 further supports ting musculature also work in less than optimal
Chaitows8 claims with respect to position/postures positions.
and activation of muscle groups. The concept of addressing dynamic hyperinflation
When considering total body pressure control, the is not new in the physiotherapy literature: this has
vocal folds and the surrounding musculature control been identified and clearly addressed regarding the
the top of the system, the diaphragm which sits in the asthma patient. The idea of decreasing the dynamic
middle plays a key role in pressure generation, and hyperinflation of the rib cage is based on the
the pelvic muscle group support at the base.62 The assumption that this intervention will decrease the
primary purpose of the human larynx is to function elastic work of breathing and allow the inspiratory
as an exchange valve, controlling the flow of air in muscles to work over a more advantageous part of
and out of the lungs.63 This system adds to not only their lengthtension relationship. There are several
to structural support but also contributes to motility treatment strategies that aim to reduce chest wall
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of fluid based systems within the body, i.e. gastro- hyperinflation.5 Similar strategies could be consid-
intestinal, lymphatic drainage, arterial and venous ered when treating dynamic inflation with no organic
circulation. It also creates phonation and voice lung disorder present.
production.64 When a system is under load respira-
Motor pattern changes
tion will dominate at the expense of voice and
Dynamic hyperinflation can result due to habitual
locomotion and postural control.
motor patterns; e.g. increased resting tone of the
It is important to consider how these diverse
abdominal muscles in particular the oblique muscles
functions are inter-related and can be co-ordinated
at rest. This can have a corset effect preventing
into physiotherapy treatment regimes, for example,
diaphragm distension, resulting in the breathing
treatment regimes utilizing all systems, breath, move-
pattern changing to one of upper chest (apical); this
ment and voice.
leads to over use of the respiratory accessory muscles,
Lengthtension relationship pectoralis minor tightens lifting the chest apically,
Pressure determines the lengthtension relationship. their action opposed by the trapezii muscles which
If a BPD is present respiratory accessory muscles work harder.68 Forward head posture occurs, and
shorten, and the diaphragm is unable to return to its temporomandibular joint compression may occur,
optimal resting position, thus potentially contribut- and potentially mouth breathing.69 The tension
ing to dynamic hyperinflation, causing pressure relationship is altered, and consequently the dia-
changes and further compounding the disorder. Not phragm cannot return to optimal resting point, so
only is accessory muscle load increased, but the dynamic hyperinflation occurs. At rest the work
muscles are also working from a shortened disad- of breathing has exceeded the normal values.
vantaged position. Shortened muscles create less Unbeknown to the fashion conscious or fab ab
force, hence the muscle length tension relationship seeker, there is a host of serious physiological and
is altered.65 Patients with neck pain commonly have mechanical, as well as psychological changes taking
faulty breathing patterns.66 place. This process challenges the deep motor
It is advantageous to keep this in mind, musculo- patterns that control trunk stability. The expiratory
skeletal techniques will not address an altered length reserve volume is increased where tidal volume may
tension ratio unless the driving BPD is addressed. It is remain the same but inspiratory reserve volume
also important to note that sustained muscular decreases, suggesting a dynamic hyperinflated pat-
contraction may occlude local vasculature, momen- tern. If hypocapnia is present, this can further alter
tarily impeding blood flow to activated muscle; this the resting muscle tone and ultimately motor pattern
can lead to trigger point development in these changes via the increased excitability in the nervous
muscles.67 system and muscular system.7073
who have focused on ventilation and the delivery ability to maintain pulmonary ventilation, proper
of oxygen. Research is now beyond the capacity of regulation of arterial blood gases and pH and overall
ventilation and starting to look at the muscles of homeostasis.
respiration and breathing patterns.11 The fundamen- Harms et al.74 identified that the work of breathing
tal goal of our system is the protection of oxygen during maximal exercise resulted in marked changes
delivery to the respiratory muscles, thus ensuring the in locomotor muscle blood flow, cardiac output and
both whole-body and active limb O2 uptake. They studies retrospectively assessing for asthma show a
identified the compromised locomotor blood flow higher correlation.
was associated with noradrenaline (norepinephrine)
suggesting enhanced sympathetic vasoconstriction. BPD, asthma and exercise
This concept has been referred to as blood stealing, a Exercise is commonly thought to be a trigger for
novel idea that literally the muscles of respiration asthma, and whilst it is true for some, for others the
steal O2 rich blood from the lower limbs. Further anxiety-inducing breathlessness they attribute to
work by Sheel75 and St Croix76 provide evidence for asthma may be due to hyperinflation and excessive
the existence of a metaboreflex, with its origin in the respiratory effect due to faulty breathing patterns.
respiratory muscles. They believe this reflex can Kinnula and Sovijarvi84 using cycle ergometry, noted
modulate limb perfusion via stimulation of sympa- consistent hyperventilation in all the female asth-
thetic nervous system vasoconstrictor neurones. matics, despite no evidence of bronchospasm at one
minute after exercise or differences in exercise
Breathing pattern retraining capacity. The findings are similar to a study by
Vickery11 conducted ground breaking research asses- Hammo and Wienburger85 which assessed 32 patients
sing the effect of breathing pattern retraining on diagnosed with exercise-induced asthma, for hyper-
performance in competitive cyclists. Results sup- ventilation. Of the 21 patients who experienced
ported that four weeks of specific breathing pattern asthma symptoms, 11 had no significant decrease in
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retraining enhanced endurance performance and FEV1, but demonstrated the lowest PETCO2, sug-
incremental peak power and positively affected gesting hyperventilation, rather than asthma, was
breathing pattern and perceived exertion. It appears responsible for their symptoms. Hibbit and Pilsbury86
that our system has the potential to become sensitized observed their asthmatic subject began hyperventilat-
in its protective role and fire too early resulting in ing prior to exercise, with slightly lowered peak flow
premature dyspnoea. Perhaps this is the phenomenon (470 L min21 versus 500660 expected norm). A
that is occurring in some cases of exercise induced marked decrease in PCO2 occurred during exercise
bronchospasm? and following exercise peak flow dropped to
Exercise-induced bronchoconstriction has a high 385 L min21, with the subject feeling anxious and
prevalence in athletes and in particular elite athletes, distressed. After two months of breathing retraining
predominately affecting endurance athletes, winter and increased physical activities, the exercise test was
athletes and swimmers.77 However, exercise-induced repeated, with the same initial peak flow, but with
bronchoconstriction also occurs in up to 10% of considerably less PCO2 changes during exercise, no
subjects who are not known to be atopic or decrease in PEFR afterwards, and no need for
asthmatic.78 treatment.
A Cochrane review by Holloway and Ram87
Breathing Pattern Disorders and Lung Disease reported a trend for improvement in asthma symp-
Breathing pattern disorders and asthma toms after breathing retraining. More consistent
The altered breathing pattern that occurs with acute improvements related to quality of life markers
asthma is similar to the hyperinflated, rapid upper rather than changes in lung physiology.10,88 The
chest, shallow pattern common in BPD, and there- authors87 conclude that it is the lack of consistent,
fore it appears reasonable that chronic asthma may robust data with a clear description of the retraining
contribute to a habitual disordered breathing pattern, method that limits the conclusions that can be made,
as well as a habitual poor breathing pattern exacer- rather than necessarily the effectiveness of the
bating the symptoms of asthma.52,79 Thomas et al.80 breathing retraining itself.
noted an incidence of hyperventilation of 29% in a People with chronic asthma may also have lower
sample of 219 known asthmatics in their clinic. resting PeCO2 making them more vulnerable to the
Martinez-Moragon et al. 81 similarly observed 36% sympathetic arousal hypocapnia can induce which
(n517/157) of asthmatics at a pulmonary outpatient they will feel as anxiety.82,89
clinic had a BPD. A higher correlation is seen in
studies assessing patients with known hyperventila- Breathing pattern disorders, anxiety and COPD
tion. Saisch et al.82 noted asthma was certain or A review by Brenes90 indicates a higher rate of
probable in 78% (17) of patients attending an anxiety in people with COPD than the general
emergency department with acute hyperventilation, population. Other studies have linked anxiety in this
including asymptomatic asthma. Similarly, Demeter population to negative quality of life status and lower
and Cordasco83 recorded 80% (38/47) of patients with functional status.91,92 Supporting this, Livermore
hyperventilation, at a private pulmonary clinic, also et al.93 observed a correlation between higher anxiety
had asthma. More accurate assessment and including in COPD patients and lower threshold for perceived
mild/asymptomatic asthma is the likely reason the dyspnoea when breathing against a set resistance
CliftonSmith, they have produced dynamic breathing and improve function, whether it is for activities of
for asthma,121 and breathe stretch and move.122 All daily living or high performance sport.131134
these books place emphasis on self-management. Massery has successfully incorporated breathing,
respiratory control and re-education into rehabilita-
Breathing retraining tion covering many neurological conditions such as
The terms breathing exercises, breathing retraining cerebral palsy, complex paediatric cases, spinal cord
and breathing pattern training are used interchange- injuries, as well as respiratory and bio-mechanical
ably in the physiotherapy literature. There is varia- disorders. Massery utilizes a multi-system approach
tion, even within the physiotherapy discipline, of with breathing/respiration as an integral part. Mas-
what parameters of normal breathing are. Cluff105 sery remains adamant breathing is the first step of
states the rate should be 812 average sized breaths all rehabilitation.135 Massery incorporates breath
per minute at rest, with gentle, silent, rhythmical and movement into her treatment regimes at all
diaphragmatic (tummy) breathing, with little upper levels of functioning and views breathing retraining
chest movement. West123 reports breathing rate for and postural control strategies as simultaneous
an adult at rest is 1014 breaths per minute. interventions. Motor impairments are never just
The treatment of BPD is under recognized. a musculoskeletal problem or just a neuromotor
Guidelines for the physiotherapy management of problem. We are born with systems that interact
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the adult, medical, spontaneously breathing patient to give us the control we need for health and
have been recently published.124 These guidelines participation.136
represent an extensive amount of work collating and An extensive list of Mary Masserys publica-
analyzing research to support current physiothera- tions can be viewed: http://www.masserypt.com/html/
peutic management in the area of cardiorespi- pub.html137
ratory, neuromuscular diseases and musculoskeletal.
Breathing pattern disorders were not mentioned Research addressing treatment efficacy for BPD
during the review, except used in the context as a The variability of treatment regimes and poor des-
historical reference when referring to the treatment cription of the regime details have made it difficult to
by physiotherapists in the management of disordered gain a cohesive understanding of what the research to
breathing.125,126 Breathing retraining was only used date has shown. Despite this variation, the authors
in reference to asthma and secondary disordered report improvements are achieved, suggesting key
breathing. elements are covered within the treatment pro-
The BradCliff MethodH looks at breathing dys- gramme.138,139 The Papworth method has shown
function as an indicator of physiological and mechan- favourable outcomes, significantly reducing respira-
ical imbalances and psychological stress in the human tory symptoms and improving health-related quality
body. It is structured on current physiotherapy of life in a group of patients with asthma.140,141
research assessing and treating individuals from Other papers from the UK also support breathing re-
children with asthma to elite athletes.127 education/training within physiotherapy practice.142,143
We are now able to have a better informed Singh144 reviewed the literature with respect to
approach however, no longer assuming an adequate physiotherapy treatment and hyperventilation. The
breathing pattern at rest is necessarily an optimal review concluded that the definition and diagnosis of
breathing pattern for all the activities our client is hyperventilation is difficult; however, once identified
involved with. Diaphragmatic breathing remains the physiotherapy intervention can provide an effective
foundation of our treatment, but it is no longer the intervention to significantly reduce the symptoms and
only aspect of our treatment. improve quality of life. The query over diagnosis was
the hyperventilation versus breathing pattern disor-
Musculo-skeletal component der debate. It has been shown clearly in studies that
Musculo-skeletal issues are addressed which are breathing retraining has a positive effect on improv-
impeding an effective breathing pattern. Alongside ing symptoms where the subject does not exhibit low
the mechanical validation of respiratory muscle levels of CO2highlighting that not only do we see
contribution to motor control, research into the people with chronic hyperventilation (lowered CO2)
training of respiratory muscle strength has gained but perhaps a bigger group who present with
momentum,128,129 Much of the research was initially symptoms due to mechanisms directly related to
surrounding dyspnoea and organic respiratory dis- other pathways.145
orders and it is well established that the respiratory A 2004 Cochrane review of breathing exercises
muscles could be strengthened.130 There is evidence for asthma concluded that, due to the diversity of
supporting the role of inspiratory muscle trainers to breathing exercises and outcomes used, it was
strengthen the inspiratory muscles, to reduce dyspnoea impossible to draw conclusions from the available
cyclists. They suggested breathing pattern can be As a profession our diversity is an asset. The key
retrained to exhibit a controlled pattern, without a points of breathing pattern disorders are common to
tachypnoeic shift (increased respiratory rate leading whomever we treat. Our expertise is in our unique
potentially to breath stacking and an irregular assessment and treatment skills, which enable us to
pattern that may impair alveolar ventilation) during develop specific programmes relevant to the indivi-
high intensity cycling. Results also showed that dual cases whether it is the child with asthma or the
respiratory and peripheral perceived effort was elite athlete. The diversity of our profession enables
diminished. This research could open avenues of us to approach breathing pattern disorders from
practice not yet proven before within the field of different perspectives, yet allows us a cohesive
sports physiotherapy, emphasizing the importance of informed approach, as physiotherapy aims to treat
breathing patterns and ultimate performance. the whole person not just the system.
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