Dysfunctional Breathing

Dysfunctional breathing is an umbrella term for an altered biomechanical pattern of breathing that causes intermittent or chronic respiratory and non-respiratory symptoms in the absence of, or out of proportion to, organic disease. It includes hyperventilation (over breathing), upper chest dominant breathing, periodic deep sighing, thoraco abdominal asynchrony, forced abdominal expiration, and breath holding or irregular patterns.

• Prevalence is about 9 to 10% of the general adult population, about 30% of people with asthma, and a similar proportion of patients with unexplained breathlessness. It affects more women than men (about 2 to 3 times), and mainly adults aged 15 to 55 years, though it also affects adolescents and athletes.
• Mechanisms: abnormal control of ventilation, increased chemoreceptor and cortical drive, anxiety, habit, altered breathing from pain, chronic disease (asthma, chronic rhinosinusitis, reflux), post-viral change, and musculoskeletal factors (poor posture, tight neck, shoulder and chest muscles, a weak diaphragm).
• Triggers: stress, anxiety, panic, exercise, emotion, pain, respiratory infection (including COVID-19), speech, and certain odours. Risk factors are anxiety, depression, trauma, hypermobility, chronic pain, obesity and asthma.
• The condition frequently coexists with organic disease such as asthma, vocal cord dysfunction, and cardiac conditions, and is often misdiagnosed as asthma, leading to excess use of inhaled corticosteroids and oral steroids.

• Breathlessness at rest or on mild exertion that is out of proportion to examination findings, air hunger (an inability to take a satisfying deep breath), frequent sighing, yawning, a dry cough, throat clearing, chest tightness, chest pain, palpitations, light headedness, tingling of the hands, face and feet, fatigue, poor concentration, sleep disturbance, bloating and belching.
• Symptoms vary from day to day and with emotion or stress, and may be worse at rest than with exercise. Patients may describe good days and bad days, with an inability to breathe deeply, and a feeling of the chest being "stuck."
• Examination: an irregular rate and rhythm of breathing, an upper chest and shoulder movement with minimal abdominal excursion, frequent sighs, mouth breathing, accessory muscle use, and tight neck and shoulder muscles. Oxygen saturation is normal (97 to 100%) and the chest examination is clear. A reversed breathing pattern (the abdomen moving inward on inspiration) may be seen.
• Differential diagnosis: asthma, chronic obstructive pulmonary disease, pulmonary embolism, interstitial lung disease, heart failure, arrhythmia, anaemia, thyroid disease, deconditioning, obesity, vocal cord dysfunction, anxiety and panic disorder, neuromuscular disease, diaphragm weakness, and pulmonary hypertension.
• Red flags: breathlessness at rest with low oxygen saturation, exertional chest pain, syncope, haemoptysis, orthopnoea, leg swelling, clubbing, weight loss, wheeze and abnormal spirometry, abnormal chest X-ray, and symptoms that start after the age of 50 years.
• Complications: reduced exercise tolerance, anxiety and depression, loss of work and social function, repeated emergency attendance, unnecessary medication, and poor asthma control.

• Clinical diagnosis after exclusion of organic disease. Document symptom pattern, triggers, past breathing and psychological history, medicines, and impact.
• Examine breathing pattern at rest and on speaking: observe the chest and abdomen, rate, rhythm, sighing, and accessory muscle use. Palpate the neck, shoulder girdle and chest wall for tension.
• Baseline tests in all patients: pulse oximetry at rest and on exercise, spirometry with bronchodilator reversibility, chest X-ray, electrocardiogram, full blood count, thyroid function tests, glucose, electrolytes, and B-type natriuretic peptide when heart failure is possible.
• Additional tests as indicated: echocardiogram, peak flow diary, fractional exhaled nitric oxide, bronchial challenge, D-dimer or CT pulmonary angiography, lung volumes and diffusing capacity, cardiopulmonary exercise testing (a hyperventilation pattern with low end tidal carbon dioxide, a high ventilatory equivalent for carbon dioxide, and normal cardiovascular and metabolic response), continuous laryngoscopy for exercise related inspiratory noises.
• Use a validated symptom questionnaire for dysfunctional breathing (a score above 23 of 64 suggests the diagnosis) and a hyperventilation provocation test where appropriate, performed safely.
• Screen for anxiety and depression with validated tools.

• Explanation and reassurance: dysfunctional breathing is common, is not dangerous, and responds to retraining. Explain the link between breathing pattern, carbon dioxide, and symptoms, using a clear model.
• Breathing retraining delivered by a respiratory physiotherapist or speech and language therapist (4 to 6 sessions over 6 to 12 weeks, plus daily practice):
  • Diaphragmatic breathing: one hand on the upper chest and one on the abdomen, breathing in through the nose so the abdomen rises (4 seconds), and breathing out slowly through pursed lips (6 seconds), at about 6 breaths per minute, practised for 10 minutes twice daily.
  • Nasal breathing, relaxed shoulders, reduced sighing, and avoidance of mouth breathing and breath holding.
  • Relaxation training, posture correction, and manual therapy for neck, shoulder and chest tension.
  • Breathing control during exertion, talking and stress, and a rescue technique for acute episodes (stop, relax the shoulders, breathe out slowly, and use a controlled nasal rhythm).
  • Graded aerobic exercise to improve fitness (30 minutes, 3 to 5 days per week), which reduces breathlessness.
• Optimise coexisting disease: review the diagnosis and inhaler use in asthma, and step down inhaled corticosteroid doses where there is no evidence of airway inflammation or reversibility. Treat rhinitis (fluticasone propionate nasal spray 50 micrograms per spray, 2 sprays into each nostril once daily), reflux (omeprazole 20 mg daily for 8 weeks), and sleep disorders.
• Psychological therapy: cognitive behavioural therapy for anxiety, panic, and health anxiety, trauma focused therapy for post-traumatic stress, and mindfulness based approaches.
• Medicines (only when psychiatric comorbidity needs them): sertraline 25 mg orally daily for 1 week, then 50 mg daily, up to 100 to 200 mg daily, or escitalopram 5 mg daily, increased to 10 to 20 mg daily. Avoid benzodiazepines in the long term, and avoid inappropriate repeated courses of oral steroids and bronchodilators.
• Acute episode: calm reassurance, coaching of slow nasal breathing, a comfortable position, and no oxygen unless saturation is below 94%.
• Special groups:
  • Children and adolescents: a physiotherapist trained in paediatric breathing disorders, family support, school and sport adjustments, and psychological assessment. Exclude asthma and exercise induced vocal cord dysfunction.
  • Athletes: exercise testing with laryngoscopy, breathing retraining, and communication with the coach.
  • Pregnancy: breathing exercises, reassurance, and exclusion of embolism and anaemia.
  • Elderly: investigate for heart, lung and neuromuscular disease, because dysfunctional breathing is a less common cause of new breathlessness.
  • Post-COVID and post-infectious: breathing retraining is helpful, with gradual activity.
  • Obesity and hypermobility: weight management, posture and core strengthening.
• Follow up: review at 6 to 8 weeks after the start of training, then every 3 to 6 months. Refer to respiratory physiotherapy, a respiratory physician, or a mental health service for persistent symptoms, diagnostic doubt, or complex disease.