The Management of Breathing Pattern Disorders

Introduction

Dysfunctional breathing (DB) is defined as chronic or recurrent changes in the breathing pattern that cause respiratory and non-respiratory complaints.[1] For a discussion of the aetiology of breathing pattern disorders and assessment techniques, please click here.

Management

When managing breathing pattern disorders, it is important to consider factors that may have initially triggered the BPD or that could cause future events.[2] These causative factors need to be addressed if we are to successfully rehabilitate the habitual dysfunctional breathing pattern.[3]

Education

Education about the pathophysiology of BPD/HVS is key and should be the initial step of any management plan. Important points to cover include:

  • the effects of abnormal versus diaphragmatic breathing
  • reassurance that symptoms have a physiological basis and are treatable[2]

Manual Therapy Techniques

Many patients who have BPDs have co-existing musculoskeletal concerns, particularly back and neck pain.[4] Manual techniques on their own will not be sufficient to address changes in length/tension; the BPD needs to also be addressed.[2] However, manual techniques can still be beneficial.[3]

The choice of technique will depend on assessment findings, but there are several techniques that can be used to help address issues such as increased tone or activity, elevated and depressed ribs and alterations in the mobility of thoracic articulations. These include thoracic mobilisations, stretches, muscle energy techniques (MET), positional release, trigger point release and integrated neuromuscular inhibition techniques.[3]

Breathing Retraining

When retraining breathing, there are four principles to consider:[3]

  1. Becoming aware of faulty breathing patterns
  2. Being able to relax the jaw, upper chest, shoulders and accessory muscles
  3. Re-education on abdominal/low-chest nose breathing pattern
  4. Being aware of normal breathing rates and rhythms at rest, as well as during speech and activity[3]

It is important to note that a patient may report transient discomfort or air hunger when beginning breathing re-education. Using pulse oximetry at various stages during the treatment can help to reinforce to patients that their SpO2 remains at a normal level.[3]

Pursed lip breathing has been shown to relieve dyspnoea, slow respiratory rate, increase tidal volume, and restore diaphragmatic function. It can be a useful starting point when retraining breathing.[5] It is essentially an eccentric exercise for the diaphragm and will slow down exhalation, which is key in breathing retraining.[5] To teach this technique:

  • Ask your patients to imagine blowing out a candle
  • They should exhale until they feel the first sign that they need to breathe in.
  • Advise them to close their lips and pause for one count.
  • They then take a breath in through their nose.
  • Patients should be advised to only exhale as long as they can tolerate. The exhalation time should gradually increase.
  • As patients become familiar with the pattern, ask them to count for the exhale (100, 200, 300 etc), pause for 1 and then breath in. Ultimately the exhalation:inhalation ratio should be 2:1[5]

Encourage your clients to practice 2 x per day for approximately 5 minutes. This will retrain their ability to tolerate higher levels of CO2.

Ideas to reduce the activity of the upper chest muscles:

  1. Sit in an armchair. Rest arms on armrests. During inhalation, lightly press down on arms (minimal force to be applied).
  2. Figure 1.
    Interlock hands with palms facing upwards. On the inhalation, push finger pads together (see figure 1)
  3. Interlock the fingers behind the head in supine (ie beach pose)
  4. Figure 2.
    Sit forward on a chair and let arms drop so palms are facing forward. On the inhalation, turn the palms out (see figure 2)
  5. Figure 3.
    Stand with hands in front of the body. Grasp wrist with other hand and pull very lightly on the wrist[5] (see figure 3)

Aim to do 30-40 cycles (approx 3-4 minutes) in order to slowly habituate the body to a higher level of CO2.[5]

Remind client to test their CO2 tolerance, by doing a breath-hold after exhalation. Their time should slowly increase to around 25 seconds.[5]

Speech

Because speech affects breathing rhythm, coordinating speech and breathing can be problematic for patients with HVS/BPDs Patients with speech problems tend to fall into one or more of the following categories:[3]

  1. Patients who are required to speak a lot at work. They often report:
  • problems with breath control and vocal tone
  • loss of confidence/performance anxiety

2. Mouth breathers with chronic sinus problems/postnasal drip. They present with:

  • cough, throat dryness, soreness

3. Patients with anxiety/stress/depressive disorders with increased sympathetic arousal, upper thoracic tension and sighing respirations. The present with:

  • excessive jaw/throat tightness/pain
  • often speak in a monotone.

4. Patients with a history of hiatus hernia or gastro-oesophageal reflux disease. They often complain of:

  • irritated throat
  • chronic throat clearing
  • shoulder tension
  • vocal fold impairment.

Because of frequent abdominal pain, they adopt upper chest breathing; abdominal bracing results in ineffective breath control when speaking.[3]

Speech should be assessed in sitting/standing once an abdominal breathing pattern is re-established. A simple assessment method is to ask the patient to read a simple text or say at the alphabet.[3]

To correct speech, consider the following steps:

  • Relaxed breath out before speaking
  • Breathe in softly through the nose to start
  • Light, low chest mouth-breaths between sentences
  • Speak slowly

Any ongoing issues should be referred onto speech therapist.[3]

Exercise

Our ability to exercise depends on the capacity of our cardiovascular and respiratory systems to deliver oxygen to the tissues and remove excess carbon dioxide and metabolites.[3]

At rest, the normal oxygen cost of breathing is less than 2% of resting oxygen consumption. During episodes of hyperventilation, this can increase to 30% of total consumption. Thus, patients who have chronic HVS/BPD, may present with limited exercise capacity.[3]

It is essential to consider patient safety before prescribing exercise. It is recommended that physiotherapists discourage fatigued patients from commencing aerobic exercise until they have re-established balanced breathing and improved sleep patterns. When beginning exercise, accumulated exercise times can gradually increase towards a total of 30 mins brisk activity per day, 6-7 times per week.[3]

Complimentary Treatments

Relaxation

It is important to first educate patients about the stress response followed by the relaxation response to help them to learn to identify and switch off anxiety or stress responses. This can be achieved by regular practice of “calm stillness of mind and body”. Low volume, low chest breathing is an essential part of this process.[3]

Nutrition

When patients have a tendency towards HVS, blood sugar levels can exacerbate symptoms when they are on the lower end of the normal range. Thus, nutrition is very important in the treatment of BPDs.[5]

Rest and Sleep

Patients with BPDs often experience erratic sleep patterns and vivid dreaming.[3] Patients who have chronic BPDs with low level or varying CO2 levels commonly report waking at night. This is because, once asleep, CO2 levels start to rise when compared with a patient’s usual daily levels.[3] This stimulates the respiratory centres to increase the respiratory drive in order to reduce CO2 levels back to the patient’s normal daily level.[3] Vivid dreams/nightmares often occur at this time, along with pounding heart. Breathing retraining during the day helps to re-establish higher CO2[3] tolerance by the respiratory centres. It is also important to consider providing education about sleep hygiene.

References

  1. Lum L 1987 Hyperventilation syndromes in medicine and psychiatry: a review. J. R Soc Med. 80:229-231.
  2. 2.0 2.1 2.2 Clifton‐Smith T, Rowley J. Breathing pattern disorders and physiotherapy: inspiration for our profession. Phys Ther Rev. 2011; 16: 75–86.
  3. 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 3.14 3.15 3.16 3.17 Chaitow, L., Bradley, D., and Gilbert, C. Recognizing and Treating Breathing Pattern Disorders. Chaitow, L., Bradley, D., and Gilbert, C. 2014, Elsevier.
  4. McLaughlin L, Goldsmith CH, Coleman K. Breathing evaluation and retraining as an adjunct to manual therapy Man Ther. 2011 Feb;16(1):51-2.
  5. 5.0 5.1 5.2 5.3 5.4 5.5 5.6 Chaitow, L. Dysfunctional Breathing Course Videos. Physioplus 2019. https://members.physio-pedia.com/2014/04/01/breathing-disorders/#resource