Dysfunctional breathing context, causes and contributing-spree cast may 2013
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Dysfunctional breathing context, causes and contributing-spree cast may 2013
- 1. Dysfunctional Breathing -Context, Causes and Contributing Factors Dr. Rosalba Courtney ND, DO, PhD Lecture for Airway and Facial Development Collaborative- May 2013
- 2. Functional Breathing is Adaptive, Appropriate, Responsive Functional breathing is breathing that performs and adapts its various functions to quickly and appropriately meet the changing needs of the individual and changes in the internal and external environment. It adapts appropriately to rest and activity.2Rosalba Courtney 2013
- 3. Functional breathing- efficiently maintains the functions of breathing • Primary – Biochemical- Optimise O2 and CO2, pH regulation and metabolism. – Biomechanical- Optimise neuromuscular respiratory pump. • Secondary – motor control and postural stability – regulation of homeostatic e.g. cardiorespiratory oscillations via cardiopulmonary coupling – regulation of ANS and modulation of vagal activity – self-regulation of stress and emotion. – psycho-spiritual functions 3Rosalba Courtney 2013
- 4. Functional breathing is the most efficient breathing for the conditions 4Rosalba Courtney 2013
- 5. What is Dysfunctional Breathing • Dysfunctional breathing is not adaptive, responsive or appropriate. • Dysfunctional breathing is not the most efficient breathing for the conditions Dysfunctional breathing results in disturbance or inefficiency of the primary or secondary functions of breathing. Dysfunctional Breathing contributes to symptoms and pathology. 5Rosalba Courtney 2013
- 6. Dysfunctional Breathing has several dimensions Biochemical • CO2 • pH • O2 • Hyperventilation Biomechanical • Paradoxical • Thoracic Breathing • Irregular • Inefficient/Weakness, Co- ordination Psycho- physiological • Symptoms • Perception • Stress • Anxiety/Fear • Depression Rhythms and Oscillations Stability Homeostatis Cardiorespiratory Control and Efficiency Autonomic Nervous System Rosalba Courtney 2013 6
- 7. Separate dimensions of DB- overlap but not completely Neuro Muscular- Breathing Pattern and Habits - Biochemical- CO2, O2, pH Breathing Symptoms Psychophysiological- 7Rosalba Courtney 2013
- 8. 8Rosalba Courtney 2013 COURTNEY, R., GREENWOOD, K. & COHEN, M. 2011. Relationships between measures of dysfunctional breathing in a population with concerns about their breathing. Journal of Bodywork and Movement Therapies, 15, 24- 34.
- 9. - target the breathing therapy to the individual. -consider underlying factors and treat causes if possible - consider key aspects of breathing functionality - evaluate and measure progress Rosalba Courtney 2011 To be most effective breathing therapy should focus on the patient, their specific breathing dysfunction and its causes
- 10. Breathing responds to many conditions. Breathing functionality depends on context. BREATHING Psychophysiology Muscular and Skeletal Disease processes Homeostasis 10Rosalba Courtney 2013
- 11. Breathing patterns that seem dysfunctional can be appropriate in certain circumstances. LRC/ABD URC Animation adapted from Lasovetskaya 2008 Relaxed Configuration- Natural at rest, in relaxed state for healthy individual Active Configuration- natural tendency for increased respiratory drive, increased rate or volume of breathing, especially if sudden. 11 Rosalba Courtney 2013
- 12. Thoracic Breathing- URC breathing Dysfunctional when habitual and thoracic dominance persists at rest. i.e. active configuration during relaxation In some cases can preserve diaphragm length and curvature better because maintains abdominal tone. So can be appropriate in some COPD patients etc. 12Rosalba Courtney 2013
- 13. Mouth Breathing – a serious dysfunction with many consequences- structural, postural and health
- 14. Importance of context Mouth breathing in a child with obstructed breathing. Functional?? Dysfunctional ?
- 15. Children with long standing nasal obstruction have significantly lower oxygen. Parameter Normal Control Obstructed- Pre surgery Obstructed- Post surgery Oxygen Saturation (SpO2)- Range 84-94% 87-97% Oxygen Saturation (SpO2)- Mean 96.0% (1.4) 89.4% (3.0) 93.5%(3.0) Arterial Oxygen (PaO2)-Range 57-84mmHg 67-102mmHg Arterial Oxygen (PaO2)-Mean 90.33 (6.85)mmHg 70.93 (6.07)mmHg 87.83 (12.13)mmHg KHALIFA, M. S., KAMEL, R. H., ZIKRY, M. A. & KANDIL, T. M. 1991. Effect of enlarged adenoids on arterial blood gases in children. Journal of Laryngology and Otology, 105, 436-438
- 16. Mouth breathing in a child with obstructed airways Functional-Situation 1 Child closes their mouth and O2 levels drop. However mouth breathing has many negative consequences so new problems arise. Dysfunctional- Situation 2 Child closes their mouth and O2 levels rise.
- 17. Children with long standing nasal obstruction have slightly lower CO2 levels on average (some in hyperventilation range- not always). Parameter Normal Control Obstructed- Pre surgery Obstructed- Post surgery Arterial CO2 (PaCO2)- Range 32-44mmHg 33-44mmHg Arterial CO2 (PaCO2)-Mean 39.17 (1.64) mmHg 38.57 (3.54)mmHg 37.6 (3.14)mmHg KHALIFA, M. S., KAMEL, R. H., ZIKRY, M. A. & KANDIL, T. M. 1991. Effect of enlarged adenoids on arterial blood gases in children. Journal of Laryngology and Otology, 105, 436-438
- 18. Hypoxia usually decreases CO2 tolerance. Hypoxia increases the sensitivity and ventilatory recruitment threshold of the peripheral chemoreflex response to CO2. Hyperventilation to some extent be an adaptive response to hypoxia. This has a cost and negative consequences but loss of this response may also lead to problems. (see following study).
- 19. FREGOSI, R. F., QUAN, S. F., JACKSON, A. C., KAEMINGK, K. L., MORGAN, W. J., GOODWIN, J. L., REEDER, J. C., CABRERA, R. K. & ANTONIO, E. 2004. Ventilatory drive and the apnea-hypopnea index in six-to-twelve year old children. BMC Pulm Med. , 4. High CO2 and low ventilatory drive correlated with more severe sleep apnea Fifty children, 6 to 12 years of age were studied Asleep-Polysomnogram to compute the OAHI. Awake- Measured ventilatory drive – normoxia, isocapnic hypoxia,hyperoxic hypercapnia CONCLUSIONS: In awake children the OAHI correlates inversely with the hypoxic ventilatory drive and positively with the resting PETCO2. Reduced hypoxic ventilatory drive and resting CO2 retention are associated with sleep- disordered breathing in 6-12 year old children .
- 20. Context of hyperventilation and mouth breathing should guide treatment decisions Hyperventilation and Mouth Breathing may be semi- functional adaptations to obstruction and hypoxia. They may be difficult to treat until we raise oxygen levels and increase airway size.
- 21. Maladaptive Respiratory Plasticity as a Cause of Dysfunctional Breathing BAKER, T. L., FULLER, D. D., ZABKA, A. G. & MITCHELL, G. S. 2001. Respiratory plasticity: differential actions of continuous and episodic hypoxia and hypercapnia. Respiratory Physiology, 129, 25-35. Long Term Facilitation (LTF)- alters neuroplasticity of respiratory motor control. Hypoxia Hypercapnia
- 22. Hypoxia, Hypercapnia can also stimulate adaptive changes in neuroplasticity of breathing. • Activate Long Term Facilitation (LTF) – Increase chemosensitivity – Active airway dilator muscles via vagus and hypoglossal nerve. LTF can be adaptive and protective in situations like sleep apnoea or maladaptive if it results in inappropriate breathing.
- 23. Stress and Excess Allostatic Load is an important source of dysfunctional breathing. Modified from McKewen 1998 Perceived Stress-threat, helplessness, vigilance Behavioural Response Physiological Response Individual differences Allostasis Adaptation Allostatic Load Environmental Stressors Major Life Events Trauma Abuse 23Rosalba Courtney 2013
- 24. Dysfunctional breathing evidence of a general instability of the homeostatic brain. Entrophy of Respiration Cardio- respiratory coupling and HRV Balance system abnormalities Respiration, cardiovascular homeostasis are interrelated and disruptions in one often accompanied by others PERNA, G., CALDIROLA, D. & BELLODI, L. 2004. Panic disorder: from respiration to the homeostatic brain. Acta Neuropsychiatrica, 16, 57-67. 24Rosalba Courtney 2013 Hypothesis- Abnormal Function of the Homeostatic Brain
- 25. Babies especially responsive to respiratory neuroplasticity in sensitive development periods -hypoxia -hypercapnia -stress -injury -trauma Altered mature respiratory control Marcus et al. Developmental Aspects of the Upper Airway-Report from an NHLBI Workshop, March 5–6, 2009. Proc Am Thorac Soc. , 15, 6.
- 26. Birth Trauma, structural dysfunction and breathing. “all cases of persistent C0 – C1 compression are accompanied by a dysfunction of the sphenoid-vomer articulation. This pattern in its pure form is mainly inherent to children and is usually connected with a birth trauma” From …… Dr Larissa Lasovetskaya 2008
- 27. Neuro-Muscular Factors associated with dyspnea that also contribute to breathing pattern disorders and mouth breathing
- 28. Symptoms- hyperinflation, short flat diaphragm, rib cage stiffness and neuromechanical uncoupling 28Rosalba Courtney 2013 •High dyspnoea •Unsatisfied respiration •Cant take a deep or satisfying breath •Rib cage cant expand Dysfunctional Breathing •Mouth Breathing •Hyperventilation •Breathing Pattern
- 29. Disproportionate and unexplained nasal obstruction explained by dysfunctional breathing (HV and BPD) BARTLEY, J. 2006. Nasal congestion and HVS. Am J Rhinology, 19, 607-11. 14 patients with unexplained ongoing nasal congestion after surgery and medication. Breathing- 3 patients underwent capnometry and CO2 <35mmHg, all had tachypnoea, upper thoracic bpd , 12 high NQ score,
- 30. Does Hyperventilation contribute to obstruction and mouth breathing? YES • Hyperventilation increases nasal resistance. Dallimore,, 1977Acta Otolaryngol, 84, 416- 421. • Raising CO2 can decrease nasal resistance and treat seasonal rhinitis . Casale, 2008.J Allergy Clin Immunol. 121, 105-109. • There is a linear relationship. Mertz, 1984. Otolaryngol Head Neck Surg., 92, 302-307. Is Hyperventilation primary cause obstruction and mouth breathing? NO • Large amount of epidemiological and experimental evidence showing that the cause of obstructed airways and respiratory allergy is related to recent changes in the environment, diet and state of the modern human microbiome.
- 31. Causes of DB in children-increased nasal resistance and obstruction of upper airway • “mouth breathing happens whenever the body senses that nasal resistance is too high” - Food and airborne allergy -Hypertrophy lymphoid tissue -nasal changes venous engorgement, polyps
- 32. Is Hyperventilation the main cause of allergy, inflammation, asthma, sleep apnea, 150 other diseases .... NO Is Hypocapnia important...YES
- 33. Role of CO2 in the Body CO2 Mild Broncho/Vessel Dilator pH Buffering Activity of Enzymes and Mediators
- 34. Role of CO2 in the Body CO2 Mild Broncho/Vessel Dilator pH Buffering Activity of Enzymes and Mediators A Substrate for the Synthesis of Essential Aminoacids and Enzymes
- 35. Low CO2 - Bronchocontriction - Blood supply to the brain - Blood supply to the tissues Changes in pH Changes in activity of Enzymes Deficit in essential aminoacids, neuromodulators and Neurotransmitters Impairment in Oxygen utilisation Decrease in buffering capacity, wash out essential cations: - Calcium, - Magnesium, - Zinc, - Potassium, - Sodium Overexcitability of Nervous system
- 36. History Of Hyperventilation Syndrome Pre- 1980’s After 1980’s 1990’s NOW HV back on the radar-better diagnostics. Hypocapnia found to moderate symptoms in asthma, panic disorder. HVS not back. Accepted diagnosis patients with anxiety, disturbed breathing and unexplained “psychosomatic” symptoms . Argued to be common, yet infrequently recognized (Lum 1975; Lum 1976; Magarian 1982). Increasing doubts about the specific role of CO2 in symptoms of HVS and HVPT Recommended that the term hyperventilation syndrome be discontinued (Hornsveld 1997) Careers ruined. Scientists would not touch it. Labs stopped researching hypocapnia.
- 37. Hyperventilation Syndrome-Changing Definition 4th International Symposium on Psychophysiology in Southampton in 1984 3rd International Conference of Respiratory Psychophysiology Nijmegen, 1997 • “Hyperventilation syndrome is a syndrome characterized by a variety of somatic symptoms induced by a physiologically inappropriate hyperventilation and usually produced in whole or in part by voluntary hyperventilation” p287, (Howell 1990). • Hyperventilation Syndrome is “ a dysregulation of ventilation, causing hypocapnia, in the absence of somatic causes for hyperventilation, with symptoms not necessarily linked to hypocapnia” p73 (Molema and Folgering 1997).
- 38. There has been a huge increase in allergic, inflammatory and immune diseases in last 50- 60 yrs in developed world. One in three children has allergies. This accounts for about a 400% increase in the last 30-40 years. It is predicted* this will increase to 1 in 2 children by the year 2015. Asthma has increased by about 300% *Global Allergy and Asthma European Network
- 39. Figure 1: Changes in prevalence of diagnosed asthma (A) and asthma symptoms (B) over time among children and young adults. Subbarao P et al. CMAJ 2009;181:E181-E190 ©2009 by Canadian Medical Association Asthma increases are in Developed Countries
- 40. Causes of increased allergy, asthma and immune dysfunction are environmental. • International study of asthma and allergy in childhood (ISAAC) a study of 798,685 childen aged 13-14 years from 97 countries and 388,811 children aged 6-7 yrs from 61 countries. • Conclusion- The major differences between populations due to environmental factors. • ISAAC 1998. Worldwide variations in the prevalence of asthma symptoms: the International Study of Asthma and Allergies in Childhood (ISAAC). European Respiratory Journal, 12, 315-335.
- 41. Differences in Asthma and Allergy Levels between East and West Germany at Time of Re-Unification • Allergy considerably more frequent in West German children than in their peers in East Germany (36.7% versus 18.2%; ) • Asthma and hay fever also significantly higher in West Germany than East Germany (5.9% versus 3.9%). The Berlin Wall -1946-1989 VON MUTIUS, et al 1994. Prevalence of asthma and atopy in two areas of West and East Germany. American Journal of Respiratory and Critical Care Medicine, 149, 358-64.
- 42. Studies point to several environmental factors that influence allergy and asthma • Urban vs Rural Living • Prosperity • Exposure to Animals • Changes in Diet • Microbial Diversity in Water, Food, Air etc.
- 43. MORGAN et al. 2013. Biodiversity and functional genomics in the human microbiome. Trends in Genetics, 26, 51-58.
- 44. Old Friends Theory- Immune dysregulation in modern urban humans related to missing organisms we co-evolved with . . ROOK, G. A. 2007. The hygiene hypothesis and the increasing prevalence of chronic inflammatory disorders. Trans R Soc Trop Med Hyg, 101, 1072-4. The 'Hygiene' or 'Old Friends' hypothesis suggests that increases in chronic inflammatory disorders (allergies, inflammatory bowel disease and autoimmunity) in developed countries are partly attributable to diminishing exposure to organisms that were part of mammalian evolutionary history. Crucial organisms, including helminths and saprophytic mycobacteria, are recognised by the innate immune system as harmless or, in the case of helminths, as organisms that once established must be tolerated. This recognition then triggers development of regulatory dendritic cells that drive regulatory T-cell responses to the 'Old Friends' themselves and to simultaneously processed 'forbidden' target antigens of the chronic inflammatory disorders.
- 45. Many Old Friends Live in our Gut- •Intestinal microflora is major external driving force in the maturation of the immune system . •Prerequisite for development of normal tolerance to allergens. •Microflora differs between healthy and allergic infants. •Microflora differs in countries with high and low prevalence of allergies. Bjorksten “Evidence of probiotics in prevention of allergy and asthma” Curr Drug Targets Inflamm Allergy 2005;4(5):599-604
- 46. Farm milk protects against asthma whether or not you live on a farm In a study of 14,893 children aged 5 to 13, drinking raw milk was the strongest factor in reducing the risk of asthma and allergy, whether the children lived on a farm or not. Inverse Association of farm milk consumption with asthma and allergy, in rural and suburban populations across Europe” 2007 Waser M., Michels et al.Clinical and Experimental Allergy , 2007,37 (5): 661-670 I
- 47. Why ? –Effect of farm milk on gut •Presence of compounds like Lactoferrin boosts immunity •Raw Milk is perfect medium for human probiotic organisms
- 48. The gut, the lungs and the immune system •Gut interacts with intestinal bacteria • Beneficial Bacteria (BB) lead to improved gut barrier and immune stimulation. •Good gut barrier and BB produces tolerance to allergens. •Microbial environment and exposure to BB in infancy affects development of asthma and allergy. Bjorksten B.,“Effects of intestinal microflora and the environment oon the development of asthma and allergy” (2004) Springer Seminars Immunopath. 25(3-4):257-70
- 49. Clinical results improve the closer you are to fundamental causes. Symptoms and Behaviours Growth and Development Microbiome, inflammation, allergy, immune Breathing Dysfunction Structural Changes Social, Environment, Food, Stress
- 50. Thank You Dr. Rosalba Courtney breathandbody@optusnet.com.au www.breathandbody.com.au 61-2-99183460 facebook.com/RosalbaCourtneysBreathAnd BodyHealth
Editor's Notes
- “if we observe successful people we can often see that they display a wonderful flexibility in reacting, in constantly changing from activity to rest. They have flexible breathing or functional breathing” Elsa Gindler
- The term ‘dysfunctional breathing’ (DB) has been used increasingly over the last decade, particularly by those involved in breathing therapies (Thomas 2003; Hagman, Janson et al. 2008; Stanton, Vaughn et al. 2008). Its use has increased after doubts about the presence of hypocapnia in patients with the hyperventilation syndrome made the use of this term unacceptable (Dixhoorn 1997; Hornsveld 1997). At times it seems that the term dysfunctional breathing has been used as a proxy for the term hyperventilation syndrome, given that the main criteria for diagnosing DB has been the Nijmegen Questionnaire (Thomas, McKinley et al. 2001; Thomas, McKinley et al. 2005), a questionnaire that was originally validated for hyperventilation (Dixhoorn and Duivenvoorden 1985). However, at other times the term dysfunctional breathing has been used to refer exclusively to breathing pattern dysfunction (Prys-Picard and Niven 2008) or when unusual and disordered breathing patterns exist in combination with medically unexplained symptoms and anxiety (Hagman, Janson et al. 2008; Stanton, Vaughn et al. 2008).
- Biochemical – relates to levels of O2, Co2, and pH. Most common biochemical dysfunction is hyperventilation but some people also hypoventilate. Biomechanical- relates to breathing pattern dysfunction e.g. thoracic breathing, paradoxical breathing, excessively irregular breathing or where there is weakness and poor co-ordination in patterns of muscle use during breathing. Psychophysiological-
- Breathing is responsive to many factors e.g. psychological, neurological, structural and pathological Breathing that appears dysfunctional may simply be the body’s best attempt at adapting to a particular set of circumstances. To effectively correct any aspect of dysfunctional breathing it is important to take into account the context in which they occur, their causes and contributing factors.
- In a small percentage of these children asking them to close their mouth will reduce oxygen levels. In these children mouth breathing is a ‘somewhat’ functional adaptation to obstructed airways. While we do want to train all children to stop mouth breathing in this particular group it is not the first step. The first step is to somehow increase the size of the airway. In the rest asking them to close their mouth causes O2 levels to rise. In these cases mouth breathing is a dysfunctional adaptation. One of the first priorities in these children is to train them not to mouth breath. In the majority of children asking them to close their mouths, does not create any immediate change in oxygen levels. However because of the many negative effects of mouth breathing ( which I don’t have time to go through in this talk or just a quick slide), we still need to train them not to mouth breathe.
- Maladaptive Respiratory Neuroplasticity.Respiratory plasticity is defined as a persistent change in the neural control system based on prior experience.Plasticity may involve structural and/or functional alterations (most commonly both) and can arise from multiple cellular/synaptic mechanisms at different sites in the respiratory control system. Respiratory plasticity can be induced by hypoxia, hypercapnia, exercise, injury, stress, and pharmacological interventions or conditioning and occurs during development as well as in adults. Hypoxemia and hypercapnia can lead to a habitual change of breathing pattern because of the process know as Long Term Facilitation (LTF), a process in which alters neuroplasticity of respiratory motor control.
- Breathing modulates arousal, restores homeostasis.“The biological purpose of the aroused state is to allow an organism to ‘cope’ physiologically, behaviorally and emotionally with specific environmental demands. Arousal must be followed by a period of relaxation for homeostasis to be restored” (Sterling and Eyer 1988). p94
- Babies especially responsive to respiratory neuroplasticity- Developmental plasticity is induced by experiences (e.g., altered respiratory gases) during sensitive developmental periods, thereby altering mature respiratory control. The same experience later in life has little or no effect. In adults, neuromodulation plays a prominent role in several forms of respiratory plasticity. For example, serotonergic modulation is thought to initiate and/or maintain respiratory plasticity following intermittent hypoxia, repeated hypercapnic exercise, spinal sensory denervation, spinal cord injury, and at least some conditioned reflexes. Some factors that are thought to contribute to maladaptive plasticity include- Intermittent hypoxia, supplemental oxygen, maternal separation, stress, malnutrition (Marcus et al., 2009).Marcus et al. Developmental Aspects of the Upper Airway-Report from an NHLBI Workshop, March 5–6, 2009. Proc Am Thorac Soc. , 15, 6.
- Birth TraumaAccording to Dr. LassissaLasovetskyas of St Petersburg College of Osteopathic Medicine- studies of posture and skeletal motion done on more than 1000 children comparing those with normal and dysfunctional breathing patterns revealed a consistent pattern of C0-C1 dysfunction, sphenoid and vomer fixation. She and her colleagues believe that this pattern in its pure form is mainly inherent to children and is usually connected with a birth trauma. “The first movement performed by the baby during labor is flexion. It is the only kind of engagement, which allows the head to enter the birth canal with its minimal size. But there are occasions, when this kind of engagement does not happen, and instead the head is shifted forward with elements of extension. After birth it will manifest in marked C0 - C1 compression and compensatory hyper-mobility in C1 – C2 segment in flexion”.Dr. Lasovetskaya describing the children with sniffing type breathing “In 100% of cases osteopathic examination demonstrated C0 – C1 compression, absence of nodding movement at this level, translation of the whole segment anteriorly, compensatory hyper-mobility in C1 – C2 segment in flexion. Nearly in half of these children these lesions were combined with intraosseous compression of the occiput”.
- The sensation of dyspnea or breathlessness is strongly influenced by how the brain interprets and responds to the activity of the respiratory muscles, the tension in the chest wall and the shape, length and strength of the diaphragm. Dyspnea increases and reaches distressing levels when the respiratory motor output does not result in the expected response by the respiratory muscles and the chest wall.
- People with this sort of problem can be recognised by disproportionate or unexplained dyspnea, sighing respiration, a vertical breathing pattern, symptoms of “unsatisfied respiration”. “I cannot take a deep or satisfying breath”. “My ribcage feels stuck and cant expand”. They might also continue mouth breathing even though the airways are adequate.
- Abstract:Background: This article evaluates the prevalence of hyperventilation syndrome (HVS) in patients who continue to complain of ongoing nasal congestion, despite an apparently adequate surgical result and appropriate medical management.Methods: Prospective case series of 14 patients from June 2002 to October 2003 was performed. Patients, who presented complaining of nasal congestion after previous nasal surgery and who appeared to have an adequate nasal airway with no evidence of nasal valve collapse, were evaluated for HVS. When appropriate, nasal steroids and oral antihistamines also had been tested without success. Three patients had end-tidal PCO2 levels measured and five patients underwent breathing reeducation.Results: All patients had an elevated respiratory rate (>18 breaths/minute) with an upper thoracic breathing pattern. Twelve of the 14 patients complaining of nasal obstruction had an elevated Nijmegen score indicative of HVS. An average number of 2.5 procedures had been performed on each patient. End-tidal PCO2 levels were ≤35 mmHg in the three patients who had expired PCO2 levels measured. Breathing retraining was successful in correcting the nasal congestion in two of five patients.Conclusion: HVS should be included in the differential diagnosis of patients presenting with nasal congestion, particularly after failed nasal surgery. One possible explanation is increased nasal resistance secondary to low arterial PCO2 levels. Another possible explanation is reduced alaenasae muscle activity secondary to the reduced activity of serotonin-containing raphe neurons. Additional surgery may not necessarily be the answer in HVS patients complaining of nasal congestion.
- Yes. It is a contributing factor. Several studies showing that mouth breathers (those milder obstruction) can tend to lower CO2.Hyperventilation is linearly related to increased nasal resistance so its reasonable to assume it is a contributing factor. Nasal resistance decreases linearly as expired CO2 levels and exercise levels increase, minute ventilation increases linearly as expired CO2 levels and exercise levels increase, and nasal resistance varies inversely with minute ventilation during both hypercapnia and exercise. The constant relationship between nasal resistance and minute ventilation during hypercapnia and exercise suggests that nasal resistance is regulated by the respiratory center to match the level of respiratory demand. (Mertz and McCaffrey, 1984) Raising CO2 can decrease nasal resistance and treat seasonal rhinitis(Casale et al., 2008). Hyperventilation increases nasal resistance (Dallimore and Eccles, 1977)
- Before the 1980s, Hyperventilation Syndrome (HVS) was a generally accepted diagnosis for patients with anxiety, disturbed breathing and unexplained “psychosomatic” symptoms and was argued to be common, yet infrequently recognized (Lum 1975; Lum 1976; Magarian 1982). Since that time the existence of a defined HVS has been increasingly questioned. After the late 1980’s scientists began to increasingly voice doubts about the specific role of CO2 in the symptoms of HVS and the gold standard diagnostic test for HVS, the Hyperventilation Provocation Test (HVPT) (Garssen 1992; Hornsveld and Garssen 1996). While some researchers tried to develop new models that did not entirely dismiss hypocapnia in the pathophysiology of HVS (Hornsveld and Garssen 1996; Howell 1997; Folgering 1999; Wilhelm, Gertivz et al. 2001) others argued that HVS probably did not exist (Hornsveld 1997). In subsequent years, HVS became a controversial diagnosis; researchers tended to avoid it and clinicians struggled to find new names to describe patients with the combination of breathing abnormalities and unexplained symptoms (Hornsveld 1997). In recent years, researchers have begun to reconsider the importance of hyperventilation (Warburton and Jack 2006), and in the field of respiratory psychophysiology there has been a renewal of research interest in the role of hypocapnia in symptom production. This recent work tends to support a moderating role for CO2 in asthma and panic disorder (Howell 1990; Meuret and Ritz 2010).Since the beginning of the nineteenth century it has been known that central and peripheral neurovascular symptoms such as numbness, dizziness, muscle hypertonicity and tingling sensations could be brought on by voluntary forced ventilation (Bass 1989) which produces hypocapnia and respiratory alkalosis (Haldane 1908). The idea of a hyperventilation syndrome, which included these classic symptoms of hypocapnia and additional symptoms such as chest pain, palpitations, breathlessness, disorientation and anxiety, began after Kerr reported his use of the hyperventilation challenge to elicit these complaints in 35 patients whose symptoms were otherwise unexplained (Kerr 1937) (Chaitow 2002). The symptoms of one of the main diagnostic labels which preceded HVS, the “effort syndrome”, were subsequently attributed to hypocapnia and respiratory alkalosis (Soley and Shock 1938). The range of symptoms attributed to HVS eventually came to encompass a large number of symptoms of central and peripheral neurovascular, muscular, respiratory, cardiac, gastrointestinal origin (Soley 1938; Lewis 1953; Magarian 1982). Typical symptoms of HVS are shown in Table 1.
- The definition of Hyperventilation Syndrome (HVS) has changed in the last 20 years as a result of controversy about the relationship of hypocapnia with the large number of symptoms that had over time come to be associated with this syndrome. The definition agreed upon by attendees of the 4th International Symposium on Psychophysiology in Southampton in 1984 is as follows:“Hyperventilation syndrome is a syndrome characterized by a variety of somatic symptoms induced by a physiologically inappropriate hyperventilation and usually produced in whole or in part by voluntary hyperventilation” p287, (Howell 1990). The definition of the HVS, the role of hypocapnia in producing symptoms historically associated with the HVS and the very existence of the HVS itself came to be questioned over the next decade (Gardner 1995). By 1997, it became clear that the definition proposed in Southampton in 1984 was insufficient. A new definition was proposed at the 3rd International Conference of Respiratory Psychophysiology in Nijmegen, The Netherlands. This definition continues to link medically unexplained physical symptoms with dysregulated breathing but decreases the emphasis on the importance of hypocapnia as an etiological factor:Hyperventilation Syndrome is “ a dysregulation of ventilation, causing hypocapnia, in the absence of somatic causes for hyperventilation, with symptoms not necessarily linked to hypocapnia” p73 (Molema and Folgering 1997).Despite this more flexible definition, HVS remains a controversial diagnosis. The following brief review of the history of the Hyperventilation Syndrome is presented to provide a context to understanding the controversies surrounding the Hyperventilation Syndrome.
- It appears that the health issues faced by our children have to do with the social, environmental and dietary changes that have occurred over the last 50 -60 years.