physiotherapy treatment of dysfunctional breathing

1. DYSFUNCTIONAL BREATHING
Dr. Deepika Yadav
(MPT Cardiopulmonary)

2. NORMAL BREATHING
Diaphragmatic breathing including synchronized motion of upper rib
cage, lower rib cage, and abdomen which requires proper use of
diaphragm
Pryor JA PSC. Physiotherapy for Respiratory and Cardiac Problems. Edinburgh, UK: Livingstone; 2002

3. DYSFUNCTIONAL BREATHING
Dysfunctional breathing is generally characterized by alteration in the
normal biomechanical patterns of breathing that result in intermittent or
chronic symptoms which may be respiratory or non-respiratory
Vid otto LS, Carvalho CRF, Harvey A, Jones M. Dysfunctional breathing: what do we know?. J Bras Pneumol. 2019;45(1):e20170347. Published 2019 Feb 11. doi:10.1590/1806-3713/e20170347
Boulding R, Stacey R, Niven R, Fowler SJ. Dysfunctional breathing: a review of the literature and proposal for classification. Eur Respir Rev. 2016 Sep;25(141):287-94. doi: 10.1183/16000617.0088-2015.
PMID: 27581828.

4. CLINICAL PRESENTATION
• Dyspnea
• Dizziness
• Generalized fatigue
• Shortness of breath
• Frequent sighing & yawning
• Disturbed sleep
• Air hunger
• Anxiety
• Chest pain
Vidotto LS, Carvalho CRF, Harvey A, Jones M. Dysfunctional breathing: what do we know?. J Bras Pneumol. 2019;45(1):e20170347. Published 2019 Feb 11. doi:10.1590/1806-
3713/e20170347

5. DYSFUNCTIONAL BREATHING CLASSFICATION:
Boulding
• Hyperventilation syndrome
• Periodic deep sighing
• Thoracic dominant breathing
• Forced abdominal expiration
• Thoracic – abdominal asynchrony
Boulding R, Stacey R, Niven R, Fowler SJ. Dysfunctional breathing: a review of the literature and proposal for classification. Eur Respir Rev. 2016 Sep;25(141):287-94. doi:
10.1183/16000617.0088-2015. PMID: 27581828

6. HYPERVENTILATION
Related to respiratory alkalosis or independent hypocapnia
Boulding R, Stacey R, Niven R, Fowler SJ. Dysfunctional breathing: a review of the literature and proposal for classification. Eur Respir Rev. 2016 Sep;25(141):287-94. doi:
10.1183/16000617.0088-2015. PMID: 27581828.

7. Hyperventilation
Hypoxia
Dizziness ,
faintness,
visual
disturbance
Altered state of
consciousness
Numbness
,pins & needle
sensation
Tenseness,
tremors, tetany
Motor and
sensory
hyperirritability

8. PERIODIC DEEP SIGHING
• Usually associated with an
irregular breathing pattern
THORACIC DOMINANT BREATHING
• Can manifest more often in
somatic diseases
Boulding R, Stacey R, Niven R, Fowler SJ. Dysfunctional breathing: a review of the literature and proposal for classification. Eur Respir Rev. 2016 Sep;25(141):287-94. doi: 10.1183/16000617.0088-2015. PMID:
27581828.

9. FORCED ABDOMINAL EXPIRATION
• Evident when there is
inappropriate and excessive
abdominal muscle contraction
during expiration
THORACO- ABDOMINAL ASYNCHRONY
• Characterized by a delay
between intercostal and
abdominal contraction , causing
ineffective respiratory mechanics
Boulding R, Stacey R, Niven R, Fowler SJ. Dysfunctional breathing: a review of the literature and proposal for classification. Eur Respir Rev. 2016 Sep;25(141):287-94. doi: 10.1183/16000617.0088-2015. PMID: 27581828.

10. DYSFUNCTIONAL BREATHING PATTERN

11. Classification : Barker and Everard
• Thoracic Dysfunctional breathing
• Extra thoracic Dysfunctional breathing
Vidotto LS, Carvalho CRF, Harvey A, Jones M. Dysfunctional breathing: what do we know?. J Bras Pneumol. 2019;45(1):e20170347. Published 2019 Feb 11. doi:10.1590/1806-
3713/e20170347

12. PREVELANCE:
• Dysfunctional breathing may affect one in 10 people , most
common in women and in people with asthma
Thomas M, McKinley RK, Freeman E, Foy C, Price D. The prevalence of dysfunctional breathing in adults in the community with and without asthma. Prim Care Respir J. 2005 Apr;14(2):78-82. doi:
10.1016/j.pcrj.2004.10.007. PMID: 16701702; PMCID: PMC6743552.

13. ETIOLOGICAL FACTORS:
Kiesel K, rhodes T, mueller J, waninger A, butler R. Development of a screening protocol to identify individuals with dysfunctional breathing. Int J sports physther. 2017
oct;12(5):774-786. Pubmcid: 29181255; pubmcid: pmc5685417.

14. CliftonSmith, T., & Rowley, J. (2011). Breathing pattern disorders and physiotherapy: inspiration for our profession. Physical Therapy Reviews. https://doi.org/10.1179/1743288X10Y.0000000025

15. CO-EXISTING CONDITION:
Obstructive conditions:
Clifton Smith, T., & Rowley, J. (2011). Breathing pattern disorders and physiotherapy: inspiration for our profession. Physical Therapy Reviews. https://doi.org/10.1179/1743288X10Y.0000000025
Obstructive
condition
COPD
Hyper-inflated
Rapid upper
chest
Asthma
Shallow
breathing
pattern

16. Hodges PW, Gandevia SC. Changes in intra-abdominal pressure during postural and respiratory activation of the human diaphragm. J Appl Physiol (1985). 2000 Sep;89(3):967-76. doi: 10.1152/jappl.2000.89.3.967.
PMID: 10956340.
If imbalance occur
Loss of thoracic
cage compliance
Constant overuse of
accessory
respiratory muscles
Poor diaphragmatic
descend
Muscle pain and
fatigue
Chronic pain

17. Exercise induced bronchoconstriction
Holzer K, Brukner P. Screening of athletes for exercise-induced bronchoconstriction. Clin J Sport Med. 2004 May;14(3):134-8. doi: 10.1097/00042752-200405000-00005. PMID: 15166901.
During exercise
Oxygen demand of the
body increases
Breath rate: faster and
deeper
Inhale through mouth
, causing air to be
dryer and cooler then
nose inhalation
It trigger airways
narrowing
(bronchoconstriction)

18. Vocal cord dysfunction:
CliftonSmith, T., & Rowley, J. (2011). Breathing pattern disorders and physiotherapy: inspiration for our profession. Physical Therapy Reviews. https://doi.org/10.1179/1743288X10Y.0000000025
Vocal fold control upper
body pressure
Larynx primarily function
as an exchange valve ,
controlling the flow of air
in and out of the lung
Not only provide
structural support but
contribute to mobility of
fluid within the body
Also create phonation &
voice production
When this system is
under load
Respiration dominant at
the expense of voice and
locomotion and postural
control

19. Breath Holding – Ask the patient to exhale and then hold his/her breath.
People are usually able to hold their breath for 25 to 30 seconds. If someone
holds less than 15 seconds, it may indicate low tolerance to carbon dioxide.
Manual assessment of respiratory motion: Assess and quantify
breathing pattern, in particular, the distribution of breathing motion
between the upper and lower parts of the rib cage and abdomen.
Courtney R, van Dixhoorn J, Cohen M. Evaluation of breathing pattern: comparison of a Manual Assessment of Respiratory Motion (MARM) and respiratory induction plethysmography. Appl Psychophysiol Biofeedback.
2008 Jun;33(2):91-100. doi: 10.1007/s10484-008-9052-3. E pub 2008 Mar 5. PMID: 18320303.
DIGNOSTIC PROCEDURE:

20. Sniff Test - Assesses bilateral diaphragm function. It is useful in assessing upper
or lower chest pattern dominance. The therapist’s 3 fingers below the patients
xiphoid process & the patient performs a quick sniff. The therapist should feel
an outward movement of the abdominal wall. This indicates that both hemi-
diaphragms are working
Capnography - To measure end-tidal CO2 levels in exhaled air
Hyperventilation provocation test: This test was performed by asking the
patient to voluntarily hyperventilate for 2
or 3 min and was considered positive if
symptoms of hyperventilation were
reproducible
Hornsveld HK, Garssen B, Dop MJ, van Spiegel PI, de Haes JC. Double-blind placebo-controlled study of the hyperventilation provocation test and the validity of the hyperventilation syndrome. Lancet. 1996 Jul
20;348(9021):154-8. doi: 10.1016/s0140-6736(96)02024-7. PMID: 8684155.

21. Nijmegen Questionnaire
A score of over 23 out of 64 suggest a positive diagnosis of
hyperventilation syndrome.
Jan van Dixhorn et al. The Nijmegen Questionnaire and dysfunctional breathing, ERJ 2015

22. Educate the patient:
• Self –observation of breathing pattern
• Restoration to basic physiological breathing pattern: relaxed,
rhythmical nose-abdominal breathing
• Education on the pathophysiology of the disorder
• Appropriate tidal volume
• Education of stress and tension in the body
• Posture
• Breathing with movement and activity
• Clothing awareness
• Breathing and speech
Cluff RA. Chronic hyperventilation and its treatment by physiotherapy: discussion paper. J R Soc Med. 1984 Oct;77(10):855-62. doi: 10.1177/014107688407701011. PMID: 6387113; PMCID: PMC1440257.
PHYSIOTHEARPY MANAGEMENT

23. Breathing Retraining:
• Awareness of faulty breathing patterns
• Re-education on abdominal/low-chest nose breathing pattern. It can
be done by breathing in front of the mirror
• Being aware of normal breathing rate and rhythm at rest, as well as
during speech and activity
Bott J, Blumenthal S, Buxton M, Ellum S, Falconer C, Garrod R, Harvey A, Hughes T, Lincoln M, Mikelsons C, Potter C, Pryor J, Rimington L, Sinfield F, Thompson C, Vaughn P, White J; British Thoracic Society
Physiotherapy Guideline Development Group. Guidelines for the physiotherapy management of the adult, medical, spontaneously breathing patient. Thorax. 2009 May;64 Suppl 1:i1-51. doi: 10.1136/thx.2008.110726.
PMID: 19406863.
• Patient should practice at least twice a day for 20-30 minutes and focus
on his breathing for few minutes each hour in between

24. Relaxation technique:
• Relaxation therapy is based upon yoga techniques and the method
devised by Jacobson
• Coordination of breathing and relaxation
Vidotto LS, Carvalho CRF, Harvey A, Jones M. Dysfunctional breathing: what do we know?. J Bras Pneumol. 2019;45(1):e20170347. Published 2019 Feb 11. doi:10.1590/1806-3713/e20170347

25. •Pursed lip breathing: Pursed lip breathing has been shown to
relieve dyspnea, decreases respiratory rate, increases tidal volume and
restores diaphragmatic functions.
•Diaphragmatic breathing
.
Cluff RA. Chronic Hyperventilation and its Treatment by Physiotherapy: Discussion Paper. Journal of the Royal Society of Medicine. 1984;77(10):855-862. doi:10.1177/01410768840770101

26. Breathing technique:
• Papworth method: patients are taught diaphragmatic breathing
with an emphasis on controlled, slow nasal breathing
Boulding R, Stacey R, Niven R, Fowler SJ. Dysfunctional breathing: a review of the literature and proposal for classification. Eur Respir Rev. 2016 Sep;25(141):287-94. doi: 10.1183/16000617.0088-2015. PMID: 27581828.
• Buteyko technique

27. To reduce upper chest muscle work:
• Sit in an armchair. Rest arms on armrests. During inhalation, lightly
press down on arms (minimal force to be applied).
• Interlock hands with palms facing upwards. On the inhalation, push
finger pads together
• Interlock the fingers behind the head in supine

28. • Sit on a chair and let arms drop so palms are facing forward.
While inspiring, turn the palms out
• Stand by placing hands in front of the body, grasp wrist
with other hand and pull very lightly on the wrist while
inhalation

29. Manual therapy technique:
• Patients with co-existing musculoskeletal concern , particularly neck &
back pain
• Technique include thoracic mobilization , stretches, trigger point release
Speech correction:
• Relaxed breath out before speaking
• Breathe in softly through the nose to start
• Light, low chest mouth-breaths between sentences
• Speak slowly
Romer LM, McConnell AK, Jones DA. Effects of inspiratory muscle training upon recovery time during high intensity, repetitive sprint activity. Int J Sports Med. 2002 Jul;23(5):353-60. doi: 10.1055/s-2002-33143.
PMID: 12165887.

30. TAKE HOME MESSAGE
•Most oftenly Pain and hyperventilation exists
together
•Generally when we assess pain mechanism we do
not focus on respiratory pattern
• Pain could lead to increased respiratory rate
•If breathing pattern is corrected then the prognosis
will be better