Breathing Pattern Disorder

Breathing is usually thought to be an automatic process and is something we just do. However, just like our movement pattern when walking, we all have our own breathing pattern. Some people have an efficient movement pattern of their breathing muscles and chest wall, which means their breathing does not compromise their ability to complete most activities. However some people have a less efficient movement pattern of their breathing muscles, chest wall and abdomen, which can result in their breathing limiting their ability to complete physical activity and exercise.

Breathing Pattern Disorders (BPD) are also known as Dysfunctional Breathing Patterns. BPD is not well described in the literature but it is thought to include limited movement of chest wall caused by inappropriate activation of respiratory and accessory muscles. This leads to reduced volume of air per breath (tidal volume) and increased breathing frequency. A BPD increases perceptions of breathing effort, tightness around the chest, feelings of not being able to take satisfying breaths and breathing limiting individuals functional capacity  See table 2 below for signs and symptoms of BPD.

Its estimated, 8% of the population have BPD based on elevated Nijmegen questionnaire results (Thomas et al 2005). It is not known how many people with ILO/VCD or exercise induced laryngeal obstruction also have BPD, however it has been reported that BPD coexists on a regular basis in UK based athletes (Hull et al., 2021)

The causes of BPD are multifaceted and will differ between individuals.

There are several different presentations of BPD that may occur. These include:

There is no current gold standard diagnosis and many diagnoses are currently made on an exclusion basis of other conditions. However, there are some methods that can help in obtaining a more specific diagnosis of BPD, which are considered below.

The Nijmegen Questionnaire is primarily designed and validated in a healthy population to help identify individuals with hyperventilation syndrome. It is also used and validated in asthma (Grammatopoulou et al., 2014) However, its sensitivity in asthma has been questioned (Thomas et al., 2015). It has not been validated for exercise and therefore should only be used to asses symptoms at rest rather than specifically related to exercise. The questionnaire scores a range of symptoms from stress, difficulty in breathing and symptoms of hypocapnia. Scores of above 19 are indicative of hyperventilation syndrome. 

The Brompton Breathing Pattern Assessment Tool (BPAT) is a semi-quantitative screening tool designed to assess breathing pattern Initially developed for detecting breathing pattern disorders (BPT) in individuals with asthma, the BPAT involves observing a patient’s breathing for one minute while at rest and objectively scoring seven components of their breathing pattern. The resulting score can be used to identify a breathing pattern disorder (BPD).

The seven components include:

1. Abdominal or upper chest movement
2. Sound with inspiratory flow
3. Sound with expiratory flow
4. Channel of inspiration and expiration
5. Air hunter
6. Respiratory Rate
7. Rhythm 

Features of breathing pattern disorder can also be detected on cardio-pulmonary exercise testing.

Monitoring breathing during exercise is particularly important for individuals suspected of having exercise-induced BPD. Exercise challenges aimed at exploring BPD should mimic real-life scenarios where symptoms occur. A high-intensity repeated sprint protocol has proven effective in assessing an individual’s ability to recover and control breathing between efforts. Specifically, a protocol involving repeated high-intensity efforts lasting approximately 30-60 seconds, with self-selected recovery periods of up to 30 seconds between sprints, has been used to investigate BPD (Dickinson et al., 2007).

When designing the exercise challenge consider when the individual reports their symptoms, what environment triggers their symptoms and the activity the symptoms occur in. Aim to have the athlete complete 5 to 15 repeated efforts (lasting up to 60 seconds for each effort) depending on the fitness level and severity of their symptoms. The intensity of the exercise should  replicate an exercise intensity that the individual reports to trigger their symptoms The challenge only needs to continue until the athlete reports their symptoms are occurring. A familiarisation to the challenge can take place but this is not always possible in an applied setting.

During the challenge record heart rate at the end of each sprint along with the individuals  perception of breathlessness via the modified Borg Scale.  The individual can also wear a pulse oximeter to record peripheral capillary oxygen saturation (SpO2). 

It is best to observe breathing patterns in between exercise efforts and at the termination of the exercise efforts. The practitioner should watch for the degree of lateral movement of the lower rib cage and assess the synchrony between the chest and the abdomen are specific areas to observe. It is best practice to video the athletes breathing pattern. The video footage is best taken directly after the final effort and should be shot whilst the athlete stationary. Take footage from the athlete’s hips to their neck from behind them and from the side. Ten to twenty seconds from each position should be sufficient for analysis. The observations and video can be used to assess the athlete for BPD and are valuable to assist clinical reasoning of a BPD and help devise the athlete’s treatment plan. 

Individuals with BPD are at a greater risk of also experiencing EILO (Hull et al. 2021). The reduced tidal volume and increased breathing frequency from a BPD, leads to increased inspiratory flow rates which can build up and eventually trigger EILO.

Management of BPD needs to consider that the multifaceted causes of BPD. In order to do this the practitioner should review the breathing pattern of the individual and consider the causes. The practitioner can then refer to a breathing pattern ‘tool box’ as below to develop a treatment plan to support the patient to manage and overcome their BPD.

• Dysfunctional Breathing and Severe Asthma
• Physiotherapy for Breathing Pattern Disorders 
• Buteyko Breathing Association 
• Breathing Freely – Developed by an experienced multidisciplinary team at the University of Southhampton for the Breathe study, this freely available online resource provides guidance on breathing retraining for asthma.