Assessment of Breathing Pattern Disorders
Breathing Pattern Disorders (BPD) or Dysfunctional Breathing are abnormal respiratory patterns, specifically related to over-breathing. They range from simple upper chest breathing to, at the extreme end of the scale, hyperventilation (HVS).
Dysfunctional breathing (DB) is defined as chronic or recurrent changes in the breathing pattern that cannot be attributed to a specific medical diagnosis, causing respiratory and non-respiratory complaints. It is not a disease process, but rather alterations in breathing patterns that interfere with normal respiratory processes. BPD can, however, co-exist with diseases such as COPD or heart disease. This page addresses the Assessment of Breathing Pattern Disorders. Read the Physiopedia page on Breathing Pattern Disorders for in-depth knowledge on the anatomy, aetiology, classification, etc.
High scores on the Nijmegen questionnaire have been shown to be both sensitive and specific for detecting people with tendencies consistent with breathing pattern disorders. The sensitivity of the Nijmegen questionnaire in relation to the clinical diagnosis was 91% and the specificity 95%. However, a 2020 study by Pauwen and colleagues found that in a primary care setting, the Nijmegen questionnaire might have lower predictive properties than anticipated. Thus, the authors have suggested that the Hyperventilation Provocation Test is used to confirm a positive Nijmegen.
Assessment of Breathing Patterns
When assessing breathing patterns, it is important to understand what normal breathing looks like. The resting respiratory rate changes throughout the lifespan:
- Babies breathe 35 - 58 times per minute
- Toddlers 15-22 times per minute
- Adolescents 12-16 times per minute
- Once lungs stop growing at around 22 years of age, adults adopt a respiratory rate of 10-14 breaths per minute
At rest, a normal pattern will be nose / abdominal. Exhalation should be slightly longer than inhalation, with an approximate ratio of 1:2 (inhalation to exhalation). There should be a slight pause at the end of exhalation. This pattern is vital to maintain homeostasis and pH.
Important assessment tests include:
- 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 a patient holds less than 15 seconds, it may indicate low tolerance to carbon dioxide.
- Breathing Hi-Low Test - Patient is either seated or supine – Place your hands on the patient’s chest and stomach. Ask the patient to exhale fully and then inhale normally. Observe where the movement initiates and where the most movement occurs. Look specifically for lateral expansion and upward hand pivot.
- Breathing Wave – Patient lies prone. Ask him/her to breathe normally. The spine should move in a wave-like pattern towards the head. Segments that rise as a group may represent thoracic restrictions.
- Seated Lateral Expansion – Place hands on lower thorax and monitor motion while breathing. Looking for symmetrical lateral expansion.
- Manual Assessment of Respiratory Motion (MARM) - Assess and quantify breathing pattern, in particular, the distribution of breathing motion between the upper and lower parts of the rib cage and abdomen under various conditions. It is a manual technique that once acquired is practical, quick and inexpensive.
- Sniff Test - Assesses bilateral diaphragm function. It is useful in assessing for upper or lower chest pattern dominance. The therapist places his/her hand 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. Upper chest breathers usually have no diaphragmatic excursion or they may in-draw their abdominal wall.
- Respiratory Induction Plethysmography (RIP) and Magnetometry: consists of two sinusoid wires coils insulated and placed one around thoracic (placed around the rib cage under the armpits) and the second(placed around the abdomen at the level of the umbilicus). The frequency from these wires coils converted to digital respiration wave form that is an indicator for inspired breath volume.
Assessment of the Musculoskeletal System
- Observe for elevated and depressed ribs and clavicle with rib palpation techniques.
- Check for muscle tone and length especially in the psoas, quadratus lumborum, latissimus dorsi, upper trapezius, scalene, and sternocleidomastoid.
- Assess for alterations in the mobility of the thoracic and rib articulations.
Assessment of Respiratory Function
- Oximetry - to measure oxygen saturation (SpO2)
- Capnography - to measure end-tidal CO2 levels in exhaled air (as described above)
- Peak expiratory flow rate - the highest flow of air out of the lungs from peak inspiration in a fast single forced breath out
- Manual Assessment of Respiratory Motion (MARM)
- Nijmegen Questionnaire
- Rowley Breathing Self-Efficacy Scale (RoBE)
- Self Evaluation of Breathing Questionnaire )SEBQ)
- Hospital Anxiety and Depression Questionnaire (HAD)
BPDs can often mimic more serious conditions such as cardiac, neurological and gastrointestinal conditions. These must all be ruled out by the medical team.
For information on the management of BPDs, click here.
- Lum LC. Hyperventilation syndromes in medicine and psychiatry: a review. Journal of the Royal Society of Medicine. 1987 Apr;80(4):229-31..
- Sueda S et al. 2004 Clinical impact of selective spasm provocation tests Coron Artery Dis 15(8):491–497
- Ajani AE, Yan BP. The mystery of coronary artery spasm. Heart, Lung and circulation. 2007 Feb 1;16(1):10-5.
- Bradley H, Esformes J. Breathing pattern disorders and functional movement. Int J Sports Phys Ther. 2014 Feb;9(1):28-39.
- McLaughlin L. Breathing evaluation and retraining in manual therapy. Journal of Bodywork and Movement Therapies. 2009 Jul 1;13(3):276-82.
- van Dixhoorn J, Duivenvoorden HJ. Efficacy of Nijmegen Questionnaire in recognition of the hyperventilation syndrome. J Psychosom Res. 1985;29(2):199-206.
- Pauwen N, Colot T, Boucharessas F, Sergysels R, Bertuit J, Ninane V et al. Validity of the Nijmegen questionnaire for screening hyperventilation syndrome in primary care. European Respiratory Journal. 2020;56(suppl 64):2697.
- Clifton-Smith T. The Science of Breathing Well Course. Physioplus. 2020.
- Chaitow, L. Dysfunctional Breathing Course Videos. Physioplus 2019. https://members.physio-pedia.com/2014/04/01/breathing-disorders/#resource
- Rosalba Courtney, Jan van Dixhoorn, Marc Cohen; Evaluation of Breathing Pattern: Comparison of a Manual Assessment of Respiratory Motion(MARM) and Respiratory Induction Plethysmography. Appl Psychophysiol Biofeedback (2008) 33:91–100
- UFGATEP2014. DrWest seated lateral rib expansion. Available from: http://www.youtube.com/watch?v=by45ML3QMXA[last accessed 16/4/2020]
- Jade Shaw. Current clinical practices, experiences, and perspectives of healthcare practitioners who attend to dysfunctional breathing: A qualitative studyhttp://unitec.researchbank.ac.nz/bitstream/handle/10652/3589/MOst_Jade%20Shaw.pdf?sequence=1 (Accessed 16th September, 2017)
- Rosalba Courtney, Kenneth Mark Greenwood, Marc Cohen. Relationships between measures of dysfunctional breathing in a population with concerns about their breathing. Journal of Bodywork & Movement Therapies (2011) 15, 24-34
- http://www.svri.org/documents/health-and-well-being (Accessed 16th September, 2017)