Breathing Pattern Disorders
Original Editor - Leon Chaitow
Topic Expert - Leon Chaitow
- 1 Introduction
- 2 Clinically Relevant Anatomy
- 3 Epidemiology
- 4 Etiology
- 5 Clinical Presentation
- 6 Diagnostic Procedures
- 7 Outcome Measures
- 8 Management / Interventions
- 9 Differential Diagnosis
- 10 Key Evidence
- 11 Related pages
- 12 Resources
- 13 Read 4 Credit
- 14 References
Breathing Pattern Disorders (BPD) (or Dysfunctional Breathing) are abnormal respiratory patterns in relation to over-breathing which ranges from simple upper chest breathing to, at the extreme end of the scale, hyperventilation. Dysfunctional breathing (DB) is defined as chronic or recurrent changes in breathing pattern that cannot be attributed to a specific medical diagnosis, causing respiratory and non-respiratory complaints. This is not a disease process, simply alterations in breathing patterns that interfere with normal respiratory processes. They can however, co-exist with disease such as COPD or heart disease, and in some cases can mimic cardiac symptoms.
BPDs are whole person problems, especially in long term conditions where dysfunctional breathing can destabilise mind and muscles, mood and metabolism. They can play a part in, for instance, premenstrual syndrome, chronic fatigue, neck, back and pelvic pain, fibromyalgia and some aspects of anxiety and depression.
Clinically Relevant Anatomy
The Human respiratory system is located in the thorax. The thoracic wall consists of skeletal and muscular components, extending between 1st rib superiorly and rib 12th, the costal margin and the xiphoid process inferiorly. The respiratory system can be classified in terms of function and its anatomy. Functionally, it is divided into two zones. The conducting zone, extend from the nose to the bronchioles, serves as a pathway for conduction of inhaled gases while the respiratory zone, is the site for gaseous exchange. It comprises of alveolar duct, alveolar sac and alveoli. Anatomically, it is divided into upper and lower respiratory tract. The upper respiratory tract starts proximally from the nose and ends at the larynx while the lower respiratory tract continue from the trachea to the alveoli distally.
It is often reported that around 10% of patients in a population are diagnosed hyperventilation syndrome. However, far more people have a more subtle, yet likely clinically significant, breathing pattern disorder. Dysfunctional breathing is more prevalent in women (14%) than in men (2%)
Little is known about dysfunctional breathing in children. Preliminary data suggest 5.3% or more of children with asthma have dysfunctional breathing and that, unlike in adults, it is associated with poorer asthma control. It is not known what proportion of the general pediatric population is affected.
Breathing pattern disorders occur when ventilation exceeds metabolic demands, resulting in symptom-producing hemodynamic and chemical changes. Habitual failure to fully exhale - involving an upper chest breathing pattern - may lead to hypocapnia. This involves a deficiency of carbon dioxide in the blood resulting from a breathing pattern disorder, the extreme of which involves hyperventilation. The result is respiratory alkalosis, and eventually hypoxia, or the reduction of oxygen delivery to tissue. 
As well as having a marked effect on the biochemistry of the body BPD can influence emotions, circulation, digestive function as well as musculoskeletal structures involved in the respiratory process. Essentially a sympathetic state and a subtle, yet a fairly constant state of fight-or-flight becomes prevalent. This can lead to changes in anxiety, blood pH, muscle tone, pain threshold, and many central and peripheral nervous system symptoms. So, despite not being a disease, BPDs are capable of producing symptoms that mimic pathological processes. For example, overuse of accessory breathing muscles can lead to neck and shoulder pain/dysfunction. Some even mimic cardiac and gastrointestinal problems.
This diagram (from ) shows the stress-anxiety-breathing flow chart demonstrating multiple possible effects and influences of breathing pattern disorders.
There are a wide variety of symptoms, the most extreme as shown in the diagram below:
Typical symptoms can include:
- Frequent sighing and yawning
- Breathing discomfort
- Disturbed sleep
- Erratic heartbeats
- Feeling anxious and uptight
- Pins and needles
- Upset gut/nausea
- Clammy hands
- Chest Pains
- Shattered confidence
- Tired all the time
- Achy muscles and joints
- Dizzy spells or feeling spaced out
- Irritability or hypervigilance
- Feeling of 'air hunger'
- Breathing discomfort
- There may be a correlation between BPD and low back pain: www.physio-pedia.com/Low_Back_Pain_and_Breathing_Pattern_Disorders
High scores on the Nijmegan 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%
Assessment of breathing patterns
- Breath Holding – People can normally hold their breath between 25 and 30 seconds. If less than 15 seconds may mean low tolerance to carbon dioxide.
- Breathing Hi-Low Test (seated or supine) – Hands on chest and stomach, breathe normal – what moves first? What moves most? Looking for lateral expansion and upward hand pivot.
- Breathing Wave – Lay prone, breathe normal, spine should flex in a wave-like pattern towards 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.
- Respiratory Induction Plethysmography (RIP) and Magnetometry
Assessment of musculoskeletal system
- elevated and depressed ribs and clavicle.
- muscle tone and length especially psoas, QL, latissimus, upper trap, scalene, and SCM.
- alterations in mobility of thoracic and rib articulations.
Assessment of respiratory function
- Oximetry - to measure oxygen saturation (SpO2)
- Capnography - to measure end tidal CO2 levels in exhaled air
- 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) - SEE: www.physio-pedia.com/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)
Management / Interventions
Management commonly requires the removal of causative factors and the rehabilitation of habitual acquired dysfunctional breathing patterns. In order to achieve this most efficiently it may be necessary to restore normal function of the respiratory system such as thoracic mobility and muscle tone and length.
Manual Therapy Techniques
Based on your assessment, there are several manual therapy techniques that can be performed to treat muscles that have increased tone or activity, elevated and depressed ribs and alterations in mobility of thoracic articulations. These techniques include muscle energy techniques (MET), positional release, trigger point release and integrated neuromuscular inhibition techniques.
- Awareness of faulty breathing patterns
- Relaxation of the jaw, upper chest, shoulders and accessory muscles
- Abdominal/low-chest nose breathing pattern re-education
- Awareness of normal breathing rates and rhythms, both at rest, during speech and activity.
- Pursed lip breathing has been shown to relieve dyspnoea, slow respiratory rate, increase tidal volume, and restore diaphragmatic function.
- Dynamic Neuromuscular Stabilisation - to optimise a postural respiratory pattern
- Sleep retraining
BPDs can often mimic more serious conditions such as cardiac, neurological and gastrointestinal conditions which must all be ruled out by the medical team.
- Breathing pattern disorders and functional movement. Bradley H, Dr Esformes J. Int J Sports Phys Ther. 2014 Feb;9(1):28-39.
- Breathing exercises for dysfunctional breathing/hyperventilation syndrome in children. Barker NJ, Jones M, O'Connell NE, Everard ML.
Cochrane Database Syst Rev. 2013 Dec 18;12:CD010376.
- Breathing exercises for dysfunctional breathing/hyperventilation syndrome in adults. Jones M, Harvey A, Marston L, O'Connell NE.
Cochrane Database Syst Rev. 2013 May 31;5:CD009041.
- Leon Chaitow's website
- Website containing videos to go with the book - Recognizing and Treating Breathing Pattern Disorders
- Clinical interest group for physiotherapists interested in hyperventilation
Read 4 Credit
Would you like to earn certification to prove your knowledge on this topic?
All you need to do is pass the quiz relating to this page in the Physiopedia member area.
- Lum L 1987 Hyperventilation syndromes in medicine and psychiatry: a review. J. R Soc Med. 80:229-231.
- Sueda S et al. 2004 Clinical impact of selective spasm provocation tests Coron Artery Dis 15(8):491–497
- Ajani A 2007 The mystery of coronary artery spasm Heart, Lung & Circulation 16:10–15
- Peters, D. Foreword In: Recognizing and Treating Breathing Disorders. Chaitow, L., Bradley, D. and Gilbert, C. Elsevier, 2014
- Ott H et al 2006 Symptoms of premenstrual syndrome may be caused by hyperventilation Fertility and Sterility 86(4):1001.e17-1001.e19
- Nixon P, Andrews J. 1996 A study of anaerobic threshold in chronic fatigue syndrome (CFS). Biol Psychol. 43:264
- Smith M Russell A Hodges, P 2006. Disorders of breathing and continence have a stronger association with back pain than obesity and physical activity. Australian Journal of Physiotherapy 21(52):11-16
- Haugstad G Haugstad T Kirste U 2006a Posture, movement patterns, and body awareness in women with chronic pelvic pain. J Psychosom Res. 61(5):637-644
- Naschitz J et al. 2006 Patterns of hypocapnia on tilt in patients with fibromyalgia, chronic fatigue syndrome, nonspecific dizziness, and neurally mediated syncope. Am J Med Sci. 331:295-303
- Dunnett A et al. 2007 The diagnosis of fibromyalgia in women may be influenced by menstrual cycle phase. Journal of Bodywork and Movement Therapies 11:99-105
- Han J et al 1996 Influence of breathing therapy on complaints, anxiety and breathing pattern in patients with hyperventilation syndrome and anxiety disorders. J Psychosom Res. 41:481-493
- Kennedy JW (2012). Clinical Anatomy Series‐Lower Respiratory Tract Anatomy. Scottish Universities Medical Journal.1 (2).p174‐179
- Patwa A, Shah A. Anatomy and physiology of respiratory system relevant to anaesthesia. Indian J Anaesth 2015;59:533‑41
- Thomas M1, 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.
- Barker, Nicola J et al. Breathing exercises for dysfunctional breathing/hyperventilation syndrome in children. National Library of Medicine. The Cochrane database of systematic reviews12 (2013): CD010376.
- Biff F. Palmer 2012 Evaluation and Treatment of Respiratory Alkalosis Am J Kidney Dis. 60(5):834-838.
- Jensen F 2004 Red blood cell pH, the Bohr effect, and other oxygenation-linked phenomena in blood O2 and CO2 transport Acta Physiologica Scandinavica 182(3):215-227
- van Dixhoorn J 2007. Whole-Body breathing: a systems perspective on respiratory retraining. In: Lehrer P et al . (Eds.) Principles and practice of stress management. Guilford Press. NY pp. 291–332
- Chaitow, L., Bradley, D. and Gilbert, C. Recognizing and Treating Breathing Disorders. Elsevier, 2014
- van Dixhoorn J, Duivenvoorden HJ. Efficacy of Nijmegen Questionnaire in recognition of the hyperventilation syndrome. J Psychosom Res. 1985;29(2):199-206.
- 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
- 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)