Assessment of Breathing Pattern Disorders

Introduction[edit | edit source]

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).[1]

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.[1] It is not a disease process but alterations in breathing patterns that interfere with normal respiratory processes. BPD can, however, co-exist with diseases such as COPD or heart disease.[2][3] This page addresses the Assessment of Breathing Pattern Disorders. Read the Physiopedia page on Breathing Pattern Disorders for in-depth knowledge on anatomy, aetiology, classification, etc.

Diagnostic Procedures[edit | edit source]

Capnography[edit | edit source]

Capnography is a reliable diagnostic tool for BPDs. It measures the average CO2 partial pressure at the end of exhalation (End Tidal CO2).[4][5]

Nijmegen Questionnaire[edit | edit source]

High scores on the Nijmegen questionnaire are 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%.[6] 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.[7] Thus, the authors have suggested that the Hyperventilation Provocation Test is used to confirm a positive Nijmegen.[7]

Physical Assessment[edit | edit source]

Assessment of Breathing Patterns[edit | edit source]

When assessing breathing patterns, it is important to understand what normal breathing looks like. The resting respiratory rate changes throughout the lifespan:[8]

  • 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 typical 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 the exhalation. This pattern is vital to maintain homeostasis and pH.[8]

Important assessment tests include:

  • Breath Holding –  Ask the patient to exhale and then hold his/her breath. People can usually hold their breath for 25 to 30 seconds.[9] 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.[9]
  • 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.[9]
  • Seated Lateral Expansion – Place hands on lower thorax and monitor motion while breathing. Looking for symmetrical lateral expansion.[9]
  • Manual Assessment of Respiratory Motion (MARM) - Assess and quantify breathing patterns, in particular, the distribution of breathing motion between the upper and lower parts of the rib cage and abdomen under various conditions. Once acquired, it is a manual technique that is practical, quick and inexpensive.[10]
  • Sniff Test -  Assesses bilateral diaphragm function. It is useful in assessing for upper or lower chest pattern dominance. The therapist places his/her hand three fingers below the patient's 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 may in-draw their abdominal wall.[9]
  • Respiratory Induction Plethysmography (RIP) and Magnetometry: consists of two sinusoid wires coils insulated and placed one around the 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 waveform, an indicator for inspired breath volume.


Assessment of the Musculoskeletal System[edit | edit source]

Assessment of Respiratory Function[edit | edit source]

  • 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)

Outcome Measures[edit | edit source]

Differential Diagnosis[edit | edit source]

BPDs often mimic more severe conditions such as cardiac, neurological and gastrointestinal conditions. These must all be ruled out by the medical team.

Management[edit | edit source]

For information on the management of BPDs, click here.

References[edit | edit source]

  1. 1.0 1.1 Lum LC. Hyperventilation syndromes in medicine and psychiatry: a review. Journal of the Royal Society of Medicine. 1987 Apr;80(4):229-31..
  2. Sueda S et al. 2004 Clinical impact of selective spasm provocation tests Coron Artery Dis 15(8):491–497
  3. Ajani AE, Yan BP. The mystery of coronary artery spasm. Heart, Lung and circulation. 2007 Feb 1;16(1):10-5.
  4. Bradley H, Esformes J. Breathing pattern disorders and functional movement. Int J Sports Phys Ther. 2014 Feb;9(1):28-39.
  5. McLaughlin L. Breathing evaluation and retraining in manual therapy. Journal of Bodywork and Movement Therapies. 2009 Jul 1;13(3):276-82.
  6. van Dixhoorn J, Duivenvoorden HJ. Efficacy of Nijmegen Questionnaire in recognition of the hyperventilation syndrome. J Psychosom Res. 1985;29(2):199-206.
  7. 7.0 7.1 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.
  8. 8.0 8.1 Clifton-Smith T. The Science of Breathing Well Course. Plus. 2020.
  9. 9.0 9.1 9.2 9.3 9.4 Chaitow, L. Dysfunctional Breathing Course Videos. Plus2019.
  10. 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
  11. UFGATEP2014. DrWest seated lateral rib expansion. Available from:[last accessed 16/4/2020]
  12. Rowley J, Nicholls DA. Development of the RoBE self-efficacy scale for people with breathing pattern disorders.
  13. 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
  14. (Accessed 16th September, 2017)