Breathing Pattern Disorder

“Every single person I have seen with Long Covid breathes poorly” - Kelly Mitchell @thebreathingpt

My breathing story

During my recovery from acute Covid-19 infection I attended A&E twice with oxygen saturation levels of 76%. I was exhausted, I was dizzy, I was tachycardic, I couldn’t walk up the stairs with some washing without becoming incredibly breathless, numbness and tingling around my mouth and my oxygen levels plummeting. But I looked well, I could walk into the hospital unsupported and lying in a hospital bed my heart and lungs behaved themselves.

On my first visit the bare minimum was done to exclude a pulmonary embolism or ongoing Covid-19 pneumonia with bloods, blood gases and a CXR. The consultant on call was very kind but my tests were all normal and he really didn’t have a clue what to do with me.

The second visit I had further tests a CT scan, a CT pulmonary angiogram and an ECHO but again after a three day admission I was sent home with a diagnosis of “post viral asthma”. The inhalers made absolutely no difference to my desaturations on exertion, the numbness and tingling or the overwhelming breathlessness I had if I climbed the stairs, attempted to change the bedsheets or went for a walk on the flat.

I finally was seen by a respiratory consultant at another hospital who after multiple exhausting / high radiation tests diagnosed me with Dysfunctional Breathing. He gave me no explanation as to what this was, thought some physiotherapy may help, but then discharged me with no referral or follow up.

So now I am left with this strange pattern of breathing which I am acutely aware of. It still occurs doing all the tasks I mentioned above but now it is softer, less alarming and not accompanied by such huge desaturations and yet 11 months on it still persists.

What is Dysfunctional Breathing?

Dysfunctional Breathing (DB) or Breathing Pattern Disorder (BPD) are abnormal respiratory patterns, specifically related to over-breathing. They can range from simple upper chest breathing to the more extreme, hyperventilation (HVS). The terms BPD/DB are interchangeable. I prefer to use BPD as I don’t like to use the word dysfunctional with patients (or myself).

The figure above describes the normal and abnormal breathing pattern. Breath-holding: breath that held for a period of time. Deep sigh: is a deep inspiration. Hyperventilation: increase in respiration rate or increase in volume.

BPD 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, asthma, lung fibrosis or heart disease. These are the associations I am aware of as a GP. I now know it can also occur in chronic sinusitis, chronic pain syndromes and the peri menopause. Most importantly in post acute Covid-19 infection/ Long Covid breathlessness without demonstrable lung pathology is an extremely common finding.

How often does it occur?

BPD affects approximately 10% of all adults in primary care in the United Kingdom. It has been shown to occur in individuals from 17 to 88 years of age, being most common in women and in individuals with asthma. Little is known about dysfunctional breathing in children, data suggests around 5% of children with asthma have dysfunctional breathing leading to poorer asthma control. As Kelly @thebreathingpt says - she has seen BPD in every one of her Long Covid patients.

Why does it occur?

Breathing pattern disorders occur when the ventilation exceeds the metabolic demands of the body resulting in symptom-producing haemodynamic and biochemical changes. If you continually fail to fully breath out it may lead to hypocapnia - a deficiency of carbon dioxide in the blood. This can lead to hypoxia - a deficiency of oxygen in the blood, and the reduction of oxygen delivery to the tissues of the body explaining the long list of associated symptoms listed below.

BPD can influence emotions, circulation, digestive function as well as musculoskeletal structures involved in the respiratory process. A sympathetic state with a subtle, yet a fairly constant state of fight/flight or freeze becomes prevalent. This in turn can cause anxiety, as well as changes in blood pH, muscle tone, pain threshold, and many central and peripheral nervous system symptoms. Musculoskeletal imbalances often exist in patients with BPDs.These include loss of thoracic mobility, overuse/tension in accessory respiratory muscles and dysfunctional postures that affect the movement of the chest wall.

How does it present?

Breathing pattern disorders manifest differently based on the individual. Some people may exhibit high levels of anxiety/fear whereas others have more musculoskeletal symptoms, chronic pain and fatigue. Over 30 possible symptoms have been described in relation to BPDs.

Typical symptoms can include:

  • Frequent sighing and yawning

  • Shortness of breath especially on exertion

  • Breathing discomfort

  • Disturbed sleep

  • Erratic heartbeats - especially tachycardia

  • Feeling anxious and uptight

  • Pins and needles

  • Upset gut/nausea/bloating

  • Clammy hands

  • Chest Pains

  • Reduced confidence

  • Fatigue

  • Aching muscles and joints

  • Dizzy spells

  • Irritability or hypervigilance

  • Feeling of 'air hunger'

  • Breathing discomfort

All sounds very dysautonomic/ POTSey to me? Also I note no mention of brain fog which I feel must be a feature too?

Diagnosing BPD

The following are some of the methods used to diagnose BPD:

  1. Nijmegen Questionnaire is the most widely used instrument for identifying individuals with BPD - Nijmegen Questionnaire

  2. Observation of breathing pattern and musculoskeletal system

  3. Pulse oximetry - to measure oxygen saturation (SpO2)

  4. Capnography - to measure end-tidal CO2 levels in exhaled air

  5. Peak expiratory flow rate - the highest flow of air out of the lungs from peak inspiration in a fast single forced breath out

  6. Lung function tests (LFTs) - there is compelling evidence that individuals with primary DB have normal lung function, whereas other studies have shown that FEV1 or FVC are 10-15% below the predicted values in such individuals. My lung function tests were normal. Please don’t let normal results discourage you from pursuing a diagnosis.

  7. Cardiopulmonary Exercise Testing (CPET) - this testing has been recommended when patients symptoms occur on exertion. This is the test that diagnosed me with BPD. However due to fatigue and post exertional malaise those with LC need to be careful during and after this test. Your consultant should be aware if you are having any chest pain.

  8. Quality of Life questionnaire (QoL) - BPD can lead to a reduced QoL and needs to be assessed.

  9. Anxiety and Depression assessment - BPD can lead to anxiety and depression Hospital Anxiety and Depression Questionnaire (HAD)

  10. Exclusion of other lung and heart problems that can cause breathlessness first

Self Management

Physiotherapy is beyond my level of expertise so I would like to refer now to the advice of Kelly Mitchell a physiotherapist dealing with many, many patients with BPD as part of their Long Covid.

She has produced an excellent blog on this subject which I encourage you to read.

From this my take home messages on the management of my own BPD were:

  • Rest

  • Pacing

  • Hydration

  • Good nutrition

  • Improved Sleep

  • Paced exercise when stable

  • Avoid stimulants - sugar, coffee, alcohol

  • Stress management

  • Learn relaxation techniques

  • Look after your mental health

Time and time again the above list comes up in my posts. Currently it really is the only way to manage your own Long Covid. Other things I have learnt in my own self management:

Normal breathing rate is 12-16

Recognising when you are over breathing

Mindfully changing to a more controlled way of breathing

Being aware of normal breathing rates both at rest and during activity

Nose breathing rather than breathing though your mouth

Yoga helps you open up your chest and focus on your breathing

You can educate yourself more on BPD by following Kelly on instagram @thebreathingpt . There is also the @breathewellphysio team in the USA.

I have also found physio-pedia invaluable in writing this post -

NHS advice -

Always be aware that BPD is a respiratory condition that is often poorly understood among health care professionals worldwide, leading to its underdiagnosis and misdiagnosis in clinical practice. This leads to, as in my case, doctors failing to provide patients with an appropriate education, resources and treatment, which could lead to impaired quality of life. My advice is to make sure you are referred to a Long Covid Clinic as many are actually run by physiotherapists and therefore your breathlessness at least will be addressed. And be hopeful breathing retraining does have a positive affect on quality of life.


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