Breathing pattern disorders (functional yet dysfunctional breathing)

PowerPoint PresentationCounties Manukau Health
8:30 - 9:25 WS #215: Breathing Pattern Disorders
9:35 - 10:30 WS #227: Breathing Pattern Disorders (Repeated)
Ms Sarah Butler Physiotherapist
Breathing pattern disorders (functional yet dysfunctional breathing)
Sarah Mooney and Sarah Butler Private Practitioners, NZ Respiratory and Sleep Institute
Counties Manukau Health / Waitamata District Health Board
AUT University
Workshop overview
• Overview • Definition and historical perspective • The ‘too many’ and ‘too hard basket’
• Screening and assessment tips • Typical and atypical signs and symptoms • Observing functional vs dysfunctional breathing • Nijmegen Questionnaire and other tests
• Management (rather than treatment) • Useful tips, resources and apps
• Take home messages
• Breathing pattern disorders/dysfunctional or disordered breathing
• “Breathing which is unable to perform its various functions efficiently for the needs of the individual at that time”
Courtney R., The functions of breathing and its dysfunctions and their relationship to breathing therapy (2009) International journal of osteopathic medicine 12(3), 78-85
The ‘too many’ and ‘too hard’ basket
• Adults • General population: 5-11% ; Asthma: 83% ; Female: male ratio: 7:2 (Thomas, 2005)
• Children/youth: • 27% children with exercise-induced asthma found to have exercise-induced BPD (Seear et al., 2005)
• 5% of referrals to paed/youth asthma clinic had BPD (de Groot et al., 2013)
• 18.6% of non-asthmatics and 55% of asthmatics identified as having BPD (Gridina et al., 2013)
• USA GP practices/surgeries: 10% • Middlemore Hospital (Lock & Wright 2019)
• 1958 patients, 133 pts presented with non-cardiac chest pain; 92 with SOB; 39 wheeze, 20 costo-chrondritis
• ?how many admissions due to breathing pattern disorders
• Breathing pattern disorders • Can result from multiple sources including:
• Mechanics • Physiological/chemical • Psychological states • Combination of one/two/all
• Can present: • Acute, chronic, or acute on chronic
• Can exist in isolation or on a background of other conditions
• Can be: • Mask ‘A’ problem
• Amplify ‘A’ problem
• Be ‘THE’ problem
• Increases anxiety of patients/clients
• Management is multi-dimensional • Common aim to promote wellness • Requires a repertoire of tools and approaches • Cannot separate psychology from physiology and mechanics
• A significant burden to individuals and healthcare providers
• Growing numbers in youth and children
“A diagnosis begging for recognition” (Magarian, 1982)
Screening and assessment tips
• Over-reliant on stimulants … including exercise
• Non-responsive to salbutamol inhalers or other therapies
• ?personality type
• Depression, Anxiety, Stress Scale (DASS21)
• Symptoms
• “… just not feeling right”
Common symptoms in teens
• Paraesthesia / anaesthesia in muzzle area, hands and feet
• Feeling dizzy
increased anxiety,
CO2 (acid) is expelled & blood becomes more alkaline
Kidneys retain acid and excrete more bicarbonate
to stabilise pH balance
pH returns to false, fragile equilibrium but bicarbonate levels are low
Normal breathing difficult;
Hyperventilation needs to continue to maintain pH as much of the
bicarbonate buffer has gone.
‘Normal’ breathing feels insufficient, requiring person to persist with BPD
to try to maintain feeling of equilibrium
Muscles and BPD
Massery, M. (2009). The Patient Puzzle: Piecing It Together. Cardiopulmonary Physical Therapy Journal . 20:2
Breathing and abdominal muscles
• Corseting effect
• BPD more common in women
• Associated with progesterone rise on day 22 which stimulates respiratory drive
- increased minute ventilation
- increased sensitivity of CO2 receptors in the brain; urge to breathe
• Progesterone high through out pregnancy
Observation
• Dysfunctional breathing • ?tense posture with elevated shoulders/tight trapezius muscle • Dominant apical breathing pattern • Altered inspiratory/expiratory ratio • Noisy breathing /? multiple sighs or yawns • ? Poor voice quality
Screening and assessment tips
• Score greater than 23/64 indicative • Consider alongside other assessment tools
• Breath hold following normal exhalation • Following exhalation to empty ie residual volume or maximal inhalation (total lung
capacity) • People with normal breathing: mean 45 seconds (35-56 seconds);
• People with COPD/CHF mean 25 secs
• People with BPD: < 10—12 secs
Nijmegen Questionnaire
• 3 relate to respiratory symptoms;
• 13 peripheral and central neurovascular or general tension
(Mitchell, Bacon & Moran, 2016)
(Courtney, Greenwood et al. 2011)
Breath hold
Ultrasound
• Regular food & fluid intake
• Review stressors
• Nose MUST BE CLEAR! - Triggers a relaxed diaphragmatic breathing pattern
- Mouth breathing - Dries the airways
- Over-stimulates the sympathetic nervous system
Breathing and food
• Increasing evidence to show high glucose levels may increase panic/BPD
• Hypocapnia and hypoglycaemia = reduced cerebral blood flow
• Effects of hypocapnia on EEG
= much more significant during periods of hypoglycaemia
Breathing and sleep
• Useful conversation topics • Reassure++++
• Check / treat nasal congestion
• Basic breathing assessment/treatment • Position: beach pose position
• Fixing of accessory muscles / reduced abdominal tension
• Pattern: promote nose breathing and breathing pattern • Abdominal breathing pattern; do NOT push abdominals!
• Normal I:E ratio of 1:2 (or modified)
• Typically cycles of 4-6 breaths
• Persevere
• Progressive breathing retraining: • Nasal breathing
• Abdominal pattern and normal I:E ratio
• Integrated with: • Voice management /core stability
• Eating and swallowing
• Optimise posture/mechanics/core stability/mobility of upper ribs
• Consideration of psychology support
• Public • Out-patient Respiratory Physiotherapy Department
• Private • NZ Respiratory and Sleep Institute (Auckland) • Breathing Works (Auckland) and practitioners • Buteyko Health New Zealand
• University • Some university-based physiotherapy clinics
• ie AUT Integrated Clinic, Northcote
Useful tips, apps and resources
• Cynicism is expected! • Commonly look for ‘medical diagnosis’ and associated ‘fix or medication’
• Changing disordered breathing takes time, particularly if the person has been doing it for a while
• Reassure and explain about muscle adaptation
• Be patient and encourage practice • Reassure that:
• Overactive muscles require retraining
• Underactive muscles require training
• Books (e-books/hard copy)
• Breathing: • Breathe • Breathe+ • Paced Breathing • The Breathing app • Breathe pacer • Breathekids
• Be mindful ….. • Some apps promote ‘deep breathing’ NOT normal quiet tidal volume breathing (I:E ratio) • Others encourage ‘hold’
Useful tips, resources and apps
• Breathing and mindfulness: • http://www.freemindfulness.org/download
• People can be ‘functional’ but … have ‘dysfunctional’ breathing
• Symptoms can be global, specific or ‘atypical’ • Typically investigations are ‘normal’
• Remember BPDs can be/mask/amplify a problem
• Reassure and REFER to physiotherapy
Thank you
Private Practitioners, NZ Respiratory and Sleep Institute
Counties Manukau Health / Waitamata District Health Board
AUT University