Posted by on Nov 9, 2018 in Uncategorized

Dysfunctional breathing

In the book titled ‘Physiotherapy for Respiratory and Cardiac Problems: Adults and Paediatrics’, Innocenti and Troup (2014) state:

“The term ‘dysfunctional breathing’ is, in itself, confusing. One would expect it to mean that a particular breathing pattern does not fulfil its function, yet it appears to be used as a synonym for hyperventilation.”

In citing other authors, Depiazzi and Everard (2016) have made the following points about dysfunctional breathing:

  • It can be considered an umbrella term that describes: “An alteration in the normal biomechanical patterns of breathing that result in intermittent or chronic symptoms which may be respiratory and/or non-respiratory”.
  • Patients with dysfunctional breathing present with a variety of respiratory and non-respiratory symptoms, including EID (exercise-induced dyspnoea), shortness of breath at rest, “wheeze”, stridor, throat tightness, sighing, chest pain, throat clearing, “air hunger” (a sense of being unable to get a complete breath in even after a maximal inspiratory manoeuvre), tingling, dizziness and general fatigue.
  • Frequently a number of symptoms coexist, although one may predominate.
  • Patients appear to develop symptoms of dysfunctional breathing when abnormal breathing patterns pattern disordered breathing (PDP) becomes habitual. This PDB can be constant or happen intermittently when provoked by a physical or psychological stress.
  • Dysfunctional breathing appears to frequently coexist with respiratory diseases such as asthma and chronic obstructive pulmonary disease (COPD) although the nature of the relationship (causal or coincidental) remains unclear.
  • The mechanisms leading to such characteristically “abnormal” patterns of breathing are also unclear, although the condition does appear to be amenable to “breathing retraining” where it is possible to exert a level of voluntary control over the pattern and rate of respiration.

In an excellent 2016 paper titled ‘Dysfunctional breathing: a review of the literature and proposal for classification’ published in the European Respiratory Review, Boulding R, Stacey R, Niven R, et al provide a lot of interesting information about dysfunctional breathing. This is exemplified by the quotations below which are taken directly from their paper.

“Dysfunctional breathing is a term describing a group of breathing disorders in patients where chronic changes in breathing pattern result in dyspnoea and often non-respiratory symptoms in the absence of, or in excess of, organic respiratory disease.”


“Many of these breathing patterns may occur as a physiological response to disease, but in the absence of organic abnormalities they can be considered pathological. Several different phrases have been used loosely and interchangeably in the literature, these include functional breathing disorder, breathing pattern disorder and behavioural or psychogenic breathlessness.”


“The most widely recognised form of dysfunctional breathing is hyperventilation syndrome (HVS), which was first described over 70 years ago. This term is often also used synonymously with dysfunctional breathing, whereas in fact it is just one type of breathing pattern disorder and hyperventilation is not necessarily seen in dysfunctional breathers. There is no formal definition of dysfunctional breathing and no gold standard diagnostic method.”


“The key symptom in dysfunctional breathing is breathlessness after organic causes have been ruled out, but associated symptoms may be attributable to hyperventilation (increased minute ventilation) and respiratory alkalosis (e.g. tingling, tetany and numbness), but these are not specific to dysfunctional breathing.”


“The patients’ overwhelming symptom is dyspnoea despite exclusion of, or treatment optimisation for, any organic disease. Breathlessness may manifest as hyperventilation, or symptoms that occur independently of hypocapnia and respiratory alkalosis such as deep sighing or the sensation of air hunger.”


“It is not possible to accurately determine the prevalence of dysfunctional breathing in the absence of gold standard diagnostic criteria.”


“Most data are available for HVS, the prevalence of which is estimated to be in the region of 6–10% in the general population, rising to 29% in asthmatics. The Nijmegen questionnaire has recently been validated in asthmatics with a single study. The approximate prevalence of HVS in asthmatics was found to be 34%. There are no data available to estimate the prevalence of other patterns of dysfunctional breathing either in the general population or in people with respiratory disease.”


“Dysfunctional breathing patterns may occur where there is coexistent respiratory disease, in particular asthma, and so difficulty arises when trying to untangle which of the two are contributing most to the reported symptoms.”


“Recognising variations in breathing pattern in asthmatics may provide a way of identifying those patients who would benefit from breathing retraining to target abnormal breathing mechanics.”


“A clear link between dysfunctional breathing and other respiratory diseases has not been made in the literature, but in our experience dysfunctional breathing patterns do occur in some patients with diseases such as chronic obstructive pulmonary disease (COPD) and interstitial lung disease.”


“Another condition that has been linked to dysfunctional breathing and in particular HVS is panic disorder, which comprises many of the symptoms listed in the Nijmegen questionnaire.”


“Dysfunctional breathing, particularly HVS, is commonly seen in those with anxiety related disorders. In these related conditions it is difficult to assess whether HVS is causative or simply a secondary effect of anxiety related disorders.”


“There is an extensive body of research that implicates respiratory processes and particularly hyperventilation in panic disorder. Asthma itself is associated with an increased prevalence of reported panic disorder at 9.7%.”


These authors have proposed 5 types of dysfunctional breathing based on the literature and their own experience. These are:

  1. Hyperventilation syndrome: the most commonly described and researched type of dysfunctional breathing.
  2. Periodic deep sighing – this type of dysfunctional breathing is characterized by frequent sighing and irregular breathing patterns, sometimes overlapping with hyperventilation.
  3. Thoracic dominant breathing – also called apical breathing, occurs when there is predominant use of the upper thorax with lack of lateral costal expansion.
  4. Forced abdominal expiration – the least described breathing pattern in the literature. However, it can be observed in clinical settings especially in individuals with COPD (chronic obstructive pulmonary disease).
  5. Thoraco-abdominal asynchrony – due to a delay between rib cage and abdominal contraction resulting in ineffective breathing.

As mentioned earlier, the most widely recognised form of dysfunctional breathing is hyperventilation syndrome (HVS). According to Schwartzstein and Richards (2014):

“The hyperventilation syndrome describes a condition in which an inappropriate increase in minute ventilation beyond metabolic needs (i.e. a respiratory alkalosis) is associated with a wide range of symptoms without a clear organic precipitant.”


“As with other medical “syndromes,” there is controversy about the aetiology, diagnosis, and treatment of this condition. While it is generally accepted that hyperventilation episodes (or “attacks”) are frequently related to or caused by concomitant panic disorder, other precipitants may also be important.”


“The prevalence of hyperventilation syndrome is difficult to assess accurately given estimates based upon small sample sizes, varying diagnostic criteria, and its association with psychological symptoms. There is substantial overlap between hyperventilation syndrome and panic disorder and panic attacks.”


“The prevalence of hyperventilation syndrome has been reported to range from 25 to 83 percent in patients with an anxiety disorder and up to 11 percent in patients with non-psychiatric medical comorbidities.”

Innocenti and Troup (2014) note that the vast array of commonly reported signs and symptoms of HVS can be loosely grouped as they affect different systems which they list as: cardiovascular, gastrointestinal, general, musculoskeletal, neurological, respiratory, and psychological/psychiatric. (p. 532). By ‘general’ they refer to signs and symptoms such as exhaustion, lethargy, weakness, headache, sleep disturbance, excessive sweating, disturbance of concentration and memory.

In relation to the causes of hyperventilation, Innocenti and Troup (2014) note that many circumstances may stimulate a hyper-ventilatory response which may or may not become a chronic disorder. They categorise the causes of hyperventilation as follows: drugs, organic disorder, physiological, psychiatric, and psychological. (p.534)



Innocenti DM, Troup F, Chapter 17 of ‘Dysfunctional Breathing’ in Physiotherapy for Respiratory and Cardiac Problems: Adults and Paediatrics (eds Pryor JA, Prasad SA) Churchill Livingstone (2014)


Depiazzi J, Everard ML. Dysfunctional breathing and reaching one’s physiological limit as causes of exercise-induced dyspnoea, Breathe 2016 12: 120-129


Boulding R, Stacey R, Niven R, et al; Dysfunctional breathing: a review of the literature and proposal for classification Eur Respir Rev 2016; 25: 287-294


Schwartzstein RM Richards J. Hyperventilation Syndrome UpToDate