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PRIMARY CARE: Mike Thomas, R K McKinley, Elaine Freeman, and Chris Foy Prevalence of dysfunctional breathing in patients treated for asthma in primary care: cross sectional survey BMJ 2001; 322: 1098-1100 [Abstract] [Full text]

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Dysfunctional breathing in asthma.

Matthew A Garner   (11 May 2001)

Dysfunctional breathing in asthma, anxiety and Buteyko

James Oliver   (16 May 2001)

Dysfunctional breathing in asthma: hyperventilation, obstruction, or anxiety?

Thomas Ritz   (19 May 2001)

Effective therapy for panic disorder should be acknowledged in discussion of treatment...

Simon J C Davies, Peter R Jackson, L E Ramsey   (1 June 2001)

Dysfunctional breathing and asthma

Jan van Dixhoorn   (6 June 2001)

Physiotherapy for Dysfunctional Breathing

Victoria Johnson, Jacqueline Crosby   (2 July 2001)

Authors' reply

Mike Thomas   (17 July 2001)

Dysfunctional breathing in asthma. 11 May 2001
Matthew A Garner, 3rd year medical student University of Newcastle-Upon-Tyne Send response to journal: Re: Dysfunctional breathing in asthma.	Editor, Thomas et al studied the prevalence of dysfunctional breathing in patients treated for asthma in the primary care setting(1). This interesting study has highlighted an important area for further research. Keeley and Osman’s comments regarding the validity of Nijmengen questionnaire and the authors’ interpretation of the results were highly relevant(2). We would like to raise some additional points. Population variations in socioeconomic status, smoking rates, pollution exposure and concurrent lung disease may affect the prevalence of asthma and dysfunctional breathing. Therefore, as a single centre study, we doubt that these results can be applied to a general population. It is important to know the prevalence of dysfunctional breathing in asthmatics, but these data are only meaningful in relation to the prevalence in the general population. We believe that further research could take the form of a larger cross-sectional study. This would allow comparison of the prevalence of dysfunctional breathing in asthmatics and the general population, as well as the investigation of other variables. A multi-centre study will take account of these regional population variations. The diagnosis of dysfunctional breathing should be made using both anxiety and symptom- based questionnaires, rather than the Nijmengen alone. Such a study would cast further light on an area where uncertainty over diagnosis and management exists. Matthew A Garner Daniel Hedwat Katharine E Neville-Smith James A Shand Dominic P Waddington Third Year Medical Students Department of Epidemiology and Public Health, The Medical School, University of Newcastle upon Tyne 1. Mike Thomas, R K McKinley, Elaine Freeman, Chris Foy, Prevalence of dysfunctional breathing in patients treated for asthma in primary care: cross sectional survey BMJ 2001;322:1098-1100 2. Keeley, D., Osman, L. Dysfunctional breathing and asthma. BMJ 2001;322: 1075-1076
Dysfunctional breathing in asthma, anxiety and Buteyko 16 May 2001
James Oliver, General Practitioner Mullion Health Centre, Mullion, Cornwall. TR12 7HS Send response to journal: Re: Dysfunctional breathing in asthma, anxiety and Buteyko	EDITOR- By connecting dysfunctional breathing in asthma with the anxiety related hyperventilation syndrome Thomas et al (1) may have inadvertently led to some misunderstanding regarding the intended role of breathing exercises such as Buteyko in the treatment of this condition. Physiological hyperventilation is a common finding in patients with mild, symptomatic asthma as shown by a raised minute volume of respiration, lowered arterial pCO2 and consequent respiratory alkalosis(2,3). However, this does not in itself imply that such patients are suffering from excessive anxiety. In many cases the desire of an asthmatic patient to breathe deeply can be seen as a natural response to the feeling of restricted breathing. This is entirely analogous to the way in which a patient with eczema develops a habit of scratching, or a patient with mechanical back pain adopts an abnormal posture. In each case the patient's own behaviour, whilst understandable, can nevertheless lead to an exacerbation of the underlying condition. Reviewing the literature there is substantial evidence that hyperventilation in itself can lead to significant increases in the resistance of human airways (4). Several possible mechanisms have been put forward to explain this including stimulation of autonomic reflexes or even as a direct effect of lowered carbon dioxide levels. The emphasis of breathing pattern modification is therefore directed towards the prevention of such hyperventilation induced bronchospasm. The crucial point is that this approach is effective irrespective of whether or not the underlying hyperventilation is related to anxiety. This latter point is entirely consistent with my own experience of teaching the Buteyko method which has shown that the majority of well motivated, asthmatic patients derive significant benefit in terms of improved symptom control and reduction in medication use. In particular, although entirely subjective, my impression is that less anxious patients tend to respond more favourably. We all know that changing patients' behaviour can be difficult. Therefore any attempt must be well-organised and involve adequate support. However, taking into account the current high expenditure on asthma I believe that the Buteyko method offers a serious and cost effective adjunct to conventional care. It should not simply be seen as treatment reserved for the worried well. James Oliver General Practitioner Mullion Health Centre, Cornwall TR12 7HS oliver@kerdevez.demon.co.uk 1. Thomas M, McKinley RK, Freeman E, Foy C. Prevalence of dysfunctional breathing in patients treated for asthma in primary care: cross sectional survey. BMJ 2001;322:1098-100 2. Tobin MJ, Tejvir SC, Jenouri G, Birch SJ, Hacik B, Gazeroglu BS, Sackner MA. Breathing Patterns 2. Diseased subjects. Chest 1983;84(3):286 -94 3. McFadden ER, Lyons HA. Arterial blood gas tension in asthma. NEJM 1968;278:1027-1032 4. Sterling GM. The mechanism of bronchoconstriction due to hypocapnia in man. Clin. Sci. 1968;34:277-285
Dysfunctional breathing in asthma: hyperventilation, obstruction, or anxiety? 19 May 2001
Thomas Ritz, Senior Research Scholar Department of Psychiatry and Behavioral Sciences, Stanford University and VA Palo Alto HCS Send response to journal: Re: Dysfunctional breathing in asthma: hyperventilation, obstruction, or anxiety?	Editor - Thomas et al. (1) must be complimented on drawing attention to the important issue of hypocapnic breathing in asthma. An editorial pointed out a lack of validation of the Nijmegen questionnaire for an asthmatic population (2), but a more general problem of questionnaire research is becoming apparent. The multi-dimensionality of symptom reporting in asthma has been demonstrated by Kinsman and others in research on the Asthma Symptom Checklist (ASC; 3), but this fact is not reflected in recent developments of health status measures that measure symptoms as part of a broader range of indicators of treatment outcome or quality of life in asthma (4). The strength of these instruments lies in their ability to gauge overall health status, but in some contexts more specific instruments are needed for measuring particular aspects of health status such as symptoms. For example, when the aim is to identify subgroups of asthma patients with distinct symptom patterns such as dysfunctional breathing, psychometrically validated high fidelity symptom report measures are needed. Unfortunately, the Nijmegen questionnaire does not provide information of sufficient quality in bronchial asthma. The cut-off score of >=23 for the diagnosis of ‘dysfunctional breathing’ could theoretically be reached by maximum or near maximum values on seven items related to typical asthmatic airway obstruction symptoms (‘shortness of breath’, ‘tightness across chest’, ‘fast or deep breathing’) and states of anxiety (‘feeling tense’, ‘cold hands or feet’, ‘palpitations in the chest’, ‘anxiety’), without being indicative of hyperventilation. Other items on the questionnaire have a greater face validity for hyperventilation in asthma. It would be useful to examine the factorial structure of the Nijmegen questionnaire in asthmatics. It is conceivable that this would reveal factors corresponding to the symptom dimensions already identified by Kinsman et al. in the ASC, such as panic-fear, obstruction, and hyperventilation. Although these and other symptom dimensions are often moderately correlated, questionnaire scales based on these dimensions could provide more valid criteria for identifying those asthma patients who really suffer from hypocapnic breathing, not only from the typical airway obstruction and ensuing anxiety. Ultimately, only ambulatory recording of symptoms and PCO2 levels in daily life will reveal the real prevalence of hypocapnic breathing in asthma. (1) Thomas M, McKinley RK, Freeman E, Foy C. Prevalence of dysfunctional breathing in patients treated for asthma in primary care: cross sectional survey. BMJ 2001; 322:1098-100. (2) Keeley D, Osman L. Dysfunctional breathing and asthma. BMJ 2001; 322:1075-6. (3) Kinsman RA, Luparello T, O’Banion K, Spector S. Multidimensional analysis of the subjective symptomatology of asthma. Psychosom Med 1973; 35:250-67. (4) Richards JM, Hemstreet MP. Measures of life quality, role performance, and functional status in asthma research. Am J Respir Crit Care Med 1994; 149: S31-9.
Effective therapy for panic disorder should be acknowledged in discussion of treatment... 1 June 2001
Simon J C Davies, *Senior House Officer, Bristol, Bath and Weston Psychiatry Rotation. New Friends Hall, Stapleton, Bristol., Peter R Jackson, L E Ramsey Send response to journal: Re: Effective therapy for panic disorder should be acknowledged in discussion of treatment...	Effective therapy for panic disorder should be acknowledged in discussion of treatment for dysfunctional breathing. Thomas et al [1] report an appreciable prevalence of dysfunctional breathing in adults with asthma and discuss the scope for wider use of breathing therapy. Neither investigators nor the authors of the accompanying editorial [2] consider whether such symptoms might occur equally frequently in the normal population or represent panic attacks/ disorder, well defined entities common in otherwise healthy people. Without a control group their study is incapable of identifying the prevalence of dysfunctional breathing associated specifically with asthma. Dysfunctional breathing and the hyperventilation syndrome are by no means the same as panic syndromes, but overlap between them may be considerable. Thomas et al acknowledge limitations of the Nijmegen Questionnaire [3]. Notably, the instrument cannot differentiate the "chimeric" hyperventilation syndrome from the well-defined phenomena of panic attacks and panic disorder. The sixteen items in the Nijmegen questionnaire include "anxiety", "feeling tense" and 9 of the 13 panic attack symptoms listed in DSM-III-R. The questionnaire was not defined to attempt to make this distinction. A 23% lifetime prevalence of spontaneous panic attacks has been reported in asthmatics [4]. This figure is not dissimilar to the 29% of asthmatics labelled by Thomas et al as having experienced dysfunctional breathing, and again suggests appreciable overlap. The lifetime prevalence of asthmatics meeting DSM-III-R criteria for panic disorder in the same study was 9.7% [4]. We reported a significant excess of panic attacks and panic disorder among primary care and hospital patients with hypertension compared to matched normotensives, and 202 of 287 people who had experienced panic attacks related "shortness of breath" or "difficulty catching breath" as being symptoms in their worst panic attack [5]. The relation of history of panic attacks to gender in our sample was strikingly similar to that reported for dysfunctional breathing [1], with a significant excess in females of around 15% in both studies. The importance of considering panic disorder in a discussion of dysfunctional breathing lies in the availability of treatment of proven efficacy. Thomas et al limit their consideration of therapeutic intervention to breathing therapy. In a patient with recurrent difficult breathing and history suggestive of panic disorder, a much broader range of treatment, from tricyclic antidepressants and selective serotonin reuptake inhibitors to cognitive therapy may be effective. Failure to identify panic attacks or panic disorder may deprive patients of valuable treatment options, some of which can be instigated in primary care. Dr Simon JC Davies, Senior House Officer, Bristol, Bath and Weston Psychiatry Rotation. Dr Peter R Jackson, Reader and Honorary Consultant, Clinical Pharmacology and Therapeutics, University of Sheffield. Professor Lawrence E Ramsay, Clinical Pharmacology and Therapeutics, University of Sheffield. REFERENCES [1] Thomas M, McKinley RK, Freeman E, Foy C. Prevalence of dysfunctional breathing in patients treated for asthma in primary care: cross sectional survey. BMJ 2001; 322: 1098-1100. [2] Keeley D, Osman L. Dysfunctional breathing and asthma. BMJ 2001; 322: 1075-6. [3] van Dihoorn J, Duivenvoorden HJ. Efficacy of Nijmegen Questionnaire in recognition of the hyperventilation syndrome. J Psychosom Res 1985; 29: 199-206. [4] Carr RE. Lehrer PM, Rausch LL, Hochron SM. Anxiety sensitivity and panic attacks in an asthmatic population. Behav Res Ther 1994; 32: 411 -8. [5] Davies SJC, Ghahramani P, Jackson PR, Noble TW, Hardy P, Hippisley-Cox J, Yeo WW, Ramsay LE. Association of panic disorder and panic attacks with hypertension. Am J Med 1999; 107: 310-6.
Dysfunctional breathing and asthma 6 June 2001
Jan van Dixhoorn, medical head cardiac rehabilitation unit Kennemer Hospital, Haarlem, The Netherlands Send response to journal: Re: Dysfunctional breathing and asthma	Editor- Thomas et al (1) recently showed that 29% of asthmatic patients in general practice have a high score on Nijmegen questionnaire, indicating the presence of dysfunctional breathing and suggesting scope for therapeutic intervention. Their point is that asthmatic breathlessness may coexist with breathlessness due to dysfunctional breathing and respond to breathing therapy, which has been shown to reduce complaints on Nijmegen questionnaire (2). Keeley and Osman, in their critical comment (3), misunderstood this point and assumed that the authors meant that 29% was wrongly diagnosed. Furthermore, Keeley and Osman equated dysfunctional breathing and hypocapnia. The authors however tried to avoid this very equation, which reduces all breathing abnormalities to hyperventilation, by using the term dysfunctional breathing. This refers to unnecessary tension in breathing, unrelated to the extent of the somatic illness. It has recently been shown to be also present in patients with lung cancer and respond to proper treatment, including breathing and relaxation therapy (4). I feel therefore that the next step of Thomas et al is valid, that is to assess the response to breathing therapy. A positive response includes a shift towards a more functional breathing pattern and a reduction of complaints on Nijmegen questionnaire. This confirms dysfunctional breathing to be a cause of complaints. It is different from psychological help to patients with asthma to cope with anxiety, that Keeley & Osman advice. 1. Thomas M, McKinley RK, Freeman E, Foy C. Prevalence of dysfunctional breathing in patients treated for asthma in primary care: cross sectional survey. Brit Med J 2001; 322: 1098 1100. 2. Han JN, Stegen K, DeValck C, Clement J, van de Woestijne KP. Influence of breathing therapy on complaints, anxiety and breathing pattern in patients with hyperventilation syndrome and anxiety disorders. J Psychosom Res 1996; 41:481-93. 3. Keeley D, Osman L. Dysfunctional breathing and asthma. Brit Med J 2001; 322:1075-6. 4. Bredin M, Corner J, Krishnasamy M, Plant H, Bailey C, A'Hern R. Multicentre randomised controlled trial of nursing intervention for breathlessness in patients with lung cancer. Brit Med J 1999; 318:901-4.
Physiotherapy for Dysfunctional Breathing 2 July 2001
Victoria Johnson, Senior Respiratory Physiotherapists Nottingham City Hospital, Jacqueline Crosby Send response to journal: Re: Physiotherapy for Dysfunctional Breathing	We found the results of Thomas et al interesting but unsurprising. We have used the Nijmegan questionnaire as part of an audit to evaluate respiratory intervention in out patients presenting with dysfunctional breathing. Following a course of physiotherapy treatment, including education, relaxation, breathing control and exercise, all patients showed an improvement in their Nijmegan questionnaire (p=0.0001) and we noted a reduction in respiratory rate. In an attempt to measure the ‘avoidable morbidity’ described by Thomas et al (2001) we used two visual analogue scales (VAS) measuring perceived breathlessness and degree of ‘bother’. The VAS relating to how much the patients’ breathing troubled them was reduced significantly (p=0.0014) following treatment. Patients were less ‘bothered’ by their breathing and this may demonstrate that our patients are better able to cope with their breathing disorder, even if other objective measures, such as the Nijmegan questionnaire and resting respiratory rate, showed less improvement. The suggestion that patients experienced an improvement in their quality of life following their course of treatment was supported by the positive comments we received, although not formally measured. We agree with Thomas et al that effective intervention exists and our audit shows that respiratory physiotherapy is an important component in the diagnosis and management of these patients. Further research of these interventions is needed in the form of a randomised-controlled trail.
Authors' reply 17 July 2001
Mike Thomas, GP Minchinhampton Send response to journal: Re: Authors' reply	Editor, We would like to thank the authors of the editorial and letters for their interest in our work(1). In their editorial, Keeley and Osman agree that people with asthma may experience functional breathing problems. They maintain that our study overestimates the problem yet make no reference to data to support their assertion(2). They are correct in that the Nijmegen Questionnaire has not been validated in asthmatic populations, but neither has it has it been specifically validated for any disease sub-group. Four questions relate to respiratory symptoms which may occur in asthma but six questions relate to symptoms common to cardiac, five to neurological and four to psychiatric conditions. Ritz comments on the multidimensionality of the symptoms experienced by people with asthma and Davies et al on the excess of panic disorder in people with asthma, which may further confound this problem. Our view is that the questionnaire examines a constellation of symptoms that are common to several disease processes but suggest the presence of dysfunctional breathing when they occur together. Research is needed into optimal methods of diagnosis, whether by ambulatory capnography or by the response of people with asthma and symptom scores suggestive of dysfunctional breathing to specific therapies. We do not however suggest that these people who may have dysfunctional breathing do not have asthma. We agree with van Dixhoorn that asthma and dysfunctional breathing may co-exist, and are not suggesting widespread mis-diagnosis of asthma. Nevertheless it is possible that symptoms due to dysfunctional breathing may be mis-attributed to asthma, and further studies which include objective measures of asthma, such as bronchial hyper-reactivity and sputum eosinophilia, in patients labelled as asthma who have symptoms suggestive of dysfunctional breathing are needed. Such studies should be multicentred and determine the prevalence of dysfunctional breathing in the general population (thought to be 6-10% (4)) and in those who have asthma, as Garner et al and Davies et al have suggested. Keeley and Osman state that breathing exercises have not been proven to be of benefit in asthma, although a recent Cochrane review of breathing exercises in asthma(3) concluded that the evidence is insufficient rather than absent. We therefore welcome the data presented by Johnson and Crosby indicating that physiotherapy based breathing retraining can improve the quality of life of patients with respiratory disease and co-existing dysfunctional breathing, and agree that well designed randomised controlled trials are needed. Oliver comments on the Butekyo method of treating asthma. Studies are needed to determine its benefits and compare them with those which may be achieved by other interventions either pharmalogical or non-pharmalogical We feel that our study and the correspondence raise rather than answer questions, and point towards the need for further research. Nevertheless they raise the possibility that an important minority of people treated for asthma in the community may be helped by simple non- pharmacological interventions which should be investigated. Dr M Thomas, Department of Primary Care, University of Aberdeen and Minchinhampton Surgery, Stroud, Gloucestershire GL6 9JF RK McKinley, Department of General Practice and Primary Health Care, University of Leicester 1. Thomas M, McKinley RK, Freeman E, Foy C. Prevalence of dysfunctional breathing in patients treated for asthma in primary care: cross sectional survey. BMJ 2001;322:1098-100. 2. Keeley D,.Osman L. Dysfunctional breathing and asthma. BMJ 2001;322:1075-6. 3. Holloway E and Ram FSF. Breathing exercises for asthma (Cochrane review). The Cochrane Library Issue 3. 2000. Oxford, Update Software. 4. Vansteenkiste J, Rochette F, Demedts M. Diagnostic tests of hyperventilation syndrome. Eu Respir J 1991;4:393-9.