I spent many hours in 2017 contemplating the importance of one key element of human survival - breathing. As a physiotherapist working with patients in chronic pain and also while teaching pilates, I have continually questioned myself about:
- the appropriate time and way to assess breathing,
- the most efficient method to educate patients about normal and abnormal breathing patterns, and
- the timing of teaching breathing cues, variety of verbal cueing and type of therapeutic exercise to choose.
I strongly fear that breathing is unanimously recognised as a vital component of human posture and function yet braised past quickly when we are taught as clinicians and when we teach our patients.
Breathing underlies all dynamic movement and function.
So, in order to expand my personal knowledge I've been studying a well-regarded textbook; Recognizing and Treating Breathing Disorders. It is incredibly well written and packed with information from multiple clinical domains and approaches. The goal for these next few blogs is to summarise the key learnings from the book and highlight areas of focus for 2018 to improve how I assess and treat breathing disorders in patients presenting to physical therapy in a private practice setting.
Why is breathing so important?
I have a personal fascination with the history of our profession and love reading about howe we began, where we came from and our evolution over time. There was a surge or maybe the real birth of physiotherapy which came after the second world war. But, the patients, diseases and injuries that physiotherapy was focussed around is so vastly different to what we see now as clinicians in 2018. Something I've observed is that through this evolution our professional streams have become more defined: musculoskeletal, neurological, cardiopulmonary, paediatric, sport etc. But, they didn't begin that way. My fear is that this streamlining or specialisation has caused our younger generations to loose their skills in connecting the streams together.
Breathing is vital for human life and non specific to any domain of our profession. In order to better understand the musculoskeletal, neurological, cardiac, pulmonary, emotional, psychological and behavioural determinants of breathing, we must delve across into other streams. This book has helped me understand how this expanded approach is possible in an outpatient setting. We just have to start thinking more broadly again.
What are breathing pattern disorders?
It was around the 1980's when physiotherapists (Innocenti and Cluff) ramped the discussion about the impact that Co2 levels have physiologically in patients and their associated symptoms, in particular, hyperventilation syndrome (HVS) (Chaitow, Bradley et Gilbert., 2014, p.3-5). What they speculated/studies is that:
- Reduced Co2 causes increased pH and a more alkaline environment.
- Increased breathing rate leads to reduced CO2 levels and respiratory alkalosis.
- Physiological effects of HVS include exhaustion, tingling, cramps, weakness, irregularities of heart rhythm and more.
- Psychological effects of HVS include tiredness, sensory disturbance and dizziness.
Breathing pattern disorders describe a variety of different presentations that often lead to hyperventilation syndrome or disruption in carbon dioxide levels. They occur in about 1/10 people (not everyone). It is important to reinforce from the beginning that BPD is not a disease, but a disorder that can coexist with many diseases and something that also mimics other disease processes (Chaitow, Bradley et Gilbert., 2014, p.4). BPD are a cluster of symptoms and signs of abnormal breathing that present in patients who have systemic changes as well and altered posture, movement and pain. (BPD) are being "increasingly recognized as a major cause of ill health, though still remain widely underdiagnosed and undertreated" (Chaitow, Bradley et Gilbert., 2014, p.1).
“Structure and function are intertwined and interdependent, in respiration as in most other body processes.” (Chaitow, Bradley et Gilbert., 2014, p.5).
Signs of normal breathing:
- The upper seven ribs should move synchronously with the sternum and move anteriorly during inspiration, not cranially.
- Visible accessory muscle activation is not seen in normal quiet breathing.
- When the diaphragm and intercostal muscles activate, the thoracic cavity should enlarge anteriorly and laterally at the same time.
- During inspiration, the lower ribs shoulder expand laterally with the thoracic cavity.
- Normal alignment of the clavicle is considered a 25-30 degrees angle from the horizontal while the thoracic spine is erect.
- Ribs should align with the pelvis. “When the thoracic spine is erect, the ribcage is positioned parallel to the pelvis and the centrum tendineum of the diaphragm is on a horizontal plane.” This horizontal alignment of the central tendon allows for the diaphragm to act in a caudal direction, “as a piston against the pelvic floor”. (Konlar, Kobesova, Valouchova et Bitnar., 2014, p. 13).
- PaCo2 35-40 mmhg, Bicarbonate 24 mEg/L, pH 7.4, SpO2 95-98%, respiratory rate is 10-14 breaths per minute, and breathing occurs through nose (Bradley., 2014, p.64).
- There should be a relaxed pause at the end of exhalation to allow the diaphragm to relax.
- The mean swallowing rate is 3-4 times per 15 minutes (Bradley., 2014, p.64).
- You should be unaware of your breathing.
Signs of abnormal breathing:
These are a few of the symptoms which I see more commonly, not the entire list (Bradley., 2014, p. 53):
- Neuro signs: increased sympathetic NS activation, reduced concentration and memory, tremors, sweating, palpitations, dizziness, weakness, visual disturbance, spinal hyperreflexia
- Cardiac signs: chest pain
- Gastro signs: gulping, bloating, burping, IBS
The diagnosis of hyperventilation syndrome (HVS) is a clinical one. It is also a diagnosis of exclusion. The symptoms are full body and can mimic more severe disease processes eg. air hunger, dry cough, sighing, pain, myalgia, increased muscle tone, dizziness, headache, fainting, tingling, chest pain, arrhythmia and impaired thinking. Therefore, subjective symptomology is not a reliable diagnostic tool, but, important for understanding the depth and variety of different system symptoms. As physical therapists we can look at breathing patterns (abdominal, pursed lip, apical, paradoxical etc), controlled pause, respiratory rate, heart rate - which I will go into more detail in the next blog.
Why is the nose so important?
“The nasal cycle, which is part of an overall body cycle, is controlled by the hypothalamus. Increased airflow through the right nostril is correlated to increased left brain activity and enhanced verbal performance, whereas increased airflow through the left nostril is associated with increased right brain activity and enhance spatial performance.” (Bartley., 2014, p.46).
- There is twice as much airway resistance in nasal breathing compared to mouth breathing,
- This causes an increased in total lung volume, functional residual capacity, and improved arterial oxygen concentration (about 10% increase) (Gilbert., 2014, p. 82).
- Nasal breathing is achieved by placing the tongue gently behind the top teeth on the hard palate during inspiration. No noise should be heard when inhaling.
- Slower breathing is better for O2 and Co2 concentration.
- Mouth breathing is a habit that may be triggered by an event (a cough or congestion) but does not subside and it must be untrained once established!
Building nose breathing into the assessment:
- Is the patient a nose or mouth breather?
- Mouth breathing is connected with nasal obstruction and congestion.
- Do they have a septal deviation? This would cause a unilateral nasal obstruction
- Do they report snoring or sleep apnoea?
- Do they report inappropriate daytime somnolence? This is assessed with the Epworth Sleepiness Scale
- They they have other symptoms such as sneezing, itchy nose or eyes or nasal discharge or fascial pain?
What this all means is that there is a very well designed system within our body that maintains our pH levels and is vital for function of all body systems. Maintaining disequilibrium is a term I learnt during chemistry about how the chemical reactions within the body are always counteracting the external environment. The outcome of a balanced flow of oxygen in and carbon dioxide out is that our tissues get a steady supply of oxygenated blood and that carbon dioxide remains stable. Breathing is fundamental in maintaining this balance, which is known as homeostasis. (Gilbert., 2014, p 61).
In summary, breathing is vital to our survival and while breathing pattern disorders may only occur in 1/10 patients we see clinically, knowing how to observe breathing, questions for breathing difficulties and educate patients about normal versus abdnormal breathing techniques, can have a profound impact on many other systems in their body. This blog was focussed on understand the importance of breathing and the next blog is focussed deeply on improving assessment.
A thought to finish on...
Patients don’t just choose to breath abnormally - their bodies are forcing them to adapt to a problem and our role as therapists is to understand the underlying drivers.
Chaitow, L., Gilbert, C., & Morrison, D. (2014). Recognizing and Treating Breathing Disorders E-Book. Elsevier Health Sciences.