Breathing Pattern Disorder

BrPD is best understood as a functional and heterogeneous problem, in which breathing is altered relative to what the body needs rather than being driven by a single structural fault. Patterns vary between people and may include thoracic-dominant breathing, poor coordination between chest and abdomen, an irregular rate or depth, frequent sighing, periodic deep breaths, breath-holding or inappropriate over-breathing, occurring alone or in combination and at rest, during exercise or in recovery.

Symptoms may arise through several overlapping mechanisms. A biomechanical pattern, such as upper-chest breathing using the neck and shoulder muscles, can increase the work and the perception of breathing and strain the chest wall. In some athletes ventilation exceeds metabolic demand and blows off too much carbon dioxide (CO2), producing hypocapnia and the classic symptoms of light-headedness, tingling around the mouth and fingers, and air hunger, while others show a disordered pattern without demonstrable hypocapnia.

Exercise, stress and anxiety commonly trigger or amplify the pattern, and it may begin after a chest infection or run alongside asthma, which is why the two are so often tangled together. The pattern tends to become habitual and self-sustaining, reinforced by the anxiety the symptoms create.

The hallmark is breathlessness that does not fit. Athletes describe air hunger, an inability to get a full or satisfying breath, and a need to sigh or yawn, often with chest or throat tightness, light-headedness and tingling in the fingers or around the mouth. Symptoms may occur at rest, during exercise or afterwards, and they frequently do not follow the tidy timing of the other exertional breathing conditions, which is itself a clue. Performance suffers, and athletes are often frustrated at being told there is nothing wrong or that it is simply nerves.

Assessment starts with a general cardiorespiratory examination, recording respiratory rate, heart rate and oxygen saturation and checking for anaemia, features of asthma and upper-airway symptoms where relevant. Observing the breathing is then central, but the pattern must be judged in context, since faster, deeper and more mouth-dominant breathing is normal at high intensity.

Watch the rate, depth, rhythm and the coordination between chest and abdomen, along with accessory muscle use, sighing and breath-holding, at rest, during symptom-provoking exercise and in recovery, and judge whether the pattern suits the effort and whether it reproduces the athlete's symptoms. Persistent asthma symptoms or frequent reliever use call for objective asthma review rather than being put down to BrPD alone.

The diagnosis rests on recognising a disordered pattern in context and excluding significant disease, not on a single positive test. History and a structured assessment of the breathing pattern do most of the work, evaluating rate, rhythm, depth, chest and abdomen coordination, sighing, breath-holding and the response to exercise, and tools such as the Breathing Pattern Assessment Tool can help document this without replacing clinical judgement. The Nijmegen Questionnaire may support symptom screening, particularly where hyperventilation features are present, but it is not diagnostic and should not be used alone.

Normal resting spirometry does not exclude asthma or EIB, so where these are suspected the appropriate objective asthma pathway or an exercise or indirect bronchial challenge is used, and inspiratory throat-level symptoms at peak effort should prompt consideration of continuous laryngoscopy during exercise for EILO.

Where the diagnosis remains uncertain or symptoms are mainly exertional, cardiopulmonary exercise testing (CPET) is valuable, since it can reproduce the athlete's symptoms, show whether ventilation is appropriate to demand, and identify competing cardiac, respiratory or deconditioning causes. An erratic rate or tidal volume, excessive ventilation or a reduced end-tidal carbon dioxide may support BrPD, though none is diagnostic alone. Further tests such as a full blood count, electrocardiogram or echocardiography are guided by the presentation rather than done routinely.

BrPD often improves with treatment, and the mainstay is not a drug. Education comes first, because understanding that the breathing pattern itself is generating the symptoms, that it is recognised and modifiable, and that it is not simply anxiety, is reassuring and sets up the rest of treatment.

The cornerstone is breathing retraining, delivered by a respiratory physiotherapist with relevant expertise, with speech and language therapy where upper-airway or laryngeal dysfunction coexists. Treatment is individualised to the observed pattern and may include improving coordination between chest and abdomen, easing unnecessary accessory muscle use, regulating rate and depth, reducing recurrent sighing or breath-holding, and building effective breathing strategies for exercise and recovery. Nasal breathing may be practised at rest or lower intensities where helpful, but it should not be imposed during high-intensity exercise, where more oral breathing is normal and necessary.

Contributing factors are managed alongside this. Where anxiety or stress is a genuine driver it is addressed in its own right, with psychological support or cognitive behavioural approaches where appropriate, and any coexisting asthma, rhinitis or reflux is treated on its own merits. There is no specific medication for BrPD itself, and a practical point for the SEM clinician is to avoid escalating asthma treatment when asthma is not the problem. Response varies and the evidence base remains limited, so treatment focuses on symptom control, confidence, function and the ability to manage the pattern during sport.

Rehabilitation is about carrying the new breathing skills into the demands of sport. Techniques are practised first at rest, then during progressively harder training, so the athlete can maintain an appropriate and controllable breathing response as intensity, fatigue and competitive pressure rise, rather than a quiet resting pattern held throughout exercise. Progress is monitored and the breathing work is built into normal training rather than treated separately.

Once serious disease and any inadequately controlled coexisting condition have been addressed, continued or graded return to sport is usually appropriate, individualised to symptoms, technique and the demands of the sport. Where an athlete does not improve as expected, the diagnosis and its contributors are revisited, since unrecognised asthma, EIB, EILO, a cardiac cause or a significant anxiety disorder may be part of the picture.

• •A United Kingdom respiratory physiotherapy position statement, from the Association of Chartered Physiotherapists in Respiratory Care, sets out current terminology and a structured approach to assessing breathing pattern disorder.
• •Respiratory and sport and exercise medicine reviews recognise BrPD as a cause of unexplained breathlessness that frequently overlaps with asthma and the exertional breathing conditions, and propose combining symptom screening, physical breathing-pattern assessment and exclusion of underlying disease.
• •Systematic reviews of assessment tools and of breathing retraining note their value while highlighting that the evidence base is still limited.
• •Current United Kingdom asthma guidance remains relevant for objectively assessing and treating coexisting asthma.

• •Breathing pattern disorder, or dysfunctional breathing, causes breathlessness out of proportion to normal cardiac and respiratory tests.
• •It is heterogeneous, and symptoms such as air hunger, sighing, light-headedness and tingling may come with or without demonstrable low carbon dioxide.
• •The breathing pattern is judged in context, since faster, more oral breathing is normal at high intensity.
• •The Nijmegen Questionnaire is a symptom screen, not a diagnostic test, and cardiopulmonary exercise testing can reproduce symptoms and exclude organic disease.
• •It commonly coexists with asthma, exercise-induced bronchoconstriction or exercise-induced laryngeal obstruction, so assess for these.
• •First-line treatment is individualised breathing retraining with a respiratory physiotherapist, not escalating asthma medication.