Association of dysfunctional breathing with health-related quality of life: A cross-sectional study in a young population

Validity study of the Japanese version of the Nijmegen Questionnaire for verifying dysfunctional breathing in Japanese asthma patients

Background

Dysfunctional breathing (DB) is a clinical condition characterized by irregular breathing patterns presenting a sensation of dyspnea and a feeling of chest tightness. DB is a known comorbidity of asthma that is difficult to control, leading to poor quality of life, so early diagnosis and therapeutic intervention are essential to improve the clinical condition of asthma. The Nijmegen Questionnaire (NQ), developed to screen for DB and translated into various languages, is used worldwide. However, a Japanese NQ (JNQ) is unavailable, so DB has not been clinically verified in people with asthma in Japan.

Objective

This study aimed to prepare a JNQ, verify its reliability and validity, and demonstrate its clinical benefits in asthma treatment.

Methods

The JNQ was prepared by back-translating the NQ with the author's consent. The answers to self-administered questionnaires, including the JNQ, Asthma Control Test (ACT), Asthma Control Questionnaire (ACQ), Mini Asthma Quality of Life Questionnaire (Mini-AQLQ), and Patient Health Questionnaire 9 (PHQ-9), were obtained with the consent of 68 people with asthma (average age ± SD, 52.04 ± 12.43 years) who visited Nihon University Itabashi Hospital. The reliability of the JNQ was analyzed by the Cronbach alpha coefficient. A comparative test was conducted for each questionnaire (ACT, ACQ, Mini-AQLQ, PHQ-9), considering a JNQ score of 23 as the cutoff value. Patients with a score of 23 or more were assigned to the DB group, whereas patients with a score of less than 23 were assigned to the non-DB group. We analyzed the correlation between the JNQ and each questionnaire.

Results

The JNQ showed sufficient reliability (Cronbach alpha = 0.875). Correlation analysis between the JNQ score and each questionnaire revealed negative correlations with the ACT score (r = 0.262) and Mini-AQLQ score (r = -0.453) and positive correlations with the ACQ score (r = 0.337) and PHQ-9 score (r = 0.539). All of these correlations were statistically significant. As a result of the comparative test, the DB and non-DB groups showed a significant difference in Mini-AQLQ (P = .023) and PHQ-9 (P = .003) scores. No significant difference was observed between ACT (P = .294) and ACQ (P = .177) scores.

Conclusions

The JNQ validates DB in Japanese people with asthma and reflects the deterioration of asthma control, decreased quality of life, and depression. Using the JNQ, early diagnosis and therapeutic intervention (eg, breathing exercises and a psychosomatic approach) for DB in people with asthma may help suppress the severity of asthma in Japan.

Validity and reliability of outcome measures to assess dysfunctional breathing: a systematic review

OBJECTIVE

This study aimed to systematically review the psychometric properties of outcome measures that assess dysfunctional breathing (DB) in adults.

METHODS

Studies on developing and evaluating measurement properties to assess DB were included. The study investigated the empirical research published between 1990 and February 2022, with an updated search in May 2023 in the Cochrane Library database of systematic reviews and the Cochrane Central Register of Controlled Trials, the Ovid Medline (full), the Ovid Excerta Medica Database, the Ovid allied and complementary medicines database, the Ebscohost Cumulative Index to Nursing and Allied Health Literature and the Physiotherapy Evidence Database. The included studies' methodological quality was assessed using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) risk of bias checklist. Data analysis and synthesis followed the COSMIN methodology for reviews of outcome measurement instruments.

RESULTS

Sixteen studies met the inclusion criteria, and 10 outcome measures were identified. The psychometric properties of these outcome measures were evaluated using COSMIN. The Nijmegen Questionnaire (NQ) is the only outcome measure with 'sufficient' ratings for content validity, internal consistency, reliability and construct validity. All other outcome measures did not report characteristics of content validity in the patients' group.

DISCUSSION

The NQ showed high-quality evidence for validity and reliability in assessing DB. Our review suggests that using NQ to evaluate DB in people with bronchial asthma and hyperventilation syndrome is helpful. Further evaluation of the psychometric properties is needed for the remaining outcome measures before considering them for clinical use.

PROSPERO REGISTRATION NUMBER

CRD42021274960.

Development of the Short-Form Yin Deficiency Scale Using Three Item Reduction Approaches

Background

Yin deficiency (YD) is a pathological condition characterized by emaciation, afternoon fever, dry mouth, and night sweats. The incidence of YD is 23.3%. A 27-item Yin Deficiency Scale (YDS) was developed to estimate the clinical severity of YD. This study aimed to develop three short-form YDS versions to reduce the burden of response time, using three item-reduction approaches: Rasch, equidiscriminatory item-total correlation (EITC), and factor-based analyses.

Methods

Two datasets were analyzed from previous studies (169 outpatients from May to June 2009 and 237 healthy college students from January to April 2016). The optimal response category was examined using Rasch analysis. Items with higher item-total correlations were determined using the EITC. Using a factor-based approach, the items were reduced, while maintaining the original YDS construct. Reliability was estimated using the person separation index (PSI) and Cronbach's α values. The predictive accuracy was examined using the area under the curve (AUC). Finally, the relationship between YD and dysfunctional breathing (DB) was examined using factor scores from the YDS and the Korean version of the Nijmegen Questionnaire (KNQ).

Results

We developed two 14-item YDS versions using the Rasch and EITC approaches, and a 16-item YDS version using a factor-based approach. Rasch analysis suggested an optimal response category of five points. The PSI of Rasch and Cronbach's α of the EITC and factor-based versions were 2.19, 0.855, and 0.827. The AUCs of the three short-form YDS were 0.812, 0.811, and 0.818. The sensitivity of the EITC-YDS was 0.632, which was lower than its specificity of 0.875. The fatigue-related scores of the factor-based YDS were fairly correlated with the factor scores of the KNQ estimating the DB (r = 0.349-0.499).

Conclusion

The 14-item Rasch- and 16-item factor-based YDS may replace the original YDS during YD's primary screening, epidemiological surveys, and health checkups.

Validating the Breathing Vigilance Questionnaire for use in dysfunctional breathing

BACKGROUND

Dysfunctional breathing is common among people with and without primary respiratory pathology. While anxiety can contribute to dysfunctional breathing, the underpinning mechanism is unclear. One explanation is that anxiety induces conscious, vigilant monitoring of breathing, disrupting "automatic" breathing mechanics. We validated a new tool that quantifies such breathing-related "vigilance": the Breathing Vigilance Questionnaire (Breathe-VQ).

METHODS

323 healthy adults (mean (range) age 27.3 (18-71) years; 161 males) were analysed. We developed an initial Breathe-VQ (11 items, 1-5 Likert scale) based on the Pain Vigilance and Awareness Scale, using feedback from the target population and clinicians. At baseline, participants completed the Breathe-VQ, Nijmegen Questionnaire (NQ), State-Trait Anxiety Inventory form 2 and Movement-Specific Reinvestment Scale (assessing general conscious processing). 83 people repeated the Breathe-VQ 3 weeks later.

RESULTS

Five items were removed based on item-level analysis. The resulting six-item Breathe-VQ questionnaire (score range 6-30) has excellent internal (α=0.892) and test-retest reliability (intraclass correlation 0.810), a minimal detectable change of 6.5 and no floor/ceiling effects. Validity was evidenced by significant positive correlations with trait anxiety and conscious processing scores (r=0.35-0.46). Participants at high risk of having dysfunctional breathing (NQ >23; n=76) had significantly higher Breathe-VQ score (mean±sd 19.1±5.0) than low-risk peers (n=225; mean±sd 13.8±5.4; p<0.001). In this "high risk of dysfunctional breathing" group, Breathe-VQ and NQ scores were significantly associated (p=0.005), even when controlling for risk factors (e.g. trait anxiety).

CONCLUSIONS

The Breathe-VQ is a valid and reliable tool to measure breathing vigilance. High breathing vigilance may contribute to dysfunctional breathing and could represent a therapeutic target. Further research is warranted to test Breathe-VQ's prognostic value and assess intervention effects.

The Thai version of the Nijmegen questionnaire

Purpose

The Nijmegen questionnaire is a screening tool for detecting hyperventilation syndrome. The present study aimed to cross-culturally adapt the questionnaire to Thai language and test its psychometric properties for screening hyperventilation syndrome, in which the prevalence is increasing due to the impacts of the COVID-19 pandemic.Design/methodology/approach: The Thai version of the Nijmegen questionnaire (NQ-TH) was generated following a cross-cultural adaptation guideline including initial translation, synthesis of forward translation, back translation, expert committee review, and prefinal testing. Fifty control participants and one-hundred patients with symptoms related to hyperventilation syndrome were enrolled in this study for the determination of psychometric properties. Content validity, construct validity, internal consistency reliability, and test-retest reliability of the NQ-TH were assessed. Its discriminant ability and cutoff point for screening hyperventilation syndrome were also revealed.

Findings

The obtained IOC and disappeared floor and ceiling effects indicated excellent content validity of the questionnaire. There were significant correlations between the total scores of the NQ-TH and other questionnaires and recorded respiratory measurements obtained from the patients, i.e., SF-36-TH (r = -0.257), HADS-TH (r = 0.331), RR (r = 0.377), and BHT (r = -0.444). This supported the construct validity of the NQ-TH. An acceptable internal consistency was also observed (Cronbach's alpha = 0.789). Test-retest repeatability of the questionnaire was high (ICC = 0.90). Moreover, the NQ-TH reliability was also ensured by calculated MDC (2.68). The cutoff point of the NQ-TH was at 20 with 98% sensitivity and 94% specificity.Originality/value: The NQ-TH established by the present study is a valid and reliable tool for screening hyperventilation syndrome among Thais.

Pilot study of physiotherapist-led versus music therapist-led breathing control exercises for young adults living with breathing pattern disorder: a randomised controlled trial protocol

INTRODUCTION

Breathing pattern disorder (BPD) is an abnormal breathing pattern associated with biochemical, biomechanical and psychophysiological changes. While physiotherapy is often offered, limited evidence-based therapies for BPD are available. Music therapy-based singing exercises have been shown to improve quality of life for individuals with respiratory conditions and may also be beneficial for individuals living with BPD. No study has previously compared these participatory interventions in the treatment of people living with BPD.

METHODS AND ANALYSIS

This is a study protocol for an assessor blinded 1:1 randomised controlled trial and qualitative interview study. Forty participants aged 18-40 years who score at least 19 on the Nijmegen Questionnaire (NQ) and do not have any underlying respiratory conditions will be recruited. Participants will be randomised to receive either physiotherapy-led or music therapy-led breathing exercises for 6 weeks. The primary outcome will be between-group difference in NQ post-intervention. Semistructured interviews with a purposive sample of participants will be performed. Qualitative data will be analysed using thematic analysis to better understand participants' intervention and trial experiences.

ETHICS AND DISSEMINATION

This study has received ethical approval by Brunel University London College of Health, Medicine and Life Science's Research Ethics Committee (32483-MHR-Mar/2022-38624-3). The anonymised completed dataset will be made available as an open-access file via Brunel University London Figshare and the manuscript containing anonymised patient data will be published in an open-access journal.

TRIAL REGISTRATION NUMBER

This trial is registered on the Open Science Framework Registry (https://osf.io/u3ncw).

Extrapulmonary symptoms of patients with asthma treated in specialist pulmonary care

OBJECTIVE

Patients seeking treatment for their asthma are most likely motivated by a change in their experience of symptoms, but primary complaints are not always related to the pulmonary system. This study aimed to determine the frequency of such extrapulmonary symptoms in asthma outpatients and their association with psychopathology and asthma outcomes.

METHODS

This cross-sectional study utilized data collected as part of a nationwide, clinical-epidemiological study. The final sample of 572 asthma patients represented all levels of asthma control and severity. Information on demographics and respiratory function was obtained from physicians' documentation. Symptoms were explored using a standardized checklist.

RESULTS

Primary symptoms reported by asthma patients were not necessarily airway-related. Patients reported feeling at least occasionally "tired" (72.1%) and "exhausted" (66.8%) more than any other asthma symptom. Hyperventilation and mood symptoms were experienced by 34.4-42.6% of patients. Anxiety or depression diagnoses indicated higher scores in all symptom domains. Controlling for asthma-related factors and psychopathology, fatigue had a small but significant effect on both asthma-related quality of life (AQLQ) (r_sp² = 0.02, P < .001) and asthma control (r_sp² = 0.01, P = .003). Mood symptoms also showed a small but significant effect on AQLQ (r_sp² = 0.02, P < .001).

CONCLUSION

Findings suggest that extrapulmonary symptoms are endorsed more frequently than previously reported. Symptoms nonspecific to asthma can play a substantial role in clinical presentation and exclusive focus on airway symptoms may miss important information related to patients' well-being. Surveillance of extrapulmonary symptoms alongside pulmonary function is warranted for an integrated medicine approach to asthma management.

Disruption of Pathological Patterns in a Young Population with Dysfunctional Breathing

Dysfunctional breathing (DB) is characterized by abnormal breathing patterns and often results from psychogenic causes in the absence of organic diseases. Although acupuncture and herbal treatments have been suggested as alternative therapies for DB, few studies have addressed the relationship between DB and pathological patterns from a diagnostic perspective. We asked 237 college students (130 men aged 21.4 ± 1.9 years; 107 women aged 21.4 ± 3.0 years) to complete the Korean version of the General Health Questionnaire-30 (K-GHQ-30) and four validated pathological pattern questionnaires regarding qi and yin deficiencies, phlegm, and cold-heat patterns. The Korean version of the Nijmegen Questionnaire was used to classify participants into DB and non-DB groups. Effects of age, gender, and DB on pathological patterns were examined using simple regression and two-way MANCOVA models. Age had an effect on all pattern scores except heat pattern scores (β: 0.154-0.098). DB group showed a moderate main effect (η 2 = 0.167) on pathological patterns, while gender showed a minimal main effect (η 2 = 0.096); qi and yin deficiencies, phlegm, and cold-heat pattern scores in DB and female groups were higher than those in non-DB and male groups. The K-GHQ-30 scores showed significant positive correlations with the pathological pattern scores (r: 0.243-0.533), indicating that disruption of pathological patterns could be associated with patients' psychological disturbance. In conclusion, these questionnaires may help to identify pathological patterns related to DB and determine individually tailored alternative therapies.