Getting the basics right resolves most cases of uncontrolled and problematic asthma

AIM

The prevalence of true therapy-resistant asthma among children whose asthma remains uncontrolled, despite daily controller therapy, is unknown. The aim of this study was to investigate the underlying causes in children with uncontrolled asthma.

METHODS

This was a retrospective chart review of 142 children aged from five to 17 years over a five-year period. The patients had uncontrolled asthma and were referred by general practitioners to a hospital-based paediatric asthma clinic.

RESULTS

An underlying cause for uncontrolled asthma was found in 138 children (97.2%). The causes were poor adherence (n = 53, 37.3%), ongoing exposure to environmental triggers (n = 40, 28.2%), comorbidities (n = 28, 19.7%), incorrect inhaler technique (n = 11, 7.7%) and incorrect diagnosis (n = 6, 4.2%). After properly addressing these basics in asthma management, the asthma was well controlled in all 138 patients and lung function was normal. Only four children (2.8%) fulfilled the criteria for true therapy-resistant asthma.

CONCLUSION

A remedial cause in the basics of asthma management could be found in 97% of children with uncontrolled asthma referred to a hospital-based asthma clinic. True therapy-resistant asthma was found to be very rare in children.

Associations of symptoms of anxiety and depression with health-status, asthma control, dyspnoea, dysfunction breathing and obesity in people with severe asthma

BACKGROUND

Anxiety and depression are comorbidities of severe asthma. However, clinical characteristics associated with coexisting severe asthma and anxiety/depression are poorly understood. The study objective is to determine clinical characteristics associated with anxiety and depressive symptoms in severe asthma.

METHODS

Severe asthma participants (N = 140) underwent a multidimensional assessment. Categorization of symptoms of anxiety and depression were based on HADS scale sub-scores and divided into four groups (< 8 on both subscales; ≥ 8 on one subscale; ≥ 8 on both subscales). Clinical characteristics were compared between subgroups. Multivariate logistic regression determined associations of clinical characteristics and anxiety and/or depressive symptoms in people with severe asthma.

RESULTS

Participants were (mean ± SD) 59.3 ± 14.7 years old, and 62% female. There were 74 (53%) severe asthma participants without symptoms of anxiety/depression, 11 (7%) with symptoms of anxiety, 37 (26%) with symptoms of depression and 18 (13%) with symptoms of anxiety and depression. Quality of life impairment was greater in participants with symptoms of depression (4.4 ± 1.2) and combined symptoms of anxiety and depression (4.4 ± 1.1). Asthma control was worse in those with symptoms of depression (2.9 ± 1.1) and combined anxiety and depression (2.6 ± 1.0). In multivariate models, dysfunctional breathing was associated with symptoms of anxiety (OR = 1.24 [1.01, 1.53]). Dyspnoea was associated with symptoms of depression (OR = 1.90 [1.10, 3.25]). Dysfunctional breathing (OR 1.16 [1.04, 1.23]) and obesity (OR 1.17 [1.00, 1.35]) were associated with combined symptoms of anxiety and depression.

CONCLUSION

People with severe asthma and anxiety and/or depressive symptoms have poorer QoL and asthma control. Dyspnoea, dysfunctional breathing and obesity are associated with these symptoms. These key clinical characteristics should be targeted in severe asthma management.

Factors Associated with Dysfunctional Breathing in Patients with Difficult to Treat Asthma

BACKGROUND

Understanding of dysfunctional breathing in patients with difficult asthma who remain symptomatic despite maximal inhaler therapy is limited.

OBJECTIVE

We characterized the pattern of dysfunctional breathing in patients with difficult asthma and identified possible contributory factors.

METHODS

Dysfunctional breathing was identified in patients with difficult asthma using the Nijmegen Questionnaire (score >23). Demographic characteristics, asthma variables, and comorbidities were assessed. Multivariate logistic regression was performed for dysfunctional breathing, adjusted for age, sex, body mass index, and airflow obstruction.

RESULTS

Of 157 patients with difficult asthma, 73 (47%) had dysfunctional breathing. Compared with patients without dysfunctional breathing, those with dysfunctional breathing experienced poorer asthma status (symptom control, quality of life, and exacerbation rates) and greater unemployment. In addition, more frequently they had elevated sino-nasal outcome test scores, anxiety, depression, sleep apnea, and gastroesophageal reflux. On multivariate analysis, anxiety (odds ratio [OR], 3.26; 95% CI, 1.18-9.01; P = .02), depression (OR, 2.8; 95% CI, 1.14-6.9; P = .03), and 22-item sino-nasal outcome test score (OR, 1.03; 95% CI, 1.003-1.05; P = .03) were independent risk factors for dysfunctional breathing.

CONCLUSIONS

Dysfunctional breathing is common in difficult asthma and associated with worse asthma status and unemployment. The independent association with psychological disorders and nasal obstruction highlight an important interaction between comorbid treatable traits in difficult asthma.

The impact of dysfunctional breathing on the assessment of asthma control

BACKGROUND AND OBJECTIVE

Dysfunctional breathing (DB) is a respiratory disorder, which involves a pattern of breathing too deeply, too superficially and/or too rapidly. In asthma patients, DB may lead to an overestimation of the severity of asthma symptoms, and hence potentially to overtreatment. However, it is not known to which degree DB may affect estimates of asthma control, in a specialist clinical setting.

METHODS

The MAPOut-study examined all patients referred consecutively over a 12-months period for specialist assessment of asthma at the Respiratory Outpatient Clinic at Bispebjerg Hospital in Copenhagen. All patients were examined with the Nijmegen questionnaire with a DB defined as a score ≥23 and the ACQ questionnaire. Linear regression analysis of predictors of ACQ score was performed. Asthma was defined as asthma symptoms and a positive asthma test.

RESULTS

Of the 256 patients referred to the lung clinic, data on both the Nijmegen questionnaire and ACQ score was obtained in 127 patients, who were included in the present analysis. Median (range) age: 30 (15-63) years, and 76 (59.8%) were females. DB was found in 31 (24.4%). Asthmatic patients with co-existing DB had a poorer asthma control compared to asthmatics without DB (Median (range) ACQ score: 2.40 (0.20-4.60) vs 1.20 (0.00-4.40); p < 0.001.). A regression analysis showed that the effect of DB on asthma control was independent of airway hyperresponsiveness or airway inflammation in patients with DB.

CONCLUSION

Dysfunctional breathing is common among asthma patients in a specialist setting, and results in a clinically significant underestimation of asthma control, which may potentially lead to overtreatment.

Exercise-Associated Dyspnea and Stridor: Thinking Beyond Asthma

Breathlessness during sport can be caused by various cardiorespiratory conditions, but when associated with stridor, usually arises from an upper airway etiology. The term exercise-induced laryngeal obstruction (EILO) is now used to describe the phenomenon of transient glottic closure occurring in association with physical activity. Exercise-related laryngeal closure is most commonly encountered in athletic individuals and likely affects between 5% and 7% of all young adults and adolescents. The diagnosis of EILO is not always straightforward because features can overlap with exercise-induced asthma/exercise-induced bronchoconstriction. EILO can therefore remain misdiagnosed for years, and most patients receive inappropriate asthma therapy. In contrast with asthma, EILO symptoms are usually most prominent at maximal exercise intensity and resolve quickly on exercise cessation. It is important to recognize that EILO and asthma can coexist in a proportion of athletes. The criterion standard test for diagnosing EILO is continuous laryngoscopy during exercise testing, although eucapnic voluntary hyperpnea testing has also been used. Various surgical or pharmacological interventions can be used to treat EILO, but first-line treatment is breathing technique work. Further research is needed to establish the optimal treatment algorithm, and more work is needed to increase awareness of this important clinical entity.

Dysfunctional breathing is more frequent in chronic obstructive pulmonary disease than in asthma and in health

Involuntary adaptations of breathing patterns to counter breathlessness may lead to dysfunctional breathing in obstructive lung diseases. However, no studies examining dysfunctional breathing in Chronic Obstructive Pulmonary Disease (COPD) have been reported. Patients with verified COPD (n=34), asthma (n=37) and a healthy control group (n=41) were recruited. All participants completed the Nijmegen questionnaire for dysfunctional breathing as well as measures of disease activity. Comparisons between groups employed analysis of variance with post-hoc Bonferroni analyses and Pearson correlation for associations. Patients with COPD had significantly higher Nijmegen questionnaire scores than asthmatics (COPD: 23.4±10.6 versus 17.3±10.6, p=0.016) and healthy individuals (14.3±9.6, p=0.002). Significantly more patients with COPD had severe dysfunctional breathing with Nijmegen scores >23 (47%; 16/34) compared to asthma (27%; 10/37) and healthy controls (17%; 7/41) respectively (p=0.019). Dysfunctional breathing was detected in ∼50% of patients with COPD, more so than in asthma or health. Strategies to reduce abnormal breathing behaviours may have important benefits for treatment of breathlessness in COPD.

Physiotherapy in asthma using the new Lotorp method

BACKGROUND

Physiotherapy in bronchial asthma has given various results.

AIM

To test a new method focusing on breathing exercise and massage of the thoracic muscles.

PATIENTS AND METHODS

Twenty-eight adult patients with a physician-diagnosed asthma were studied during 6 weeks. All patients were prescribed asthma medication. The new method [active group, n = 17) was compared with physical training (control group, n = 12).

RESULTS

PEF was significantly improved (p = 0.001) in the active group, however, FEV1 showed no significant change. The symptoms "tightness of the chest", "difficult breathing in", "air hunger", and the individually dominating symptom (p = 0.001) were significantly reduced in the active group. Exercise-induced breathing troubles and chest expansion were also significantly reduced.

CONCLUSION

Physiotherapy including breathing exercise and massage of the thoracic muscles (the Lotorp method) in patients with physician-diagnosed asthma resulted in significantly reduced respiratory symptoms during rest and exercise and increased chest expansion. The improvements may be due to an increased mobility of the chest and diaphragm.

Asthma and Comorbid Conditions-Pulmonary Comorbidity

Pulmonary comorbidities can increase disease severity and health care costs associated with asthma management. Vocal cord dysfunction/inducible laryngeal obstruction is a common comorbidity that results from intermittent laryngeal obstruction. Patients describe distinct episodes of dyspnea that do not respond to bronchodilators. Inspiratory stridor is common. The gold standard diagnostic testing strategy is continuous laryngoscopy performed during exercise or irritant challenges. Dysfunctional breathing (DB) is an overarching term that describes conditions with a chronic change in the pattern of breathing that results in pulmonary and extrapulmonary symptoms. The prevalence of DB in asthma is up to 30%, and breathing retraining can improve symptoms and quality of life in people with DB and asthma. Asthma-chronic obstructive pulmonary disease overlap (ACO) refers to both asthmatics who develop fixed airflow obstruction after a history of exposure to smoke or biomass and patients with chronic obstructive pulmonary disease who have "asthmatic features" such as a large bronchodilator response, elevated levels of serum IgE, or peripheral eosinophil counts ≥300 per μL. Triple inhaler therapy with inhaled corticosteroid/long-acting beta-agonist/long-acting muscarinic should be considered in people with ACO and severe symptoms or frequent exacerbations. The clinical expression of bronchiectasis involves persistent mucus hypersecretion, recurrent exacerbations of infective bronchitis, incompletely reversible airflow obstruction, and lung fibrosis and can occur in up to 30% of adults with longstanding asthma. The treatable traits strategy is a useful model of care to manage the complexity and heterogeneity of asthma with pulmonary comorbidity.

Functional Respiratory Disorders in Children

Functional respiratory disorders (FRDs) are those characterized by respiratory symptoms without anatomic or organic etiology. Clinicians caring for children encounter these disorders and should be familiar with diagnosis and treatment. FRDs encompass the habit cough syndrome and its variants, vocal cord dysfunction, hyperventilation disorders, functional dyspnea, and sighing syndrome. Failure to identify these disorders results in unnecessary testing and medication. This article reviews the clinical presentation, manifestation, and treatment of respiratory FRDs in children. How health care providers can successfully identify and treat these reversible conditions in the clinical setting is discussed.

Special Considerations and Perspectives for Exercise-Induced Bronchoconstriction (EIB) in Olympic and Other Elite Athletes

Diagnosing and treating elite and Olympic athletes with exercise-induced bronchoconstriction has been well established. However, a subset of elite and Olympic athletes with exercise-induced bronchoconstriction experience symptoms of breathlessness due to lack of adherence, improper medications, and/or generalized breathing dysfunction. A short review of traditional treatment plans for elite and Olympic athletes is presented along with the challenges of adherence, managing dysfunctional breathing, and measuring and treating mental skills deficits that may impact breathing. Elite and Olympic athletes may not respond to traditional treatment for exercise-induced bronchospasm, and we present some of the reasons why the athletes fail to respond. Furthermore, we present information on how to detect and treat elite and Olympic athletes with difficult-to-treat asthma. As part of this review we developed a flow diagram for medical providers to identify the reasons for lack of response to traditional treatment plans for exercise-induced bronchoconstriction with options for other treatment modalities.

Breathing retraining in sleep apnoea: a review of approaches and potential mechanisms

PURPOSE

Anatomically based treatments for obstructive sleep apnoea (OSA) may not completely resolve OSA. This has led to interest in exploring ways of addressing physiological risk factors. This review examines the literature for research reporting on the effects of various types of breathing training and breathing activities on sleep apnoea. It also reviews and discusses proposed therapeutic mechanisms.

METHODS

A search of electronic databases was performed using the search terms related to various breathing therapies or to activities requiring high levels of breath control such as singing and the playing of musical instruments and sleep apnoea.

RESULTS

A total of 14 suitable studies were reviewed. A diverse variety of breathing retraining approaches are reported to improve sleep apnoea, e.g., Buteyko method, inspiratory resistance training, and diaphragmatic breathing. There is also a reduced incidence of sleep apnoea with intensive and regular participation in activities that require high levels of breath control, e.g., singing and playing wind instruments. Improvements in sleep-disordered breathing are thought to be related to improvements in (1) muscle tone of the upper airway; (2) respiratory muscle strength; (3) neuroplasticity of breathing control; (4) oxygen levels; (5) hyperventilation/dysfunctional breathing; and (6) autonomic nervous system, metabolic, and inflammatory status.

CONCLUSION

Breathing retraining and regular practice of breath control activities such as singing and playing wind instruments are potentially helpful for sleep apnoea, particularly for individuals with minimal anatomical deficit and daytime breathing dysfunction. Research is needed to elucidate mechanisms, to inform patient selection, and to refine clinical protocols.

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.

Pulmonary recovery directly after COVID-19 and in Long-COVID

Permanent impairment in patients after SARS-CoV-2 infection is frequent, but neither pathophysiology nor mechanisms of the so-called Post-COVID-Syndrome (Long-COVID) are well understood. We present data on pulmonary impairment, pulmonary recovery and outcome comparing patients admitted to a specific COVID-19 rehabilitation program directly after COVID-19 infection with patients long after COVID-19 infection. Diagnostic work up included echocardiography, cardiopulmonary exercise testing and pleural sonography. The rehabilitation program included multimodal respiratory therapy, endurance and resistance muscular training, psychological assistance, and educational measures. Patients in both groups showed similar pulmonary problems. Diaphragm dysfunction was common in both groups. Cardiopulmonary exercise testing showed dysfunctional breathing in most patients of both groups. The specific rehabilitation program applied yielded marked improvements with satisfying pulmonary recovery in both groups. Return to work was possible or expected in most patients. In conclusion, directly after COVID-19 infection as well as in long Covid 4 to 20 months after COVID-19 dysfunctional breathing patterns in cardiopulmonary exercise testing and diaphragm dysfunction on ultrasound are common and need diagnostic awareness and therapy measures. Specialized rehabilitation programs directly after COVID-19 as well as for Long-COVID patients are effective therapeutic options.

Characterization of adolescents with functional respiratory disorders and prior history of SARS-CoV-2

BACKGROUND

The SARS-CoV-2 pandemic has caused significant pulmonary morbidity and mortality in the adult population. Children and adolescents typically show milder symptoms; however, a relevant proportion of them report persistent pulmonary symptoms even after mild SARS-CoV-2 infection. Functional respiratory disorders may be relevant differential diagnoses of persistent dyspnea. This study aims at characterizing functional respiratory disorders that may arise after SARS-CoV-2 infection regarding their clinical presentation and pulmonary function tests as well as gaining insights into the clinical course after initiation of appropriate therapy.

METHODS

This study retrospectively identified all patients referred to an outpatient clinic for pediatric pulmonology with functional respiratory disorders manifesting after proven SARS-CoV-2 infection between January 1, 2022, and October 31, 2022. Clinical history, thorough clinical examination regarding breathing patterns, and pulmonary function tests (PFTs) were taken into consideration to diagnose functional respiratory disorders.

RESULTS

Twenty-five patients (44% female) with mean (m) age = 12.73 years (SD ± 1.86) who showed distinctive features of functional respiratory disorders after SARS-CoV-2 infection (onset at m = 4.15 (± 4.24) weeks after infection) were identified. Eleven patients showed thoracic dominant breathing with insufficient ventilation, and 4 patients mainly had symptoms of inducible laryngeal obstruction. The rest (n = 10) showed overlap of these two etiologies. Most patients had a flattened inspiratory curve on spirometry and slightly elevated residual volume on body plethysmography, but values of PFTs were normal before and after standardized treadmill exercise testing. Patients were educated about the benign nature of the condition and were offered rebreathing training. All patients with follow-up (n = 5) showed normalization of the breathing pattern within 3 months.

CONCLUSIONS

Functional respiratory disorders are important differential diagnoses in persisting post-SARS-CoV-2 dyspnea in adolescents. A combination of clinical history, detailed examination of breathing patterns, and pulmonary function tests are helpful to correctly diagnose these conditions. Reassurance and rebreathing training are the mainstay of the therapy. The clinical course is favorable.

Capnography-Assisted Learned, Monitored (CALM) breathing therapy for dysfunctional breathing in COPD: A bridge to pulmonary rehabilitation

BACKGROUND

Although dyspnea is a primary symptom of chronic obstructive pulmonary disease (COPD), its treatment is suboptimal. In both COPD and acute anxiety, breathing patterns become dysregulated, contributing to abnormal CO2, dyspnea, and inefficient recovery from breathing challenges. While pulmonary rehabilitation (PR) improves dyspnea, only 1-2% of patients access it. Individuals with anxiety who use PR have worse outcomes.

METHODS

We present the protocol of a randomized controlled trial designed to determine the feasibility and acceptability of a new, four-week mind-body intervention that we developed, called "Capnography-Assisted Learned, Monitored (CALM) Breathing," as an adjunct to PR. Eligible participants are randomized in a 1:1 ratio to either CALM Breathing program or Usual Care. CALM Breathing consists of 10 core, slow breathing exercises combined with real time biofeedback (of end-tidal CO2, respiratory rate, and airflow) and motivational interviewing. CALM Breathing promotes self-regulated breathing, linking CO2 changes to dyspnea and anxiety symptoms and targeting breathing efficiency and self-efficacy in COPD. Participants are randomized to CALM Breathing or a Usual Care control group.

RESULTS

Primary outcomes include feasibility and acceptability metrics of recruitment efficiency, participant retention, intervention adherence and fidelity, PR facilitation, patient satisfaction, and favorable themes from interviews. Secondary outcomes include breathing biomarkers, symptoms, health-related quality of life, six-minute walk distance, lung function, mood, physical activity, and PR utilization and engagement.

CONCLUSION

By disrupting the cycle of dyspnea and anxiety, and providing a needed bridge to PR, CALM Breathing may address a substantive gap in healthcare and optimize treatment for patients with COPD.

Reported Symptoms Differentiate Diagnoses in Children with Exercise-Induced Respiratory Problems: Findings from the Swiss Paediatric Airway Cohort (SPAC)

BACKGROUND

Exercise-induced breathing problems with similar clinical presentations can have different etiologies. This makes distinguishing common diagnoses such as asthma, extrathoracic and thoracic dysfunctional breathing (DB), insufficient fitness, and chronic cough difficult.

OBJECTIVE

We studied which parent-reported, exercise-induced symptoms can help distinguish diagnoses in children seen in respiratory outpatient clinics.

METHODS

This study was nested in the Swiss Paediatric Airway Cohort, an observational study of children aged 0 to 17 years referred to pediatric respiratory outpatient clinics in Switzerland. We studied children aged 6 to 17 years and compared information on exercise-induced symptoms from parent-completed questionnaires between children with different diagnoses. We used multinomial regression to analyze whether parent-reported symptoms differed between diagnoses (asthma as base).

RESULTS

Among 1109 children, exercise-induced symptoms were reported for 732 (66%) (mean age: 11 years, 318 of 732 [43%] female). Among the symptoms, dyspnea best distinguished thoracic DB (relative risk ratio [RRR]: 5.4, 95% confidence interval [CI]: 1.3-22) from asthma. Among exercise triggers, swimming best distinguished thoracic DB (RRR: 2.4, 95% CI: 1.3-6.2) and asthma plus DB (RRR: 1.8, 95% CI: 0.9-3.4) from asthma only. Late onset of symptoms was less common for extrathoracic DB (RRR: 0.1, 95% CI: 0.03-0.5) and thoracic DB (RRR: 0.4, 95% CI: 0.1-1.2) compared with asthma. Localization of dyspnea (throat vs chest) differed between extrathoracic DB (RRR: 2.3, 95% CI: 0.9-5.8) and asthma. Reported respiration phase (inspiration or expiration) did not help distinguish diagnoses.

CONCLUSION

Parent-reported symptoms help distinguish different diagnoses in children with exercise-induced symptoms. This highlights the importance of physicians obtaining detailed patient histories.

Voice bubbling therapy for vocal cord dysfunction in difficult-to-treat asthma - a pilot study

OBJECTIVE

Dysfunctional breathing often coexists with asthma and complicates asthma control, especially in difficult-to-treat asthma. Voice bubbling therapy (VBT) by a specialized speech therapist may influence the breathing pattern. This pilot study investigated the effect of voice bubbling therapy (VBT) in participants with difficult-to-treat asthma, who fulfilled criteria for dysfunctional breathing pattern.

METHOD

Twenty-four patients were randomized between VBT and usual care (UC). VBT is blowing into a glass (resonance) tube (28 cm in length, 0.9 cm inner diameter) which ends in a bowl of water (1.5 litre). Lung function, capillary blood gas and questionnaires were measured at baseline, at 6 and 18 weeks of follow up.

RESULTS

No difference in ACQ and quality of life was found after VBT compared to UC group. However, after six weeks of bubbling therapy, pCO2 levels measured in capillary blood gas were higher (baseline median (IQR) pCO2 = 33.00 (17.25 - 38.6) mmHg; week 6 pCO2 = 36.00 (29.00 - 42.3) mmHg) p = 0.01. Moreover, ΔpCO2 (baseline - 18 weeks of follow up) was significantly correlated with ΔAQLQ (rs = 0.78, p = 0.02).

CONCLUSION

VBT in participants with difficult-to-treat asthma resulted in a higher average pCO2 level, indicating the treatment may improve hyperventilation. However, this did not improve asthma control or quality of life. VBT may have value for a better management of asthma related symptoms.

Observational case series describing features of cardiopulmonary exercise testing in Postural Tachycardia Syndrome (PoTS)

Postural Tachycardia Syndrome (PoTS) is a chronic condition often affecting multiple systems with varied presenting symptoms. Diagnosis is made by demonstrating cardiovascular criteria on standing along with clinical assessment. Cardiopulmonary exercise testing has been used to demonstrate and characterise the physiological response to exercise and the severity of the syndrome. Previous studies on exercise testing in these patients have focussed on cardiovascular changes alone. This series characterises the integrated cardiac and respiratory response to exercise seen with cardiopulmonary exercise testing. Our main findings show that peak oxygen uptake, work done and peak heart rate are significantly reduced from their respective predicted values in PoTS patients. However, despite this, most patients demonstrated a normal exercise capacity. Features of ventilatory inefficiency were also seen which suggest exercise capacity in these patients may be limited more by impaired ventilatory control such as dysfunctional breathing during exercise rather than by cardiovascular issues.

The impact of mental toughness and postural abnormalities on dysfunctional breathing in athletes

Background: While asthma and exercise-induced bronchoconstriction (EIB) can explain some cases of exertional dyspnea, the differential diagnosis of dyspnea is extensive. Dysfunctional breathing (DB) is a condition that is often overlooked and underdiagnosed. Pharmacologic treatments are available and widely utilized by clinicians for exertional dyspnea, but a better understanding of the non-pharmacologic treatments as well as psychological factors that play a role in DB can provide professional, elite amateurs, and recreational athletes with more therapeutic options.Measurement tools for mental toughness: Given the psychological components involved with these conditions, a tool to measure domains of sports mental toughness in athletes could help medical providers create a more comprehensive athlete profile which can be used in conjunction with standard pharmacologic therapy to provide a more effective treatment plan.Diagnosing DB: While normal breathing mechanics help shape appropriate posture and spinal stabilization, DB has been shown to contribute to pain and motor control deficits resulting in dysfunctional movement patterns, which further contribute to DB. Most respiratory specialists are unaware of how to assess the role of faulty sports technique, especially running gait, in dysfunctional breathing patterns making it difficult to recommend appropriate treatment and offer referrals for relevant therapies.Assessing postural changes: Three key components of proper running gait are reviewed and described in detail including trunk counter-rotation, extension of atlanto-occipital joint in conjunction with a forward tilted trunk, and ankle and hip joint range of motion.Conclusions: When underlying gait abnormalities and mental skills are addressed properly, they can disrupt poor breathing mechanics, facilitating a transition away from DB and toward healthier breathing patterns.KEY POINTS In summary, the following points should be considered when evaluating athletes who are having difficulty breathing even when compliant with their medications or if there is not an indication of asthma or EIB:Assess dysfunctional breathing (DB) with Nijmegen questionnaire (NQ).If DB is present, measure mental skills using the Sisu Quiz to determine an athlete's mental skills profile.Evaluate postural changes that may impact an athlete's ability to breathe.Using the three tools of the NQ, Sisu Quiz, and Postural assessments creates an athlete profile that is clinically useful to improve breathing technique.DB is often mistaken for other conditions for which medications are prescribed. By identifying DB early and making appropriate changes may negate or reduce the need for pharmacotherapy.Improving DB will improve athletic performance.

The clinical utility of the Breathing Pattern Assessment Tool (BPAT) to identify dysfunctional breathing (DB) in individuals living with postural orthostatic tachycardia syndrome (POTS)

BACKGROUND

Dysfunctional breathing (DB) resulting in inappropriate breathlessness is common in individuals living with postural orthostatic tachycardia syndrome (POTS). DB in POTS is complex, multifactorial, and not routinely assessed clinically outside of specialist centres. To date DB in POTS has been identified and diagnosed predominately via cardiopulmonary exercise testing (CPEX), hyperventilation provocation testing and/or specialist respiratory physiotherapy assessment. The Breathing Pattern Assessment Tool (BPAT) is a clinically validated diagnostic tool for DB in Asthma. There are, however, no published data regarding the use of the BPAT in POTS. The aim of this study was therefore to assess the potential clinic utility of the BPAT in the diagnosis of DB in individuals with POTS.

METHODS

A retrospective observational cohort study of individuals with POTS referred to respiratory physiotherapy for formal assessment of DB. DB was determined by specialist respiratory physiotherapist assessment which included physical assessment of chest wall movement/breathing pattern. The BPAT and Nijgmegen questionnaire were also completed. Receiver operating characteristics (ROC) analysis was used to compare the physiotherapy assessment based diagnosis of DB to the BPAT score.

RESULTS

Seventy-seven individuals with POTS [mean (sd) age 32 (11) years, 71 (92 %) female] were assessed by a specialist respiratory physiotherapist, with 65 (84 %) being diagnosed with DB. Using the established BPAT cut off of four or more, receiver operating characteristics (ROC) analysis indicated a sensitivity of 87 % and specificity of 75 % for diagnosing DB in individuals with POTS with an area under the curve (AUC) of 0.901 (95 % CI 0.803-0.999), demonstrating excellent discriminatory ability.

CONCLUSION

BPAT has high sensitivity and moderate specificity for identifying DB in individuals living with POTS.

Vocal cord dysfunction/inducible laryngeal obstruction induced by hyperventilation in healthy individuals, people with asthma, and following coronavirus infection

OBJECTIVE

Vocal cord dysfunction/inducible laryngeal obstruction (VCD/ILO) commonly co-exists with asthma and can start after viral infections. In this setting evidence suggests that dysfunctional breathing may induce the disorder but this possibility has not been researched. We therefore postulated that dysfunctional breathing can induce VCD/ILO, more so in people with asthma and after viral infections.

METHODS

Eight healthy control subjects, 16 people with asthma and eight people who had recent COVID-19 infection (three with asthma) were recruited. Video-recorded laryngoscopy was performed at tidal breathing and during controlled hyperventilation (used as a proxy for dysfunctional breathing). VCD/ILO was diagnosed by laryngoscopy using accepted criteria and correlated with study cohorts, clinical attributes, asthma severity and spirometry.

RESULTS

Overall, 32 subjects were studied. Hyperventilation was verified in all subjects. None of the healthy control group or people with mild asthma developed VCD/ILO during or after hyperventilation but one person with moderate/severe asthma had clear evidence of VCD/ILO. In contrast, in people who had COVID-19 infection, hyperventilation induced VCD/ILO in 3/8 people (38%).

CONCLUSION

These proof-of-concept studies suggest that hyperventilation can provoke VCD/ILO in asthma and after a recent viral infection. How and why VCD/ILO develops is not known and these preliminary findings should prompt further studies of links between dysfunctional breathing, asthma, and viral infections.

Cardiopulmonary Exercise Test in the Detection of Unexplained Post-COVID-19 Dyspnea

There is emerging evidence of prolonged recovery in survivors of coronavirus disease 2019 (COVID-19), even in those with mild COVID-19. In this paper, we report a case of a 39-year-old male with excessive body weight and a history of borderline values of arterial hypertension without therapy, who was mainly complaining of progressive dyspnea after being diagnosed with mild COVID-19. According to the recent guidelines on the holistic assessment and management of patients who had COVID-19, all preferred diagnostic procedures, including multidetector computed tomography (CT), CT pulmonary angiogram, and echocardiography, should be conducted. However, in our patient, no underlying cardiopulmonary disorder has been established. Therefore, considering all additional symptoms our patient had beyond dyspnea, our initial differential diagnosis included anxiety-related dysfunctional breathing. However, psychiatric evaluation revealed that our patient had only a mild anxiety level, which was unlikely to provoke somatic complaints. We decided to perform further investigations considering that cardiopulmonary exercise test (CPET) represents a reliable diagnostic tool for patients with unexplained dyspnea. Finally, the CPET elucidated the diastolic dysfunction of the left ventricle, which was the most probable cause of progressive dyspnea in our patient. We suggested that, based on uncontrolled cardiovascular risk factors our patient had, COVID-19 triggered a subclinical form of heart failure (HF) with preserved ejection fraction (HFpEF) to become clinically manifest. Recently, the new onset, exacerbation, or transition from subclinical to clinical HFpEF has been associated with COVID-19. Therefore, in addition to the present literature, our case should warn physicians on HFpEF among survivors of COVID-19.

Cardiopulmonary exercise testing to indicate increased ventilatory variability in subjects with dysfunctional breathing

BACKGROUND

Dysfunctional breathing (DB) is a common, but largely underappreciated, cause of chronic dyspnea. Under visual inspection, most subjects with DB present with larger sequential changes in ventilation (V̇E) and breathing pattern (tidal volume (VT) and breathing frequency (f)) before and/or during incremental cardiopulmonary exercise testing (CPET). Currently, however, there are no objective criteria to indicate increased ventilatory variability in these subjects.

METHODS

20 chronically dyspneic subjects with DB and 10 age- and sex-matched controls performed CPET on a cycle ergometer. Cut-offs to indicate increased V̇E, VT, f, and f/VT ratio variability (Δ= highest-lowest 20 s arithmetic mean) over the last resting minute (_rest ), the 2^sd min of unloaded exercise (_unload ), and the 3^rd min of loaded exercise (_load ) were established by ROC curve analyses.

RESULTS

Subjects with DB presented with increased V̇E, higher ventilatory variability, higher dyspnea burden, and lower exercise capacity compared to controls (p<0.05). ΔV̇E_load (> 4.1 L/min), Δf_rest (> 5 breaths/min; bpm), Δf_unload (> 4 bpm), Δf_load (> 5 bpm), Δf/VT_rest (> 4.9 bpm/L), and Δf/VT_load (> 1.3 bpm/L) differentiated DB from a normal pattern (areas under the curve ranging from 0.729 to 0.845). High Δf, in particular, was associated with DB across all CPET phases.

CONCLUSIONS

This study provides objective criteria to indicate increased ventilatory variability during incremental CPET in dyspneic subjects with DB. Large variability in breathing frequency seems particularly useful in this context, a finding that should be prospectively confirmed in larger studies. This article is protected by copyright. All rights reserved.

Dysfunctional Breathing and Depression Are Core Extrapulmonary and Behavior/Risk Factor Traits in Type 2-High Severe Asthma

BACKGROUND

Obesity and smoking are core treatable traits (TTs) in type 2 (T2)-low asthma, contributing to its pathophysiology. In contrast, core extrapulmonary and behavior/risk factor traits remain unclear in T2-high asthma.

OBJECTIVE

This study aimed to identify core extrapulmonary and behavior/risk factor traits for T2-high asthma.

METHODS

A cross-sectional study was conducted on 187 people (aged ≥18 years) with severe asthma who completed a multidimensional assessment. T2-high asthma was defined as blood eosinophils ≥150 cells/μL and/or fractional exhaled nitric oxide ≥20 ppb. Core TTs in T2-high asthma were identified among 9 extrapulmonary traits and 4 behavior/risk factor traits, using network analysis and dominance analysis for the Asthma Control Questionnaire scores, the Asthma Quality of Life Questionnaire scores, exacerbation frequency, and lung function. Associations between the identified core TTs and biomarkers were examined in participants with T2-high asthma.

RESULTS

Of 187 participants, 151 (80.7%) had T2-high severe asthma. Dysfunctional breathing and depression had higher values of node strength than other TTs, contributing most to worse asthma symptoms, poorer quality of life, and frequent exacerbations in T2-high asthma. These conditions in T2-high asthma were associated with elevated systemic inflammation, including blood neutrophils, neutrophil-lymphocyte ratio, and serum high-sensitivity C-reactive protein, independent of obesity, oral corticosteroid dose, and anxiety.

CONCLUSIONS

Core extrapulmonary and behavior/risk factor traits in T2-high severe asthma were dysfunctional breathing and depression, contributing to worse asthma outcomes, suggesting that core TTs may differ between asthma inflammatory phenotypes. Elevated systemic inflammation may help in recognizing the presence of dysfunctional breathing and depression in T2-high severe asthma.

Prevalence and characteristics of dysfunctional breathing in patients with asthma in the Japanese population

BACKGROUND

Dysfunctional breathing (DB) is a major asthma comorbidity; however, it is not well recognized in Japan. Moreover, it has rarely been reported in the asthma population, and its clinical characteristics are unclear. We aimed to clarify the clinical characteristics of DB as a comorbidity in patients with asthma in Japan. Questionnaire surveys were conducted among patients with asthma at medical facilities in three regions of Japan (Niigata, Kumamoto, and Tokyo).

METHODS

This cross-sectional questionnaire survey targeting patients with asthma who had regularly visited medical institutions and their doctors was conducted from September to November 2021. The questionnaire addressed the control status and method of treatment. The diagnosis of DB was evaluated using the Nijmegen questionnaire (NQ).

RESULTS

There were 2087 eligible participants. Based on their NQ scores, 217 patients were classified into the DB group (NQ ≥ 19). There were significant differences with respect to sex, disease duration, Asthma Control Test (ACT) scores, Patient Health Questionnaire-9 (PHQ-9) scores, type-2 biomarkers, pulmonary function indices, treatment methods, severity, and asthma exacerbations in the previous year between the DB and non-DB groups. In the multivariate analysis, there were significant differences in sex, disease duration (≥15 y), ACT scores (<20), and PHQ-9 scores (≥10). The cluster analysis of cases with DB classified the population into four clusters.

CONCLUSIONS

The asthma population with DB exhibited several characteristics, including depression and poorly controlled asthma. Further large-scale interventional investigations with longer follow-up periods are necessary to verify these findings.