"Not everything that whistles is asthma" is a common saying in medicine. Around 10% of the population - according to one estimate - suffers from respiratory disorders for which no physical cause can be found. It is called functional breathing disorder or dysfunctional breathing. These complaints are multifaceted and there is still no "gold standard" for diagnosis. Possibly the feeling of air hunger, shortness of breath, and also difficulty holding one's breath are the closest common denominators. Functional breathing disorders used to be often equated with hyperventilation. But this is only one, albeit the most common form. In fact, however, many more types of complaints belong to it. There is still no generally accepted classification of functional breathing disorders. However, you will find an overview of the most common forms here. In the case of most functional disorders, those affected go through long, frustrating paths until the correct diagnosis is made. The most common misdiagnosis is asthma. It is true that asthmatics often suffer from additional functional respiratory disorders. But unlike true bronchial asthma, no asthma spray helps against these symptoms. In the case of functional breathing disorders, other therapy methods are necessary and we are very relieved that we have been able to develop a therapy concept in recent years.
Overview and introduction
Have you ever really thought about your breathing?
Breathing plays an incomparable role in life. Without food we can survive for weeks, without drinking we can survive for days, but without breathing we literally run out of air after 3-4 minutes.
When we breathe, we take in oxygen and give off carbon dioxide. We talk about "combustion", and in fact every stove does nothing else: it burns a fuel with the help of oxygen and gives off carbon dioxide and water in return. What wood, coal or oil is to the stove, carbohydrates, protein and fat are to us.
The regulation of this process is finely regulated in our body. The oxygen concentration of the blood in healthy people under normal circumstances (no lung disease, no extreme altitudes) is almost 100% of the maximum possible value. The carbon dioxide content is about 40 mmHg (= mm mercury column).
What is your breathing rate?
If you are reading these lines right now, you are probably sitting quietly at your computer. You need energy; accordingly, you also need little oxygen and emit little carbon dioxide. In short, your breathing is calm and probably regular.
In such a case, your breathing rate will be around 12 to 15 puffs per minute. In children and adolescents, it is much faster. Depending on age, the resting rate here is 20-30 breaths.
But these normal values can be deceiving. Some people can lower their resting breathing rate to just a few breaths. 3-4 breaths per minute or less are possible when deeply relaxed.
It is different when you are exercising or running up stairs. Now you breathe rapidly to carry lots of oxygen through the blood to the muscles. You get rid of the "exhaust gases", the carbon dioxide, in the same breath - quite practical!
Fully automatic and unconscious
Breath regulation is highly automated; we don't need to think about it. Even when we prepare for an action, we breathe a little faster and thus unconsciously adjust to the increased demand for oxygen.
This can be observed particularly well in athletes, e.g. weightlifters, who take a few deep breaths before the decisive attempt and then "get down to business". Sprinters behave similarly in the starting blocks, etc.
From a medical point of view, this makes sense, as the athletes have thus prepared themselves for the increased demand for oxygen and have already exhaled a little carbon dioxide as a prophylactic measure. It is a proven reflex that runs completely automatically.
As a result, we are not aware of our breathing. Even very conspicuous breathing (continuous mouth breathing, breathing that is too fast) usually remains hidden to those affected.
The normal respiration
About normal breathing
Breath regulation is highly automated, we don't need to think about it. Even when we prepare for an action, we breathe a little faster and thus unconsciously adjust to the increased demand for oxygen.
This can be observed particularly well in athletes, e.g. weightlifters, who take a few deep breaths before the decisive attempt and then "get down to business". Sprinters behave similarly in the starting blocks, etc.
From a medical point of view, this makes sense, as the athletes have thus prepared themselves for the increased demand for oxygen and have already exhaled a little carbon dioxide as a prophylactic measure. It is a proven reflex that runs completely automatically.
Carbon dioxide
Most people assume that the oxygen content of the blood should be decisive for the respiratory drive. But this is not the case. As a rule, the production of carbon dioxide determines whether we breathe a lot or a little.
Another important factor is the acidity of the blood (pH). The more acidic the blood is (low pH) the faster breathing becomes. Fast breathing releases moreCO2, which leads to a drop in the level of carbonic acid in the blood. Less carbonic acid means: the pH level goes back to the norm (pH 7.38-7.42).
The corresponding receptors for blood gases are located in the carotid artery (near the division point of the carotid artery) and in the aorta at the so-called aortic arch. There are also sensors in the brain stem. Right near it (medulla oblongata and pons) there is also the respiratory center, which controls respiratory activity.
Reflex regulation
But it is precisely this reflex that can also cause problems. It also runs during mental tension, during which we do not move much afterwards.
If you are upset, angry or afraid about something, you often don't have the opportunity to run or physically attack your opponent afterwards. It would also be quite strange in many work situations to punch the air or pace back and forth in the office after an unpleasant phone call.
However, the age-old breathing reflex kicks in just as if we had to run from a tiger or attack an opponent. In short: we breathe too fast, which we are usually not aware of, since this rapid breathing is quite adequate to the inner tension.
Important exhaust
Now an imbalance of the respiratory gases occurs. Thereby the oxygen concentration changes only insignificantly, since it is anyway in the range of the theoretical maximum.
The concentration of carbon dioxide is different. It drops and reaches 35 mm Hg and less, i.e. much lower than normal. One might object that it is only good to get rid of the unwanted gas. But it is not that simple.
Our body needs a basic concentration of this gas, otherwise the acid-base balance (pH) of the body changes. With too little carbon dioxide, the blood becomes too alkaline (= basic, the opposite of acidic). This has a variety of effects on other bodily functions.
Above all, the amount of freely available calcium in the blood decreases. Its concentration can thus decrease by up to 50%. Since calcium is essential for nerve and muscle activity, this is where the most severe changes are seen. Essentially, there is a general overexcitability of the nerves and a cramping of the muscles.
Classification of functional respiratory disorders
In the past, it was assumed that hyperventilation and dysfunctional breathing were synonymous. In fact, acute and chronic hyperventilation are the most common forms of so-called "dysfunctional breathing" even though exact figures are lacking.
Typical leading symptoms are shortness of breath, air hunger and shortness of breath without organic cause.
There are various attempts to classify them, andBoulding et. al. propose 5 types, which are briefly described here. In fact, the phenomena overlap. In particular, chronic hyperventilation is often found in the other forms of respiratory dysfunction.
But there is currently no "gold standard" regarding the classification. Other distinctions may also be useful.In fact, we see more or less pronounced changes in breathing in many, if not most, functional disorders.
Classification hyperventilation
Typical accompanying symptoms
Other common complaints
Acute and chronic hyperventilation
The symptoms differ considerably and yet there is a common cause: changes in breathing.While acute hyperventilation syndrome is a highly acute complaint (shortness of breath, anxiety, palpitations, dizziness, panic), chronic hyperventilation syndrome is often overlooked. It usually manifests itself only indirectly and often only after years of symptoms. However, the consequences for the quality of life are sometimes even more serious and often lead to severe impairments, even to retirement.
Frequent yawning and sighing
Frequent sighing and (often accompanying) yawning is a difficult phenomenon to describe. It can occur in addition to the normal occasional sighing up to incessantly (every minute) and can be an extremely agonizing condition. Sufferers suffer from constant breath retention and have the feeling of not being able to breathe properly.
These complaints have become very important to us. They are presented in detail here.
Video yawn and sigh
Increased chest breathing
Increased chest breathing is found in physical diseases such as heart disease, COPD, diaphragmatic hypertension and also in very overweight people. However, it can also occur as a purely functional (stress) symptom.
Increased abdominal breathing
Little known is the phenomenon of increased abdominal press. The air is actively expelled with force. In normal breathing, exhalation is a passive process. Only inhalation is actively performed. This increased abdominal press can occur in pulmonary disease is, however, also described as a functional disorder. We have seen patients who have developed veritable six-packs this way without exercise.
Paradoxical breathing
Lack of synchronization of breathing is another disorder. Normally, the abdomen expands during inhalation and becomes flatter during exhalation. However, this can also be exactly the opposite and is then called "paradoxical breathing". In addition to this extreme form, there are other forms of lack of synchronization of breathing.
Development of respiratory disorders
A breathing disorder does not develop out of nowhere. Very often we find (multiple) irritations of breathing up to true "breathing traumas!
Near suffocation
Massive respiratory distress - as in near choking - can condition chronic respiratory failure.
Frequency
Not at all rare
Hyperventilation is not an uncommon symptom. There are estimates of 6-10% of all patients in an internal medicine practice. In anEnglish rural physician study, 10% of all patients were found to have an abnormal finding on theNijmegen HyperventilationQuestionnaire. (You will get an immediate result in our online version if you are suspected of having a breathing disorder).
Usually, as a physician, one thinks it is mainly women who are affected by the symptomatology. Surprisingly, however, both sexes have more or less the same tendency to accelerated breathing. However, it could be that more women find their way to the emergency room.
Very much more frequently obvious way patients with asthma bronchiale concerned. Here, every fourth person shows signs of hyperventilation.
In the course of life, the frequency of hyperventilation decreases. In retirement age it becomes much less frequent.
Panic attacks
The frequency for panic attacks is reported to be 3-4% in the population. The greatest frequency is in the 20-30 age group. Women are affected about twice as often as men.
If one summarizes all anxiety disorders, about 15% of all people suffer from them once in the course of their lives. At any given time, that is still 7% who are affected by one of the various forms of anxiety disorder (panic attacks, agoraphobia, specific phobias, generalized anxiety disorder).
Diagnostics
Diagnostics
As a rule, acute hyperventilation is explained by the typical symptoms without further technical examination. During the physical examination by the physician, the lively reflexes (see above), which can go as far as convulsions, and the tremor are particularly noticeable.
If there is the possibility of a blood gas examination, a lowering of the carbon dioxide level and an alkalosis of the blood (blood becomes alkaline) can be found. This examination sometimes takes place, for example, at the pulmonary specialist. For this purpose, a little capillary blood (e.g. earlobe) must be taken.
Increased reflexes
Very lively or even increased reflexes are often found in a functional respiratory disorder
Blood gases and respiratory gases
In breath gas analysis, the airflow is analyzed for CO2. The method is somewhat more susceptible to interference, but has the advantage of being able to be performed without blood sampling and for any length of time.
Blood gas analysis requires a drop of blood to be drawn from the earlobe or finger. These values are more accurate, but the examination is more time-consuming.
Hyperventilation test
Often no doctor is available during a seizure. Affected people overcome the seizure on their own and do not see a doctor until later.
In such cases, a hyperventilation test can be performed subsequently. Under the protected environment of a doctor's office or clinic, the patient breathes for up to 3 minutes l ang about 60 breaths per minute. During this time, the majority of symptoms should occur: Tingling, cramping, dizziness, visual disturbances, feelings of anxiety, lumpy feeling in the throat, palpitations and anxiety.
The test is more mentally than physically stressful, but should not be performed if you have bronchial asthma, severe heart disease or vascular disease. Please consult your physician before doing so.
Side effects: Headache, dizziness, lightheadedness, tingling - just the typical hyperventilation symptoms.
Hyperventilation test
After the test
Following the test, you can also breathe back - into your hands or into a bag. Within a very short time, the symptomatology fades, which is a second proof of hyperventilation.
Small peculiarities: Not all changes result from changes in carbon dioxide and acid-base balance. The palpitations, tremors and anxiety are also due to the increased output of stress hormones and mental tension.
Especially the stress hormones need some time to be released. Thus, not all the symptoms may disappear with rebreathing, but only in the course of 30 minutes to 1½ hours, namely when the stress hormones (adrenaline, noradrenaline and cortisone) have also returned to the initial level.
Chronic hyperventilation
Chronic hyperventilation
Chronic hyperventilation is such a comprehensive topic that this breathing disorder has been given its own section.
Chronic mouth breathing
Chronic mouth breathing
Even if at first sight it is not a serious disorder, persistent mouth breathing can have a surprising number of unfavorable consequences.
Fatigue syndromes
Exhaustion and breathing
Exhaustion is first of all a completely normal feeling. If you have worked a lot or have been able to get little sleep, then you need not be surprised if you feel tired at some point. But that is not what is meant here: it is not a calm, contented tiredness, but a restless, driven exhaustion, a tension-filled emptiness.
Another difference: if you have simply done too much for a while, then a soothing night's rest, a relaxing weekend or, in a pinch, a few quiet vacation days or weeks will help.
But for patients, it's different. Neither the night sleep, nor the sick leave, nor the rest during the day somehow makes it better. They have an almost indomitable need for rest and recuperation - but that need cannot be satisfied. It seems like an evil curse: the more they rest, the more exhausted they feel. We have patients who, after months or years of rest, can practically only lie down. Even sitting overwhelms them after a short time, not to mention standing or other movement.
What kind of complaint is this? What should be done?
Odor sensitivity
Breathing and smell
Bad odors bother almost all people. However, it may be that the sensitivity to odors and fragrances is increased to such an extent that a real suffering arises from it. This is referred to by various terms: Hyperosmia, Osmophobia (fear of smell), MCS (multiple chemical sensitivity, idiopathic environmental intolerance, multiple chemical sensitivity, multiple-chemical-sensitivity-syndrome and others.
Breathing disorders are very common in patients with heightened odor sensitivity.
Vocal Cord Dysfunction - VCD
Feelings of lumpiness and compulsive throat clearing
Feelings of lumpiness and compulsive throat clearing
Patients report that they constantly suffer from the feeling, which is difficult to describe, that there is something disturbing and constricting in their throat and that it has to come out somehow. They constantly feel the need to swallow or clear their throat. For some, it also triggers an urge to cough or shortness of breath.
Muscle fasciculation
(copy 10)
The symptoms can seem extremely threatening: Suddenly, the muscles twitch in various parts of the body. At the same time, nothing moves and it does not hurt. Only under the skin do parts of the muscles seem to develop a life of their own. What are these strange complaints? Are they actually threatening?
Nocturnal breathing disorders
Nocturnal breathing disorders
It can happen when falling asleep, in the middle of the night, when waking up or even during a nap: Someone wakes up with palpitations, shortness of breath or even feelings of panic.
What is the cause?
Panic attacks
(copy 11)
Panic attacks and panic disorders are referred to as a subtype of anxiety disorders. They come suddenly "out of the blue" and are accompanied by fear of death. Most of those affected primarily experience an intense physical threat and are often surprised when no physical findings are raised. Many are skeptical when a purely psychological disorder is assumed. In fact, there are new insights into the organic background of panic that are leading to innovative, effective therapies.
Physiological consequences
Consequential misbreathing
Permanently altered breathing has a number of physiological, i.e. physical, consequences. They are presented here in detail. These videos are a bit demanding, but you may be able to understand a lot.
- Circulatory disorders
- Hypoglycemia
- Effects on the uptake and release of carbon dioxide and oxygen
- Electrolyte changes
A final video delineates the physiological and psychological changes.
Introduction
Respiration and blood vessels
Respiration and blood sugar
Bohr and Haldane effect
Respiration and electrolytes
Body and soul
Postural tachycardia and hyperventilation
In postural tachycardia, sufferers feel most comfortable when lying down. But woe betide you when you stand up. Then the pulse suddenly jumps up by 30 or more beats per minute.
But that's not all: there is a feeling of emptiness in the head, nausea, weakness, trembling, anxiety and sometimes feelings of panic. After a while, above all, a barely controllable exhaustion sets in.
Some lie down almost the whole day and are hardly able to lead a normal everyday life.
It is about backgrounds, causes and therapy options - also with our innovative app.
Irritable cough
Phagophobia
The fear of swallowing
Phagophobia or swallowing anxiety is the fear of swallowing. This is usually accompanied by a fear of choking (choking phobia) and should not be confused with globus hystericus or anorexia nervosa. In addition to the fear of choking on food, there may also be a fear of swallowing saliva.
Phagophobia is classified as a specific phobia (ICD: F40.2) and is distinguished from agoraphobia, panic disorder, and generalized anxiety disorder. The disorder is also mentioned in the DSM-5.
Constant sighing or yawning
Why do we sigh? Of course because we don't have it easy in life! But then a sigh of relief makes little sense!
We sigh from completely different mental causes: Sadness, frustration, situation boredom, stress or surprise. We give up with a sigh and we express our relief by such a deep breath.
Besides: the sigh exists in all mammals. The smaller the more frequent! Rats, for example, indicate their relief at not being electrocuted by sighing.
In short: sighing is a very old reflex, deeply connected with our biology. Since then, the meaning of sighing is also understood worldwide, completely independent of language or culture.
Therapy of respiratory disorders
In therapy, it is useful to distinguish between acute measures and longer-term therapy.
A single hyperventilation attack/panic attack can usually be quickly brought under control, provided that the symptomatology is correctly recognized. With the right technique, it is usually possible to intercept the threatening symptomatology. This alone is already a great help for those affected.
However, a deep sense of insecurity often remains after such an experience. This then usually leads to further symptoms that are not so easy to treat. These include persistent dizziness, lightheadedness, jumpiness, anxiety, pressure on the chest, difficulty swallowing or other functional disorders.
In these cases, further measures are necessary. As a rule, we then carry out a multimodal therapy.
Acute hyperventilation
Therapy of acute hyperventilation
During a panic attack with hyperventilation, a vicious circle is triggered by an external event. Usually this happens in a tense situation; sometimes, however, it is trivial situations such as quickly sitting up or physical exertion.
Accelerated breathing causes a decrease in the carbon dioxide content of the blood, a pH shift and the consequent relative calcium deficiency of the blood.
In the past, therefore, attempts were made to neutralize the pH of the blood with a buffer infusion. Calcium was also given as an injection. Both methods are abandoned today. Injection of a diazepam-type sedative (e.g., "Valium®") is also considered obsolete today.
The therapy of choice in acute seizures is sedation and rebreathing.
Chronic respiratory disorders
Confidence and trust
The permanently accelerated breathing very often leads to a state of inner agitation and deep insecurity. In a further step of the therapy, therefore, an attempt is made to restore security and well-being.
Conversations are used for this purpose, in which an understanding of the symptomatology and its origins is gained. But beyond that, it is about the sensual experience that the body feels good and vital again. Massages, physiotherapy, exercise convey confidence and trust.
In our view, this part of the therapy plays a major role in achieving quick success.
Capnometer assisted breathing training
In functional respiratory disorders, the blood carbon dioxide is usually too low. This is especially true during stress and internal tension. The problem: You cannot perceive the carbon dioxide content of your blood. It is similar to blood pressure. Even people who have had elevated blood pressure for years or decades notice little or nothing of it.
Therefore, measuring the CO2 level with a so-called capnometer (kapnos = smoke) is of central importance to us. We use such devices not only diagnostically but also therapeutically. Above all, devices that determine the CO2 content of the air we breathe have proven their worth. This corresponds to the CO2 of the blood.
If you now measure the CO2 content of the air during breathing exercises, you can see whether you are performing the exercises correctly. It is unfortunately the case that many breathing exercises, although technically correct, nevertheless lead to a highly undesirable reduction in CO2 levels.
Breath APP
Over several years, we have been able to develop an app that you can use to train at home. This is suitable as a supplement to the above measures or as a stand-alone therapy in less pronounced cases.