Dysfunctional breathing context, causes and contributing-spree cast may 2013

Dysfunctional Breathing -Context, Causes and Contributing Factors

Dr. Rosalba Courtney ND, DO, PhD

Lecture for Airway and Facial Development Collaborative- May 2013

Rosalba Courtney 2013 2

Functional Breathing is Adaptive, Appropriate, Responsive

Functional breathing is breathing that performs and adapts its various functions to quickly and appropriately meet the changing needs of the individual and changes in the internal and external environment.

It adapts appropriately to rest and activity.


Functional breathing- efficiently maintains the functions of breathing

• Primary– Biochemical- Optimise O2 and CO2, pH regulation and

metabolism. – Biomechanical- Optimise neuromuscular respiratory pump.

• Secondary– motor control and postural stability – regulation of homeostatic e.g. cardiorespiratory oscillations via

cardiopulmonary coupling– regulation of ANS and modulation of vagal activity– self-regulation of stress and emotion. – psycho-spiritual functions


Functional breathing is the most efficient breathing for the conditions


What is Dysfunctional Breathing

• Dysfunctional breathing is not adaptive, responsive or appropriate.

• Dysfunctional breathing is not the most efficient breathing for the conditions

Dysfunctional breathing results in disturbance or inefficiency of the primary or secondary functions of breathing.

Dysfunctional Breathing contributes to symptoms and pathology.

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Dysfunctional Breathing has several dimensions

Biochemical•CO2•pH•O2•Hyperventilation

Biomechanical•Paradoxical•Thoracic Breathing• Irregular•Inefficient/Weakness, Co-ordination

Psycho-physiological•Symptoms •Perception•Stress•Anxiety/Fear•Depression

Rhythms and OscillationsStability

HomeostatisCardiorespiratory Control and Efficiency

Autonomic Nervous System

Rosalba Courtney 2013


Separate dimensions of DB- overlap but not completely

Neuro Muscular-Breathing Pattern and Habits

-Biochemical- CO2, O2, pH

Breathing Symptoms

Psychophysiological-


COURTNEY, R., GREENWOOD, K. & COHEN, M. 2011. Relationships between measures of dysfunctional breathing in a population with concerns about their breathing. Journal of Bodywork and Movement Therapies, 15, 24-34.

- target the breathing therapy to the individual. -consider underlying factors and treat causes if possible

- consider key aspects of breathing functionality- evaluate and measure progress


To be most effective breathing therapy should focus on the patient, their specific breathing dysfunction and its causes


Breathing responds to many conditions. Breathing functionality depends on context.

BREATHING

Psychophysiology

Muscular and Skeletal

Disease processes

Homeostasis

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Breathing patterns that seem dysfunctional can be appropriate in certain circumstances.

LRC/ABD URC

Animation adapted from Lasovetskaya 2008

Relaxed Configuration-Natural at rest, in relaxed state for healthy individual

Active Configuration- natural tendency for increased respiratory drive, increased rate or volume of breathing, especially if sudden.



Thoracic Breathing- URC breathing

Dysfunctional when habitual and thoracic dominance persists at rest.i.e. active configuration during relaxation

In some cases can preserve diaphragm length and curvature better because maintains abdominal tone. So can be appropriate in some COPD patients etc.

Mouth Breathing – a serious dysfunction with many consequences- structural, postural and health

Importance of context

Mouth breathing in a child with obstructed breathing.

Functional?? Dysfunctional

?

Children with long standing nasal obstruction have significantly lower oxygen.

Parameter Normal Control

Obstructed-Pre surgery

Obstructed-Post surgery

Oxygen Saturation (SpO2)- Range

84-94% 87-97%

Oxygen Saturation (SpO2)- Mean

96.0% (1.4) 89.4% (3.0) 93.5%(3.0)

Arterial Oxygen (PaO2)-Range

57-84mmHg 67-102mmHg

Arterial Oxygen (PaO2)-Mean

90.33 (6.85)mmHg

70.93 (6.07)mmHg

87.83 (12.13)mmHg

KHALIFA, M. S., KAMEL, R. H., ZIKRY, M. A. & KANDIL, T. M. 1991. Effect of enlarged adenoids on arterial blood gases in children. Journal of Laryngology and Otology, 105, 436-438

Mouth breathing in a child with obstructed airways

Functional-Situation 1Child closes their mouth and O2 levels drop. However mouth breathing has many negative consequences so new problems arise.

Dysfunctional- Situation 2Child closes their mouth and O2 levels rise.

Children with long standing nasal obstruction have slightly lower CO2 levels on average (some in hyperventilation range- not always).

Parameter Normal Control

Obstructed-Pre surgery

Obstructed-Post surgery

Arterial CO2 (PaCO2)- Range

32-44mmHg 33-44mmHg

Arterial CO2 (PaCO2)-Mean

39.17 (1.64) mmHg

38.57 (3.54)mmHg

37.6 (3.14)mmHg

KHALIFA, M. S., KAMEL, R. H., ZIKRY, M. A. & KANDIL, T. M. 1991. Effect of enlarged adenoids on arterial blood gases in children. Journal of Laryngology and Otology, 105, 436-438

Hypoxia usually decreases CO2 tolerance.

Hypoxia increases the sensitivity and ventilatory recruitment threshold of the peripheral chemoreflex response to CO2.

Hyperventilation to some extent be an adaptive response to hypoxia. This has a cost and negative consequences but loss of this response may also lead to problems. (see following study).

FREGOSI, R. F., QUAN, S. F., JACKSON, A. C., KAEMINGK, K. L., MORGAN, W. J., GOODWIN, J. L., REEDER, J. C., CABRERA, R. K. & ANTONIO, E. 2004. Ventilatory drive and the apnea-hypopnea index in six-to-twelve year old children. BMC Pulm Med. , 4.

High CO2 and low ventilatory drive correlated with more severe sleep apnea

Fifty children, 6 to 12 years of age were studiedAsleep-Polysomnogram to compute the OAHI.Awake- Measured ventilatory drive – normoxia, isocapnic hypoxia,hyperoxic hypercapnia CONCLUSIONS: In awake children the OAHI correlates inversely with the hypoxic ventilatory drive and positively with the resting PETCO2.

Reduced hypoxic ventilatory drive and resting CO2 retention are associated with sleep-disordered breathing in 6-12 year old children.

Context of hyperventilation and mouth breathing should guide treatment decisions

Hyperventilation and Mouth Breathing may be semi- functional adaptations to obstruction and hypoxia.

They may be difficult to treat until we raise oxygen levels and increase airway size.

Maladaptive Respiratory Plasticity as a Cause of Dysfunctional Breathing

BAKER, T. L., FULLER, D. D., ZABKA, A. G. & MITCHELL, G. S. 2001. Respiratory plasticity: differential actions of continuous and episodic hypoxia and hypercapnia. Respiratory Physiology, 129, 25-35.

Long Term Facilitation (LTF)- alters neuroplasticity of respiratory motor control.

Hypoxia

Hypercapnia

Hypoxia, Hypercapnia can also stimulate adaptive changes in neuroplasticity of breathing.

• Activate Long Term Facilitation (LTF)– Increase chemosensitivity– Active airway dilator muscles via vagus and

hypoglossal nerve.

LTF can be adaptive and protective in situations like sleep apnoea or maladaptive if it results in inappropriate breathing.


Stress and Excess Allostatic Load is an important source of dysfunctional breathing.

Modified from McKewen 1998

Perceived Stress-threat, helplessness, vigilance

Behavioural Response

Physiological Response

Individual differences

AllostasisAdaptation

Allostatic Load

Environmental Stressors

Major Life Events Trauma Abuse


Dysfunctional breathing evidence of a general instability of the homeostatic brain.

Entrophy of Respiration

Cardio-respiratory coupling and HRV

Balance system abnormalities

Respiration, cardiovascular homeostasis are interrelated and disruptions in one often accompanied by others

PERNA, G., CALDIROLA, D. & BELLODI, L. 2004. Panic disorder: from respiration to the homeostatic brain. Acta Neuropsychiatrica, 16, 57-67.

Hypothesis- Abnormal Function of the Homeostatic Brain

Babies especially responsive to respiratory neuroplasticity in sensitive development periods

-hypoxia-hypercapnia-stress-injury-trauma

Altered mature respiratory control

Marcus et al. Developmental Aspects of the Upper Airway-Report from an NHLBI Workshop, March 5–6, 2009. Proc Am Thorac Soc. , 15, 6.

Birth Trauma, structural dysfunction and breathing.

“all cases of persistent C0 – C1 compression are accompanied by a dysfunction of the sphenoid-vomer articulation. This pattern in its pure form is mainly inherent to children and is usually connected with a birth trauma”From ……Dr Larissa Lasovetskaya 2008

Neuro-Muscular Factors associated with dyspnea that also contribute to breathing pattern disorders and mouth breathing


Symptoms- hyperinflation, short flat diaphragm, rib cage stiffness and neuromechanical uncoupling

•High dyspnoea•Unsatisfied respiration•Cant take a deep or satisfying breath•Rib cage cant expand

Dysfunctional Breathing

•Mouth Breathing•Hyperventilation•Breathing Pattern

Disproportionate and unexplained nasal obstruction explained by dysfunctional

breathing (HV and BPD)

BARTLEY, J. 2006. Nasal congestion and HVS. Am J Rhinology, 19, 607-11.

14 patients with unexplained ongoing nasal congestion after surgery and medication.

Breathing- 3 patients underwent capnometry and CO2 <35mmHg, all had tachypnoea, upper thoracic bpd , 12 high NQ score,

Does Hyperventilation contribute to obstruction and mouth breathing?

YES• Hyperventilation increases

nasal resistance.Dallimore,, 1977Acta Otolaryngol, 84, 416-

421.

• Raising CO2 can decrease nasal resistance and treat seasonal rhinitis .

Casale, 2008.J Allergy Clin Immunol.121, 105-109.

• There is a linear relationship.Mertz, 1984. Otolaryngol Head Neck

Surg., 92, 302-307.

Is Hyperventilation primary cause obstruction and mouth breathing?

NO• Large amount of

epidemiological and experimental evidence showing that the cause of obstructed airways and respiratory allergy is related to recent changes in the environment, diet and state of the modern human microbiome.

Causes of DB in children-increased nasal resistance and obstruction of upper airway

• “mouth breathing happens whenever the body senses that nasal resistance is too high”

- Food and airborne allergy

-Hypertrophy lymphoid tissue-nasal changes venous

engorgement, polyps

Is Hyperventilation the main cause of allergy, inflammation, asthma, sleep apnea, 150 other diseases .... NO

Is Hypocapnia important...YES

Role of CO2 in the Body

CO2

Mild Broncho/Vessel Dilator pH Buffering

Activity of Enzymes and Mediators

Role of CO2 in the Body

CO2

Mild Broncho/Vessel Dilator pH Buffering

Activity of Enzymes and Mediators

A Substrate for the Synthesis of Essential Aminoacids and Enzymes

Low CO2

- Bronchocontriction- Blood supply to the brain- Blood supply to the tissues

Changes in pH

Changes in activity of Enzymes

Deficit in essential aminoacids,

neuromodulators and Neurotransmitters

Impairment in Oxygen utilisation

Decrease in buffering capacity, wash out essential

cations:- Calcium,- Magnesium,- Zinc,- Potassium,- Sodium

Overexcitability of Nervous

system

History Of Hyperventilation Syndrome

Pre-1980’s

After 1980’s

1990’sNOWHV back on the radar-better diagnostics.Hypocapnia found to moderate symptoms in asthma, panic disorder.HVS not back.

Accepted diagnosispatients with anxiety, disturbed breathing and unexplained “psychosomatic” symptoms . Argued to be common, yet infrequently recognized (Lum 1975; Lum 1976; Magarian 1982).

Increasing doubts about the specific role of CO2 in symptoms of HVS and HVPT

Recommended that the term hyperventilation syndrome be discontinued (Hornsveld 1997)

Careers ruined.Scientists would not touch it. Labs stopped researching hypocapnia.

Hyperventilation Syndrome-Changing Definition

4th International Symposium on Psychophysiology

in Southampton in 19843rd International Conference of Respiratory

Psychophysiology Nijmegen, 1997

• “Hyperventilation syndrome is a syndrome characterized by a variety of somatic symptoms induced by a physiologically inappropriate hyperventilation and usually produced in whole or in part by voluntary hyperventilation” p287, (Howell 1990).

• Hyperventilation Syndrome is “ a dysregulation of ventilation, causing hypocapnia, in the absence of somatic causes for hyperventilation, with symptoms not necessarily linked to hypocapnia” p73 (Molema and Folgering 1997).

There has been a huge increase in allergic, inflammatory and immune diseases in last 50-60 yrs in developed world.

One in three children has allergies. This accounts for about a 400% increase in the last 30-40 years. It is predicted* this will increase to 1 in 2 children by the year 2015.

Asthma has increased by about 300%

*Global Allergy and Asthma European Network

Figure 1: Changes in prevalence of diagnosed asthma (A) and asthma symptoms (B) over time among children and young adults.

Subbarao P et al. CMAJ 2009;181:E181-E190

©2009 by Canadian Medical Association

Asthma increases are in Developed Countries

Causes of increased allergy, asthma and immune dysfunction are environmental.

• International study of asthma and allergy in childhood (ISAAC) a study of 798,685 childen aged 13-14 years from 97 countries and 388,811 children aged 6-7 yrs from 61 countries.

• Conclusion-The major differences between populations due to

environmental factors.

• ISAAC 1998. Worldwide variations in the prevalence of asthma symptoms: the International Study of Asthma and Allergies in Childhood (ISAAC). European Respiratory Journal, 12, 315-335.

Differences in Asthma and Allergy Levels between East and West Germany at Time of Re-Unification

• Allergy considerably more frequent in West German children than in their peers in East Germany (36.7% versus 18.2%; )

• Asthma and hay fever also significantly higher in West Germany than East Germany (5.9% versus 3.9%).

The Berlin Wall -1946-1989

VON MUTIUS, et al 1994. Prevalence of asthma and atopy in two areas of West and East Germany. American Journal of Respiratory and Critical Care Medicine, 149, 358-64.

Studies point to several environmental factors that influence allergy and asthma

• Urban vs Rural Living

• Prosperity • Exposure to Animals• Changes in Diet• Microbial Diversity

in Water, Food, Air etc.

MORGAN et al. 2013. Biodiversity and functional genomics in the human microbiome. Trends in Genetics, 26, 51-58.

Old Friends Theory- Immune dysregulation in modern urban humans related to

missing organisms we co-evolved with .

.

ROOK, G. A. 2007. The hygiene hypothesis and the increasing prevalence of chronic inflammatory disorders. Trans R Soc Trop Med Hyg, 101, 1072-4.

The 'Hygiene' or 'Old Friends' hypothesis suggests that increases in chronic inflammatory disorders (allergies, inflammatory bowel disease and autoimmunity) in developed countries are partly attributable to diminishing exposure to organisms that were part of mammalian evolutionary history. Crucial organisms, including helminths and saprophytic mycobacteria, are recognised by the innate immune system as harmless or, in the case of helminths, as organisms that once established must be tolerated. This recognition then triggers development of regulatory dendritic cells that drive regulatory T-cell responses to the 'Old Friends' themselves and to simultaneously processed 'forbidden' target antigens of the chronic inflammatory disorders.

Many Old Friends Live in our Gut-•Intestinal microflora is major external driving force in the maturation of the immune system .

•Prerequisite for development of normal tolerance to allergens.

•Microflora differs between healthy and allergic infants.

•Microflora differs in countries with high and low prevalence of allergies.

Bjorksten “Evidence of probiotics in prevention of allergy and asthma”

Curr Drug Targets Inflamm Allergy 2005;4(5):599-604

Farm milk protects against asthmawhether or not you live on a farm

In a study of 14,893 children aged 5 to 13, drinking raw milk was the strongest factor in reducing the risk of asthma and allergy, whether the children lived on a farm or not.

Inverse Association of farm milk consumption with asthma and allergy, in rural and suburban populations across Europe” 2007 Waser M., Michels et al.Clinical and Experimental Allergy , 2007,37 (5): 661-670I

Why ? –Effect of farm milk on gut

•Presence of compounds like Lactoferrin boosts immunity

•Raw Milk is perfect medium for human probiotic organisms

The gut, the lungs and the immune system

•Gut interacts with intestinal bacteria

• Beneficial Bacteria (BB) lead to improved gut barrier and immune stimulation.

•Good gut barrier and BB produces tolerance to allergens.

•Microbial environment and exposure to BB in infancy affects development of asthma and allergy.

Bjorksten B.,“Effects of intestinal microflora and the environment oon the development of asthma and allergy” (2004) Springer Seminars Immunopath. 25(3-4):257-70

Clinical results improve the closer you are to fundamental causes.

Symptoms andBehaviours

Growth and Development

Microbiome, inflammation, allergy, immune Breathing Dysfunction

Structural Changes

Social, Environment, Food, Stress

Thank You

Dr. Rosalba Courtney

[email protected]

61-2-99183460

facebook.com/RosalbaCourtneysBreathAndBodyHealth

mailto:[email protected]

http://www.breathandbody.com.au/

Dysfunctional breathing context, causes and contributing-spree cast may 2013

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