#hyperventilation syndrome

[sofekozz]

hyperventilation

[obfuscated-abstract]

Title: Breathlessness and dysfunctional breathing in patients with postural orthostatic tachycardia syndrome (POTS): The impact of a physiotherapy intervention

Date: January 2020 Published in: Autonomic Neuroscience Publicly available: It is now.

Citation: Reilly, C. C., Floyd, S. V., Lee, K., Warwick, G., James, S., Gall, N., & Rafferty, G. F. (2020). Breathlessness and dysfunctional breathing in patients with postural orthostatic tachycardia syndrome (pots): The impact of a physiotherapy intervention. Autonomic Neuroscience, 223, 102601. https://doi.org/https://doi.org/10.1016/j.autneu.2019.102601

Summary

Full text under the cut

[obfuscated-abstract]

Title: Breathlessness and dysfunctional breathing in patients with postural orthostatic tachycardia syndrome (POTS): The impact of a physiotherapy intervention

Date: January 2020 Published in: Autonomic Neuroscience Publicly available: It is now.

Citation: Reilly, C. C., Floyd, S. V., Lee, K., Warwick, G., James, S., Gall, N., & Rafferty, G. F. (2020). Breathlessness and dysfunctional breathing in patients with postural orthostatic tachycardia syndrome (pots): The impact of a physiotherapy intervention. Autonomic Neuroscience, 223, 102601. https://doi.org/https://doi.org/10.1016/j.autneu.2019.102601

Full text

Abbreviations:

BPAT: breathing pattern assessment tool

COPD: chronic obstructive pulmonary disease

DB: dysfunctional breathing

HVS: hyperventilation syndrome

POTS: postural orthostatic tachycardia syndrome

Article summary

Abstract

Introduction

POTS is a chronic syndrome with complex symptoms of orthostatic intolerance. It is defined as an increase in heart rate of ≥ 30bpm in adults (≥40 bpm in children) within 10 minutes of standing with no orthostatic drop in blood pressure.

POTS is more common in women. Symptoms can be debilitating (impairment comparable to congestive heart failure and COPD) and include palpitations, light headedness/syncope, chest discomfort, breathlessness, neuropathic pain, chronic fatigue, poor sleep efficience, gastrointestinal symptoms, syncope, cognitive slowing, and psychological distress.

Breathlessness is a common symptom in POTS. Breathlessness is often attributed to changes in breathing pattern, frequency, and/or quality occuring alongside cardiac symptoms. Breathlessness can be episodic, triggered by physical activity, stressful thoughts and events.

Dysfunctional breathing (DB) is an umbrella term describing breathing disorders where chronic changes in breathing pattern result in breathlessness and other symptoms without respiratory or cardiac disease. The most studied form of DB is hyperventilation syndrome (HVS)

Boulding et al. (2016) suggest classifying dysfunctional breathing into the following: 1) Hyperventilation syndrome (a respiratory pattern associated with symptoms both related to respiratory alkalosis and independent of hypocapnia), 2) Periodic deep sighing (frequent sighing with an irregular breathing pattern), 3) Thoracis dominant breathing (a respiratory pattern occurring separate to somatic disease may be considered dysfunctional and results in dyspnoea), 4) Forced abdominal expiration (inappropriate and excessive use of abdominal muscle contraction to aid expiration), 5) Thoraco-abdominal asynchrony (a respiratory pattern in which there is delay between rib cage and abdominal contraction resulting in ineffective breathing movements)

Patients with POTS often undergo extensive investigations due to the complexity of potential comorbidities but there is no guidance or consensus on the assessment of breathlessness.

Methods

Retrospective study of POTS patients referred to repiratory physiotherapy

Respiratory physiotherapy outpatient's referral criteria: tests performed and identification of DB/HVS are explained

Physiotherapy assessment and outcome measures

A standardised physiotherapy assessment of symptoms was performed on all patients (details provided in the paper)

Physiotherapy intervention:

The physiotherapy intervention was standaradised in terms of education and breathing re-training exercises and was delivered by a consultant physiotherapist of a highly specialised respiratory physiotherapist. Each patient was assessed and treated by the same physiotherapist.

Physiotherapy treatment

The educational component focused on patient's understanding of respiratory physiology and the mind-body link

Breathing re-training intervention involved teaching breathing control (details provided). The breathing retraining exercises were standardised and progressive. All techniques used were standard respiratory physiotherapy techniques commonly applied for acute and chronic respiratory disease. Their use for breathlessness in POTS had no previously been assessed.

Patients were discharged when they were confident to continue the re-training programme independently or if they did not attend for follow-up appointments.

Data analysis: details and figures provided in the paper

Results

Demographic information is given in Table 1

Signficiant improvements were observed and are noted in Table 2

Discussion

This paper is the first to characterise DB/HVS and investigate the impact of physiotherapy in POTS. The results indicate that breathing retraining results in significant improvements in breathing pattern and symptom burden thus potentially improving their health related quality of life. Further studies are needed.

Significance of the findings

it is estimated that DB/HVS affects 10% of the general population and is more prevalent in women than men. Patients with POTS who reported respiratory symptoms had DB/HVS. DB/HVS may coexist alongside chronic respiratory diseases and COPDalthough the relationship is unclear.

Although there were statistically significant improvements for the patient cohort as a whole, not all patients had complete resolutions of their DB/HVS and there are several limitations in interpreting the results for this study.

Unexplained breathlessness or 'air hunger' are predominant symptoms of DB/HVS and can result in significant patient morbidity and an array of non-respiratory symptoms which can themselves provoke anxiety/panic and further breathing irregularity

Whilst orthostatic tachycardia is the main symptom of POTS, orthostasis causes a variety of other symptoms through a vaireity of different mechanisms. The paper provides an overview of the hypothesised mechanisms.

Psychological influences (stress, axniety, depression, etc.) are highly prevalent in POTS patients and predispose them to DB/HVS. The impact of this study's intervention could, therefore, be partly related to a change in anxiety thanks to education, greater understanding of DB/HVS, and empowerment.

Proposed improvements for further studies include the inclusion of pre-post PaCO2 measurements, the exclusion of asthma and pulmonary hypertension, analysis of why patients attended appointments (and addressing the issues)

Access to respiratory physiotherapy outpatient services is limited across the NHS and many POTS patients are instead seen by muscluloskeletal physiotherapists due to comorbidities. Increased awareness may improve treatment for these patients

More data is needed to investigate the prevalence of dysfunctional breathing in POTS and how it relateds to other chronic conditions. More detailed investigation and assessment guidelines and techniques are needed.

Limitations

No control data were available

Outcome measures were potentially not sensitive to non-hyperventilatory dysfunctional breathing

Observational nature and small sample size did not allow exploration of the role of confounding variables

A selection bias may have been introduced due to this being a convenience sample

The Nijmegen score used to characterise these patients has not been validated in this patient population. Its limitations highlight the need for a holistic POTS-specific measure.

Physiological outcome measures for the diagnosis of HVS are often limited to specialist services so alternative diagnostic tests are sought. The Breathing Pattern Assessment Tool (BPAT) has demonstrated good sensitivity and specificity for the diagnosis of DB in refractory asthma. Responsiveness of the BPAT to treatment remains to be ascertained.

Measuring Neural Respiratory Drive (NRD) in breathlessness patients with POTS may be advantageous. NRD provides a global measure of breathlessness and a physiological correlate to breathlessness but there is no data on whether NRD is increased in POTS or on NRD pre-post respiratory interventions

Conclusion

[living-hyperbolically]

hyperventilation syndrome

sucks. i don’t want it.

however, it’s either hvs or brain damage, so here i am, crossing my fingers that my mri on tuesday comes back clear so i can really start trying to retrain my body to breathe again.

(for the record: i passed my reflexes and nerves tests with flying colors, even with nerve damage from getting stomped by a horse, so the odds of me having brain damage are incredibly low while the odds of having hvs are incredibly high.)

i’m excited, though: this is the first diagnosis i’ve (pretty much) been given that is concrete and that comes with a path forward. which mean exercising may start to become enjoyable again, or at least not terrifying. i’ve been an athlete my whole life. not only that, but i used to hike for a living and had to stop, probably because of this dumb issue. y’all have no idea how painful that was for me.

it’s also the first diagnosis that explains all of my weird symptoms, even if some of them are rather rare.

i’m calling my favorite one ‘the medusa effect’

(and by favorite, i mean i love it about as much as you’d expect someone to love being involuntarily turned into a contorted dead bug statue, completely unable to move to the point that they cut themselves with their own finger nails because their muscles are squeezing as hard as possible and they can do nothing about it.)

(micro tears for weeks.)

(literally. weeks.)

anyway, i never thought i’d be so happy to learn i had a chronic illness.

[chaaaaaaaaaaaam]

eugh my CHVS is driving me nuts today :/ need to breathe into a paper bag to restore my co2 levels but no paper bags in the immediate vicinity

[dendrochilums]

i think i’ve finally figured out what’s wrong with my breathing. i have hyperventilation syndrome.

an answer for why i’ve spent the last 7 years being unable to do something everyone else does without thinking.

[chaaaaaaaaaaaam]

struggling w/ my chronic hyperventilation syndrome right now -_- i never talk about it bc i find it actually one of the most depressing aspects of my life... i used to love the gym and riding my bike and stuff and it’s taken all moderate-heavy physical activity away from me 

if anyone has any tips on how to manage it i’d be really grateful... it’s been over 5 years of being unable to breathe properly now and i’m so so sick of it

for those who don’t know what HVS is, taken from the NHS website: 

Hyperventilation syndrome (HVS) is a name given to a collection of physical and emotional symptoms, largely brought about by hyperventilation. This happens when we over-breathe. The main signs of this are when we breathe much more quickly and more shallowly than our bodies needs. Over time, all sorts of physical changes can take place in our body. These include a decrease in carbon dioxide pressure in the alveoli (in our lungs) and arteries, an increase in arterial pH (respiratory alkalosis), constriction of cerebral arteries and increased production of lactic and pyruvial acid. 

What are the symptoms of hyperventilation syndrome? 

HVS can show itself in different ways. Most people with HVS will have experienced some, if not many, of the following symptoms. 

Respiratory symptoms: breathlessness, tightness around the chest, fast breathing, frequent sighing

Tetanic symptoms: tingling (e.g. in fingers, arms, mouth), muscle stiffness, trembling in hands

 Cerebral symptoms: dizziness, blurred vision, faintness, headaches

 Cardiac symptoms: palpitations, tachycardia (rapid heart beat) 

Temperature symptoms: cold hands or feet, shivering, warm feeling in the head

 Gastrointestinal symptoms: sickness, abdominal pain 

General symptoms: tension, anxiety, fatigue and lethargy, insomnia

[princess-charm-ing]

MY HVS STORY

Hi everyone! (Sana may time kayo to read this! 💘) You might be asking what's HVS, well, it's "Hyperventilation Syndrome" Sobrang hirap ng month na to para sa akin. Ang daming nangyari and maraming nagbago. Last tuesday (August 27), I had my first hyperventilation attack. I was working with our group project and hindi ko na naisip kumain. Nakalimutan ko na din na bread lang pala kinain ko for breakfast nung morning na yun. Ayun nga, while I was doing something, parang nahirapan na kong huminga. I told my classmate na naninikip na yung dibdib ko so, lumabas kami. Sobrang lamig sa room tapos nung lumabas ako, sobrang init at dun na nanghina yung legs at arms ko. Pumunta kami sa clinic, then nalaman namin na lunch break pero hindi ko na talaga kaya eh. Bumagsak ako sa floor and hindi ko na mabuksan yung mata ko. Naririnig ko nalang sila na nagkakagulo. Then, yung level prefect namin nagdala ng brown bag and pinahinga nila ako dun. I was shaking and crying at the same time dahil sa takot. Then, after drinking water & skyflakes, naging okay na ko. I thought, yun na yung last na attack ko, pero hindi pala. Friday. August 28. It was the day that I'm looking forward to kasi sobrang special nun sakin. Pero, wala eh. It turned out to be a very bad day. CAT namin and I was excused dahil sa nangyari. I was sitting kasama nung ibang students na excused at sobrang init nun. Lumayo ako sa kanila kasi nahihilo na ko sa init. Then, sabi ko, hihiga nalang ako sa lap nung kaklase ko. Nahirapan nanaman ako huminga. I could hear them na ginigising ako. Pero I couldn't answer & couldn't move too. They were panicking at nagpanic nadin ako. Dumating yung nurse and binuhat nila ako sa wheelchair. Dinala nila ako sa clinic and huminga ulit with a brown bag. I was still shaking but I was feeling so much better. Saturday. We've decided na magpacheckup ako. Sabi nila, HVS or Hyperventilation Syndrome. There was no cure. I wasn't allowed to be stressed, bawal din sa masikip na lugar, bawal sa mainit at kung ano ano pang bawal. Ang pinakamasakit dun, I wasn't allowed na magPEP Squad. It's really sad giving up something you love. Masakit pero kailangan tanggapin. Gusto ko nang mag-give up because di ko alam kung kelan yung susunod na attack ko. I'm scared. Gusto ko na talagang sumuko..... kasi hindi ko na kaya. Ang hirap. Here's something I want to tell everyone: Kahit na nahihirapan ako, I still think positive. Kaya, if you have HVS too, I'm here. Inhale, exhale lang. Sabay sabay tayong huminga ng maayos. Guys, appreciate the little things in life, even breathing. You won't appreciate it until nawala yung isang bagay sayo. Take care guys and God bless us all. P.S. I'll fight! Aja! 💘