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Could inefficient breathing be contributing to symptoms?

Updated: 2 days ago


Doctor taking blood pressure

Following on from my last blog on medically unexplained symptoms (click here if you have not read this blog) I hope the summary below helps health professionals and patients consider whether inefficient (dysfunctional) breathing could be causing the patient’s symptoms or contributing to their symptoms or medical problems.


A 2019 paper states 1 in 10 adults in primary care in the United Kingdom breathe inefficiently and in individuals with asthma one third of women and a fifth of men do not breathe efficiently. Personally I believe rates are much higher now due to increased rates of stress and mask wearing during the pandemic encouraging a mouth breathing habit.


Although inefficient breathing has been investigated for decades, it remains poorly understood because of a lack of high-quality research and an absence of a gold standard to diagnose this condition. Inefficient breathing is often underdiagnosed or misdiagnosed as symptoms are similar to other conditions (e.g. asthma) or sometimes the symptoms are labelled as a form of anxiety.


Below are a list of features that if present increase the likelihood of inefficient breathing. The more features that are present the higher the likelihood of inefficient breathing. I have also included aspects that are more common in sleep disordered breathing because if an individual has sleep disordered breathing they are breathing inefficiently whilst sleeping. This is not a document to diagnose inefficient breathing instead my aim is to help the health professional or patient consider whether inefficient breathing is a possibility. There are many other causes for the signs and symptoms listed below which the health professional will need to consider, manage and potentially investigate.


I have combined this list from the sources listed at the end of my blog in addition to my clinical experience as a Functional Breathing Practitioner & GP. I am also grateful to Dr Joanne Ingleby (Dentist with interest in sleep disordered breathing who delivers bespoke Mandibular Advancement Devices) & Fiona Schreuder (Cardiorespiratory physiotherapist schreuderhealth@gmail.com) for their input using their clinical experience into this article.


Medical history

Respiratory tract

Asthma, chronic rhinosinusitis, COPD, nasal polyps, previous pulmonary embolism, cough syncope, inducible laryngeal obstruction (ILO), exercise-induced laryngeal obstruction (EILO), previous tonsillectomy and/ or adenoidectomy, allergies, hay fever, vocal cord dysfunction, upper muscle tension dysphonia, previous nasal trauma.

Mental Health

Anxiety, depression, stress, ADHD, past trauma (physical or psychological), PTSD, behavioural issues, insomnia.

Cardiovascular 

Hypertension (especially if treatment resistant), atrial fibrillation, heart failure, stroke, transient ischaemic attack (TIA), Postural Tachycardia Syndrome (PoTS).

Hormonal

Type 2 diabetes, hypothyroidism, acromegaly, polycystic ovarian syndrome (PCOS), perimenopausal or post menopause, obesity or overweight.

Musculoskeletal

Chronic pain especially temporomandibular joint (TMJ) or neck or back or pelvic pain, hypermobility syndrome, Ehlers Danlos Syndrome, fibromyalgia.

Dental

Broken teeth, fractured dental restorations, protective mouth guard, previous orthodontic treatment or dental extractions.

Gut

Gastro-oesophageal reflux, irritable bowel syndrome (IBS).

Other

Long covid, age, thick medical record, multiple investigations with no underlying cause, perfectionist tendencies, Down’s syndrome, anaemia, non-arteritic anterior ischaemic optic neuropathy (sudden loss of vision in one eye due to decreased blood flow to the optic nerve).


Social history

Smoking

Alcohol

Shift work

Occupation involves a lot of talking


Observation

Respiratory tract

Are they using the mouth to breathe whilst moving/ at rest?

Can you hear wheezing & does it settle as the patient relaxes?

Are they frequently yawning or sighing or coughing?

Can you hear them breathing? Do they look hungry for air?

Are they breathing fast? Is their breathing erratic?

Nasal speech? Large tonsils or adenoids?

Long, wide, red uvula?

Unresponsive soft palate, large fleshy scalloped tongue?

Venous pooling beneath the eyes?

Mental Health

Do they look tired, depressed, anxious, irritable or hyperactive?

Cardiovascular 

Is there evidence for atrial fibrillation or heart failure?

Hormonal

Is their body mass index (BMI) raised?

Musculoskeletal

Do they have forward head posture? Poor posture? Large neck?

Upper chest (or shoulders) move with breathing?

Dental

Tiny jaw (micrognathia)? Incompetent lips?

Jaw is set back (retrognathia)

Elongated ‘adenoid’ face (long face, retrognathia, reduced nose prominence and width)? Narrow V shaped hard palate?

Crowded oropharynx (grade 3 or 4 Mallampati score)?

Mandibular tori, worn or broken teeth, fractured dental restorations.

Tongue tie.

Gut

Air swallowing, burping, bloating.


Symptoms

Respiratory tract

Shortness of breath, lump in throat, difficulties with swallowing, unsatisfying breath or air hunger, frequent sighing or yawning, cough, frequent throat clearing, dry throat, voice changes, snoring, irregular or gaps in breathing during sleep.

Mental Health or neurological

Dizziness, pins and needles, poor sleep, nightmares, twitching eyelids, tremor, unreal feelings, brain fog, difficulty in concentrating, memory impairment, headaches, fainting, double vision, irritability, mood disturbance.

Cardiovascular 

Palpitations, chest pain, Raynauds phenomenon.

Hormonal

Reduced libido.

Musculoskeletal

Chronic pain especially temporomandibular joint (TMJ) or neck or back or pelvic pain, cramps.

Dental

Bad breath, grinding, gingivitis (inflamed gums).

Gut

Vomiting, burping, bloating, constipation, diarrhoea, excess wind.

Other

Feeling weak, exhaustion, sweating, night sweats, waking from sleep to pass urine.

Repeat medication list

Respiratory tract

Nasal sprays, inhalers – especially if overused and patients feel they are ineffective, antihistamines.

Mental Health

Antidepressants, anxiety medication, medication for sleep, ADHD medication, benzodiazepines, sodium oxybate, valproic acid.

Cardiovascular 

Blood pressure medication, cardiac medication (for heart failure, secondary prevention of stroke or heart attack or atrial fibrillation), ticagrelor.

Hormonal

HRT, testosterone, levothyroxine, type 2 diabetic medication.

Musculoskeletal

Opiates, baclofen, gabapentin.

Dental

High fluoride toothpaste.

Gut

Laxatives, IBS medication, proton pump inhibitors (e.g. omeprazole or lansoprazole), antacids.

Other

Medication with risk of weight gain. As the length of the list increases the risk of inefficient breathing increases.

‘Having had several years of suffering a variety of symptoms (pins & needles all limbs and left side of face, weight loss, gut issues) that basically was making my life pretty miserable, and having had many  doctor/hospital appointments for a wide selection of tests with no diagnosis made I had given up hope and started to put up with the situation thinking there was no help available. When it got to a stage where I was only getting 3 hours sleep a night I was exhausted and could not carry on, I decided to go back to the doctors. Thankfully I saw Dr Oliver who suggested it may help me if I took part in a breathing exercise seminar as the problems I was having could be connected by me not breathing correctly. Initially I thought how bizarre what a strange thing to suggest but was so desperate I was happy to try anything so accepted her offer of a free place. Well what can I say, by doing the seminar it became very apparent that I definitely had a problem with my breathing (my comfortable breath hold time was only 3.5 seconds) even though I didn't feel breathless. I followed the exercises given which were easy to do and within a very short time my symptoms started to ease and eventually ceased, I was having between 6 and 8 hours quality sleep a night, that in itself was fantastic. I cannot thank Dr Oliver enough for her recommendations’


'I have tried many apps and read many books in an attempt to improve my sleep pattern to no avail, but this course cracked it!  I am now sleeping fully through the night which has been a life changer for me. Everyday living, work, emotions & general well-being become so much easier to manage, more positive & happier with sleep. I generally feel calmer and am more in tune with my stress levels through changes in my breathing. I have learnt so much from this course and will be forever grateful. Thank you Louise'


'I am already sleeping better, feel more refreshed when I wake and have way more energy during the day. I feel in control of my sympathetic nervous system now rather than the other way round (which I believe has been the driver of my autoimmune thyroid problem). I am able to recognise much sooner when my sympathetic nervous system is triggered and using the breath-work am better able to switch this off'


My mission is to raise AWARENESS that how we breath matters, encouraging individuals to ASSESS their breathing efficiency & empowering individuals to take ACTION to improve their breathing efficiency.


If you would like me to improve your breathing efficiency or you are curious to learn more about this topic join my group or individual programmes. Click for more information.


References


Vidotto LS, Carvalho CRF, Harvey A, Jones M. Dysfunctional breathing: what do we know? J Bras Pneumol. 2019 Feb 11;45(1):e20170347. doi: 10.1590/1806-3713/e20170347. PMID: 30758427; PMCID: PMC6534396.


Koca CF, Erdem T, Bayındır T. The effect of adenoid hypertrophy on maxillofacial development: an objective photographic analysis. J Otolaryngol Head Neck Surg. 2016 Sep 20;45(1):48. doi: 10.1186/s40463-016-0161-3. PMID: 27647047; PMCID: PMC5029043.


Al Ali A, Richmond S, Popat H, Playle R, Pickles T, Zhurov AI, Marshall D, Rosin PL, Henderson J, Bonuck K. The influence of snoring, mouth breathing and apnoea on facial morphology in late childhood: a three-dimensional study. BMJ Open. 2015 Sep 8;5(9):e009027. doi: 10.1136/bmjopen-2015-009027. PMID: 26351193; PMCID: PMC4563226.


Obstructive sleep apnoea/hypopnoea syndrome and obesity hypoventilation syndrome in over 16s. NICE guideline [NG202] & associated Clinical Knowledge Summary (CKS).


Saaresranta T, Anttalainen U, Polo O. Sleep disordered breathing: is it different for females? ERJ Open Res. 2015 Nov 3;1(2):00063-2015. doi: 10.1183/23120541.00063-2015. PMID: 27730159; PMCID: PMC5005124.


Jullian-Desayes I, Revol B, Chareyre E, Camus P, Villier C, Borel JC, Pepin JL, Joyeux-Faure M. Impact of concomitant medications on obstructive sleep apnoea. Br J Clin Pharmacol. 2017 Apr;83(4):688-708. doi: 10.1111/bcp.13153. Epub 2016 Nov 24. PMID: 27735059; PMCID: PMC5346880.


Javaheri S, Randerath WJ, Badr MS, Javaheri S. Medication-Induced Central Sleep Apnea: A Unifying Concept. Sleep. 2024 Feb 9:zsae038. doi: 10.1093/sleep/zsae038. Epub ahead of print. PMID: 38334297.


Risk Factors for OSA Observed During Orofacial Examination: A Review. Journal of Dental Sleep Medicine 11(2) April 2024. DOI:10.15331/jdsm.7330

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