Review
Breathing abnormalities in children with breathlessness

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Summary

Dysfunctional breathing, hyperventilation and vocal cord dysfunction are frequently seen in children and adults. The prevalence is unknown. There are no standardized diagnostic criteria, and for now, effective exclusion of organic disease leaves the diagnosis of dysfunctional breathing. Therapy is mainly focussed on explanation of a benign condition and reassurance. Since dysfunctional breathing is a possible chronic condition, other therapies should be evaluated. In adults physiotherapy and breathing retraining appear beneficial. In childhood there is lack of evidence, and further research is necessary in order to optimise the outcome for children with dysfunctional breathing.

Introduction

Breathlessness is the subjective sensation of difficult, laboured or uncomfortable breathing.1 In normal circumstances breathlessness is physiological when exercising beyond normal tolerance but pathologically when breathlessness occurs with little or no exertion.

Breathlessness is a key feature of pulmonary disease in children. The causes of breathing disorders vary. They include: asthma, rhinitis, emphysema, cystic fibrosis, interstitial lung disease and less frequent pulmonary disorders.2 In these pulmonary diseases the aim of the therapy is to treat and prevent breathlessness or dyspnoea. When experiencing breathlessness it is always almost associated with anxiety and, when chronic, can be disabling and severely diminish quality of life.3 Because there are no standardized criteria for the diagnosis dysfunctional breathing and the prevalence is unknown, the diagnosis is considered when other causes are excluded.4

In the absence of a pulmonary disease symptomatic breathlessness can occur. In this review the focus will be on breathlessness without distinct pulmonary disease. In breathing abnormalities in children with breathlessness with the absence of a pulmonary disease the diagnosis dysfunctional breathing should be considered. Dysfunctional breathing, including hyperventilation and vocal cord dysfunction, can cause breathlessness.5

This review will specifically consider:

  • The prevalence of dysfunctional breathing in children.

  • Clinical presentation and diagnosis.

  • Treatment of dysfunctional breathing.

  • Long term outcome.

Section snippets

Methods

Studies were identified in Pubmed, EMBASE and the Cochrane Library. The keywords “breathing abnormalities”, “breathlessness”, “dyspnoea”, “dysfunctional breathing”, “vocal cord dysfunction”, “hyperventilation, “anxiety”, “treatment” and “diagnosis” were used. The search was limited to “all child”. The references in retrieved articles were scanned to find additional relevant papers.

Definition of breathing abnormalities

Dysfunctional breathing [DB] is defined as chronic or recurrent changes in breathing pattern, causing respiratory and non-respiratory complaints.6 Symptoms of DB include dyspnoea with normal lung function, chest tightness, chest pain, deep sighing, exercise induced breathlessness, frequent yawning and hyperventilation.7, 8

Epidemiology of breathing abnormalities

Hyperventilation syndrome (HVS) is common in adults. The frequency in the general population is between 6% and 10%.13, 14 In a semirural general practice adult population 8% of the patients without previous, or current asthma showed positive screening for hyperventilation using the Nijmegen questionnaire [Table 2].15 Dysfunctional breathing was more prevalent in women (14%) than in men (2%).

The prevalence of HVS or DB in the paediatric population is unknown. Enzer et al. [1967] studied 44 cases

Diagnosis of breathing abnormalities

Beyond the clinical description there is no accepted gold standard for the diagnosis dysfunctional breathing and the differential diagnosis is broad (Table 3). Organic disease should be excluded by careful history taking and physical examination, preferably at the time of presentation. In adults, the Nijmegen questionnaire is a symptom checklist (Table 2), that can be used to discriminate normal breathers from dysfunctional breathers.15, 21 Each question in the questionnaire can score 0 (never)

Treatment of breathing abnormalities

At present there is no standardized treatment for HVS or DB. When patients are able to reproduce their symptoms with voluntary overbreathing, breathing in a (paper) bag, increasing arterial CO2-tension, could relieve the symptoms.10 When this is successful, the rapid relief of symptoms is reassuring for the patient. In 44 paediatric patients reassurance was the initial treatment. A rebreathing bag was employed in all cases with symptoms at the time of examination. This technique was universally

Prognosis of breathing abnormalities

Without organic disease the prognosis is usually good. But a recurrence of symptoms of DB will often occur. Of the 44 identified with HVS, more than one year of follow up was done in 18 patients. Of these patients 78%(n = 13) still had complaints of HVS.16

In long-term follow-up(2-28 years) in paediatric patients 40% had episodes of hyperventilation well in to adulthood.17 This suggests that HVS has the potential of becoming a chronic condition in the majority of patients.

Little is known about the

Conclusion

Breathing abnormalities in children with breathlessness include dysfunctional breathing, hyperventilation and vocal cord dysfunction. In children there is minimal literature on prevalence, diagnosis, therapy and prognosis. Looking at the adult literature, it is a frequent entity not only as a co-morbidity in respiratory disease, but also as a problem itself. In adults the diagnosis is possible and therapy seems beneficial, but again the literature is sparse. Further research in the paediatric

Educational aims

The reader will become more familiar with:

  • What is known of the prevalence of dysfunctional breathing in children.

  • The clinical presentation and diagnosis of dysfunctional breathing.

  • The possible treatment of dysfunctional breathing.

  • The long term outcome of dysfunctional breathing.

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