ReviewBreathing abnormalities in children with breathlessness
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.
References (36)
Impact of chronic obstructive pulmonary disease on quality of life: the role of dyspnea
Am J Med
(2006)The pathophysiology of hyperventilation disorders
Chest
(1996)- et al.
Vocal cord dysfunction in children
Paediatr Respir Rev
(2007) - et al.
Long-term outcome of vocal cord dysfunction
Ann Allergy Asthma Immunol
(2006) Hyperventilation: the tip and the iceberg
J Psychosom Res
(1975)Symptom patterns of the hyperventilation syndrome
Am J Med
(1950)- et al.
The prevalence of dysfunctional breathing in adults in the community with and without asthma
Prim Care Respir J
(2005) - et al.
Hyperventilation syndrome in childhood. A review of 44 cases
J Pediatr
(1967) - et al.
[Diagnostic value of the SHAPE questionnaire in recognition of the hyperventilation syndrome in childr: a pilot study]
Arch Pediatr
(2009) - et al.
Double-blind placebo-controlled study of the hyperventilation provocation test and the validity of the hyperventilation syndrome
Lancet
(1996)