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Cited by 372Respiratory and Cough-Related ResearchPsychosomatic Disorders and Their TreatmentsAsthma and respiratory diseases

Dysfunctional breathing: a review of the literature and proposal for classification

Open access
Boulding, Richard, Stacey, Rebecca, Niven, Rob, Fowler, Stephen J.·2016·European Respiratory Review
DOI 10.1183/16000617.0088-2015PMC PMC9487208
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Abstract

Dysfunctional breathing is a term describing breathing disorders where chronic changes in breathing pattern result in dyspnoea and other symptoms in the absence or in excess of the magnitude of physiological respiratory or cardiac disease. We reviewed the literature and propose a classification system for the common dysfunctional breathing patterns described. The literature was searched using the terms: dysfunctional breathing, hyperventilation, Nijmegen questionnaire and thoraco-abdominal asynchrony. We have summarised the presentation, assessment and treatment of dysfunctional breathing, and propose that the following system be used for classification. 1) Hyperventilation syndrome: associated with symptoms both related to respiratory alkalosis and independent of hypocapnia. 2) Periodic deep sighing: frequent sighing with an irregular breathing pattern. 3) Thoracic dominant breathing: can often manifest in somatic disease, if occurring without disease it may be considered dysfunctional and results in dyspnoea. 4) Forced abdominal expiration: these patients utilise inappropriate and excessive abdominal muscle contraction to aid expiration. 5) Thoraco-abdominal asynchrony: where there is delay between rib cage and abdominal contraction resulting in ineffective breathing mechanics. This review highlights the common abnormalities, current diagnostic methods and therapeutic implications in dysfunctional breathing. Future work should aim to further investigate the prevalence, clinical associations and treatment of these presentations.

AI snapshot

Written from the paper’s full text.

TL;DR

Dysfunctional breathing describes chronic abnormal breathing patterns causing dyspnoea and other symptoms in the absence of, or out of proportion to, organic disease. The authors review the literature and propose five categories: hyperventilation syndrome, periodic deep sighing, thoracic dominant breathing, forced abdominal expiration, and thoraco-abdominal asynchrony.

Key findings

  • The literature search returned 115 papers, of which 59 were considered relevant; the proposed classification is based on the reviewed literature and clinical experience.
  • Hyperventilation syndrome is the most studied pattern (43 papers in the proposed table), with estimated prevalence around 6–10% in the general population and 29% in asthmatics; one validation study found approximately 34% in asthmatics, while asthmatic children were around 5%.
  • The Nijmegen questionnaire was validated with sensitivity 91% and specificity 95%, and a score >23 is commonly used as a cut-off, although the original gold standard (hyperventilation provocation test) is no longer considered reliable.
  • The other proposed patterns have far less evidence: periodic deep sighing (12 papers), thoracic dominant breathing (4), forced abdominal expiration (2), and thoraco-abdominal asynchrony (6); no prevalence data are available for these patterns.

Methods

  • Narrative literature review: PubMed and Embase were searched using the terms dysfunctional breathing, hyperventilation, Nijmegen questionnaire, and thoraco-abdominal asynchrony.
  • The authors summarise presentation, assessment, and treatment, then propose a classification system for common dysfunctional breathing patterns.
  • The proposal is based on the reviewed literature and the authors’ clinical experience; the paper does not report a formal systematic review, meta-analysis, or primary data collection.

Limitations

  • The paper states there is no formal definition of dysfunctional breathing and no gold standard diagnostic method, making prevalence and research interpretation difficult.
  • It states the Nijmegen questionnaire was developed and validated only in exercise-induced hyperventilation syndrome but has been extrapolated inappropriately to other forms and settings; many studies had low sample sizes, mixed breathing patterns, and likely publication bias.
  • Treatment evidence is described as limited and largely uncontrolled, with most published treatment proposals targeted at hyperventilation syndrome and not necessarily appropriate for other proposed patterns; no prevalence data exist for non-hyperventilation patterns.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1183/16000617.0088-2015

Cites

67 of 67 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

33 of 98 cited sources checked · 8 supported · 2 flagged · accuracy not yet measured

  • Findingcitation

    Periodic deep sighing is linked to asthma and panic disorder.

    “| Periodic deep sighing | 12 | [8, 9, 45–47] | Asthma Panic disorder |”
    Quote in the paperNot a substantial claim1 of 5 sources checked
    • cites [8] source
    • cites [9] source
    • cites [45] Hormbrey, 1988, CO2 response and pattern of breathing in patients with symptomatic hyperventilation, compared to asthmatic and normal subjects, Eur Respir J source

      The Sighs section (page unavailable) reports that sighs were most frequent in patients with symptomatic hyperventilation, while asthmatic subjects sighed about as often as controls—not an asthma-specific link. The paper does not identify its symptomatic-hyperventilation patients as having panic disorder, so it does not establish that part of the claim either. (LLM, conf=0.85)

      Checked by a reasoning model — may be wrong.

      Experimental — accuracy not yet measured
    • cites [46] source
    • cites [47] source
  • Premisecitation

    There is an extensive body of research that implicates respiratory processes and particularly hyperventilation in panic disorder.

    “There is an extensive body of research that implicates respiratory processes and particularly hyperventilation in panic disorder [21, 22].”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [21] source
    • cites [22] source
  • Findingcitation

    More recent studies of dysfunctional breathing in asthma have looked at combining use of the Nijmegen questionnaire with symptom limited exercise testing in an attempt to improve specificity for dysfunctional breathing.

    “More recent studies of dysfunctional breathing in asthma have looked at combining use of the Nijmegen questionnaire with symptom limited exercise testing in attempt to improve specificity for dysfunctional breathing [16, 19].”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [16] source
    • cites [19] source
  • Interpretationcitation

    Recognising variations in breathing pattern in asthmatics may provide a way of identifying those patients who would benefit from breathing retraining to target abnormal breathing mechanics.

    “Recognising variations in breathing pattern in asthmatics may provide a way of identifying those patients who would benefit from breathing retraining to target abnormal breathing mechanics [18].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [18] source

      The Introduction (page unavailable) says dysfunctional breathing can coexist with genuine asthma and reports that patients treated for asthma who had symptoms suggestive of dysfunctional breathing benefited from breathing retraining. The paper does not establish that recognising variations in breathing pattern identifies which patients with asthma will benefit: its Intervention section says the asthma comparison group received no retraining. (LLM, conf=0.84)

      Experimental — accuracy not yet measured
  • Premisecitation

    The diagnosis of hyperventilation syndrome is based on the Nijmegen questionnaire only after organic disease has been ruled out or optimally controlled.

    “The diagnosis is based on the Nijmegen questionnaire only after organic disease has been ruled out or optimally controlled, and is often difficult to distinguish from asthma and anxiety disorders [5, 16, 21].”
    Quote in the paperNot a substantial claim3 of 3 sources checked
    • cites [5] source

      The Participants and methods section describes the Nijmegen questionnaire as a screening instrument, and the Limitations of study section says it identifies characteristic symptom patterns but cannot establish a certain diagnosis. Neither section says organic disease must first be ruled out or optimally controlled. Page numbers were not available in our copy. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [16] source

      The Material and methods section says the Nijmegen questionnaire was used to screen for dysfunctional breathing in adults with asthma, with positive results confirmed by progressive exercise testing. The Discussion (Incidence of dysfunctional breathing) likewise distinguishes a positive questionnaire score from a confirmed diagnosis. The paper does not state that organic disease must first be ruled out or optimally controlled, or that the questionnaire alone establishes the diagnosis. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [21] source

      Section 1 says that criteria for hyperventilation syndrome were never agreed upon; it does not describe diagnosis using the Nijmegen questionnaire. Searches for the questionnaire and for a requirement to rule out or optimally control organic disease found no passage establishing the claimed diagnostic procedure. The copy has no page numbers for these passages. (LLM, conf=0.72)

      Experimental — accuracy not yet measured
  • May combine two claims. 49
  • Classified as probably not a substantial claim. 35

  • May combine two claims.

    Findingcitation

    Other than MARM and the Nijmegen questionnaire (which correlate weakly), these methods have yet to be shown to correlate with one another.

    “It is important to note that, other than MARM and the Nijmegen questionnaire (which correlate weakly), these methods have yet to been shown to correlate with one another [31].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [31] source

      Table 4 shows no significant correlation between either MARM measure and the Nijmegen Questionnaire (p = .70 and .90), contrary to the claimed weak correlation. The Results also report strong correlations between the two symptom questionnaires and between the two breath-holding measures, contrary to the claim that the other methods have not been shown to correlate. Page numbers are not available in our copy. (LLM, conf=0.88)

      Checked by a reasoning model — may be wrong.

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingcitation

    MARM has been shown to have good inter-examiner reliability and is consistent with older and more complex methods such as RIP, which has limitations when posture is slumped.

    “It has been shown to have good inter-examiner reliability and is consistent with older and more complex methods such as respiratory induction plethysmography (RIP), which has limitations when posture is slumped [29].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [29] source

      The methods passage (Psychiatric assessment; page unavailable) describes measuring breathing with a pneumotachograph and capnograph, while the Discussion addresses agreement between end-tidal and arterial PCO₂. Searches for MARM, inter-examiner reliability, RIP, and slumped posture found no passage addressing the attributed comparison or posture limitation. (LLM, conf=0.76)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingcitation

    Most data are available for HVS; prevalence is estimated at 6-10% in the general population, rising to 29% in asthmatics.

    “Most data are available for HVS, the prevalence of which is estimated to be in the region of 6–10% in the general population, rising to 29% in asthmatics [5, 12].”
    Quote in the paperNot a substantial claim2 of 2 sources checked
    • cites [5] source

      The Results report that 29% of respondents treated for asthma in one general practice scored above the Nijmegen questionnaire threshold for dysfunctional breathing. The paper does not give a 6–10% estimate for the general population, and its Limitations of study section cautions that a questionnaire score does not establish a diagnosis of hyperventilation syndrome. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [12] source

      The Results report 9.5% positive screening scores in the overall adult population and 29% among people diagnosed and treated for asthma, consistent with the quoted estimates. But the Methods and Discussion describe these as Nijmegen Questionnaire scores suggesting dysfunctional breathing, not confirmed HVS diagnoses; the paper also does not establish that most available data concern HVS. No page numbers are available in our copy. (LLM, conf=0.85)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingcitation

    The Nijmegen questionnaire has not been validated in children and symptoms of dysfunctional breathing specific to children are not included in it.

    “It must also be noted that the Nijmegen questionnaire has not been validated in children and that symptoms of dysfunctional breathing specific to children are not included in the Nijmegen questionnaire [17].”
    Quote in the paperNot a substantial claim1 of 1 sources checked

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingcitation

    Other suggested methods of diagnosis include the SEBQ, end-tidal carbon dioxide measurement, breath holding time, and MARM.

    “Other suggested methods of diagnosis include other questionnaires such as the Self Evaluation of Breathing Questionnaire (SEBQ), end-tidal carbon dioxide measurement”
    • Also stated in: § Methods of assessment · plain
      “and manual assessment of respiratory motion (MARM) [27–30].”
    Quote in the paperNot a substantial claim1 of 4 sources checked
    • cites [27] source
    • cites [28] source
    • cites [29] source

      The Psychiatric assessment section reports measuring end-tidal PCO₂, and the Discussion says those measurements accurately reflected arterial PCO₂ in patients with mild or moderate asthma. The paper does not suggest the SEBQ, breath-holding time, or MARM as diagnostic methods; its questionnaires were the STAI and BDI. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [30] source

  • May combine two claims.

    Findingcitation

    Asthmatics with HVS tend to be female, have poor asthma control, frequent exacerbations and comorbid anxiety states.

    “Asthmatics with HVS tend to be female, have poor asthma control, frequent exacerbations and comorbid anxiety states [16].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [16] source

      The Results (Table 1; page unavailable) show that asthmatics with dysfunctional breathing were more often female, lacked asthma control, and were frequent exacerbators; the Results and Discussion also report anxiety disorders in this group. The study assessed dysfunctional breathing, however, not a separately identified hyperventilation syndrome (HVS) group, so it does not establish the full profile specifically for asthmatics with HVS. (LLM, conf=0.82)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingcitation

    In asthmatic children the prevalence appears much lower, around 5%, although the study was in severe asthmatics and difficult to extrapolate to all patients.

    “In asthmatic children the prevalence appears to be much lower in the region of 5% [17], although this study was performed in severe asthmatics and is therefore difficult to extrapolate to all patients.”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [17] source

      The Discussion reports dysfunctional breathing in about 5% of children with asthma, much lower than the rate reported in adults. The study was conducted in a specialist clinic, which limits extrapolation to all children with asthma, but describing its participants simply as “severe asthmatics” overstates the source: the Discussion calls them relatively severe or difficult to treat, while the Results say most had well-controlled asthma. (LLM, conf=0.82)

      Experimental — accuracy not yet measured

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation

    Asthma itself is associated with an increased prevalence of reported panic disorder at 9.7%.

    “Asthma itself is associated with an increased prevalence of reported panic disorder at 9.7% [5, 23].”
    Quote in the paperNot a substantial claim1 of 2 sources checked
    • cites [5] source

      The Introduction links asthma with increased anxiety and depression indices, but does not report panic disorder prevalence. The Methods and Results assess dysfunctional breathing, not panic disorder; searches for “9.7%” and “panic disorder prevalence” found no supporting passage in our copy. (LLM, conf=0.76)

      Experimental — accuracy not yet measured
    • cites [23] source

  • May combine two claims.

    Findingcitation

    Hyperventilation syndrome is linked to asthma and panic disorder.

    “| Hyperventilation syndrome | 43 | [1, 2, 5, 15] | Asthma Panic disorder |”
    Quote in the paperNot a substantial claim1 of 4 sources checked
    • cites [1] Folgering, 1999, The pathophysiology of hyperventilation syndrome, Monaldi Arch Chest Dis
    • cites [2] source
    • cites [5] source

      The Introduction (page not supplied) says asthma has been linked with symptomatic hyperventilation. It mentions anxiety in asthmatic patients and lists references about panic disorder, but does not establish a link between hyperventilation syndrome and panic disorder. (LLM, conf=0.84)

      Experimental — accuracy not yet measured
    • cites [15] source

  • May combine two claims.

    Findingcitation

    Another study comparing the Buteyko method with asthma education in asthmatics that scored over 23 on the Nijmegen questionnaire showed improvement post-training at 6 months in HADS, asthma-related quality of life and Nijmegen questionnaire scores with no change in respiratory physiology.

    “Another study comparing the Buteyko method with asthma education in asthmatics that scored over 23 on the Nijmegen questionnaire showed improvement post-training at 6 months in HADS, asthma-related quality of life and Nijmegen questionnaire scores with no change in respiratory physiology [40].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [40] source

      Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingcitation

    In recent years, yoga has been trialled in patients with COPD and asthma with limited effect and studies remain highly heterogeneous in design.

    “In recent years, yoga has been trialled in patients with COPD and asthma with limited effect and studies remain highly heterogeneous in design [33, 41, 42].”
    Quote in the paperNot a substantial claim2 of 3 sources checked
    • cites [33] source
    • cites [41] source

      The Results section (page unavailable) reports four yoga-breathing trials in people with COPD, with a disease-related quality-of-life effect in only one, supporting the limited-effect portion. The paper excludes diseases other than COPD and does not establish effects in asthma; its Conclusion describes variable trial quality, not highly heterogeneous study designs. (LLM, conf=0.86)

      Experimental — accuracy not yet measured
    • cites [42] source

      The Abstract reports a trial in asthma of a device mimicking pranayama, a yoga breathing technique, with no significant difference in bronchial responsiveness between groups. The Discussion notes differences in design between this and previous controlled studies. The paper does not address COPD, and its findings on one aspect of yoga do not establish that yoga trials across both conditions have had limited effects or are highly heterogeneous. (LLM, conf=0.86)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingcitation

    Another small study showed similar improvement over 24 months in both the Nijmegen questionnaire and HADS, but no correlation between the two scores.

    “Another small study showed a similar improvement over 24 months in both the Nijmegen questionnaire and HADS, but no correlation between the two scores [38].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [38] source

      The P203 abstract (Thorax supplement, p. A149) reports no correlation between pre-intervention Nijmegen and HAD scores, and a reduction in Nijmegen scores after a six-week intervention. It does not report improvement in HAD scores. Its 24-month period describes patient referrals, not follow-up or improvement over 24 months. (LLM, conf=0.90)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Interpretationcitation

    Forced abdominal expiration may be a normal physiological adaptation in patients with COPD and pulmonary hyperinflation, but is typically dysfunctional in the absence of these conditions.

    “This may be a normal physiological adaptation in patients with COPD and pulmonary hyperinflation, but is typically dysfunctional in the absence of these conditions [63].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [63] source

      The Introduction (page unavailable) reports enhanced abdominal-muscle use in patients with COPD and describes some changes as adaptations. It does not identify forced abdominal expiration as a normal adaptation; instead, it says most breathing abnormalities suggest respiratory-muscle malfunction. The paper also does not establish that forced abdominal expiration is typically dysfunctional in people without COPD or hyperinflation. (LLM, conf=0.78)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingcitation

    Sighing is more frequent (up to 15 times in a 15 min period) and associated with dyspnoea in those with dysfunctional breathing.

    “Sighing occurs in healthy individuals and asthmatics, but is more frequent (up to 15 times in a 15 min period) and associated with dyspnoea in those with dysfunctional breathing [8, 45, 46, 61].”
    Quote in the paperNot a substantial claim1 of 4 sources checked
    • cites [8] source
    • cites [45] Hormbrey, 1988, CO2 response and pattern of breathing in patients with symptomatic hyperventilation, compared to asthmatic and normal subjects, Eur Respir J source

      The Sighs section reports sighs in healthy controls and asthmatics and a higher frequency in patients with symptomatic hyperventilation. It gives a range of 4–18 sighs per run, not an upper limit of 15 in 15 minutes. The Subjects section reports breathing discomfort in these patients, but does not establish that sighing itself was associated with dyspnoea. (LLM, conf=0.88)

      Experimental — accuracy not yet measured
    • cites [46] source
    • cites [61] source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationcitation

    Postural hyperventilation may be due to overstimulation of the vestibular system's influences on the autonomic and respiratory systems in hyperventilation syndrome.

    “This may be due to the influences of the vestibular system on the autonomic and respiratory systems, which may be over stimulated in HVS [60].”
    Quote in the paperNot a substantial claim1 of 1 sources checked
    • cites [60] source

      The Discussion (page not specified) suggests that an autonomic reflex affecting respiratory drive may be enhanced in patients with HVS. It does not mention the vestibular system or attribute that enhancement to vestibular overstimulation. (LLM, conf=0.85)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Findingcitation

    Sighing occurs in healthy individuals and asthmatics.

    “Sighing occurs in healthy individuals and asthmatics, but is more frequent (up to 15 times in a 15 min period) and associated with dyspnoea in those with dysfunctional breathing [8, 45, 46, 61].”
    Quote in the paperNot a substantial claim1 of 4 sources checked
    • cites [8] source
    • cites [45] Hormbrey, 1988, CO2 response and pattern of breathing in patients with symptomatic hyperventilation, compared to asthmatic and normal subjects, Eur Respir J source
    • cites [46] source
    • cites [61] source

  • Classified as probably not a substantial claim. May combine two claims.

    Findingnone given

    There is no formal definition of dysfunctional breathing and no gold standard diagnostic method.

    “There is no formal definition of dysfunctional breathing and no gold standard diagnostic method.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    PubMed and Embase search returned 115 papers, of which 59 were considered relevant.

    “A total of 115 papers were returned, of which 59 were considered relevant to this topic.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingcitation

    The Nijmegen questionnaire comprises 16 questions; seven relate to respiratory symptoms, four to excessive ventilation, and five concern central nervous system symptoms relating to hypocapnia and central tetany.

    “This questionnaire, developed by a group in the Netherlands, comprises 16 questions about symptoms. Of these, seven relate to respiratory symptoms, four to excessive ventilation and five concern central nervous system symptoms relating to hypocapnia and “central tetany” [25].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [25] source

  • May combine two claims.

    Findingcitation

    Breathlessness may manifest as hyperventilation, or symptoms that occur independently of hypocapnia and respiratory alkalosis such as deep sighing or the sensation of air hunger.

    “Breathlessness may manifest as hyperventilation, or symptoms that occur independently of hypocapnia and respiratory alkalosis such as deep sighing or the sensation of air hunger [2, 8, 9].”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites [2] source
    • cites [8] source
    • cites [9] source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation

    A score of >23 is commonly used as a cut-off for HVS.

    “A score of >23 is commonly used as a cut-off for HVS, although this was calculated using a positive hyperventilation provocation test as the gold standard, which itself is no longer considered a reliable way of diagnosing HVS [26].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [26] source

  • May combine two claims.

    Findingcitation

    Associated symptoms in dysfunctional breathing may be attributable to hyperventilation and respiratory alkalosis but are not specific to dysfunctional breathing.

    “The key symptom in dysfunctional breathing is breathlessness after organic causes have been ruled out, but associated symptoms may be attributable to hyperventilation (increased minute ventilation) and respiratory alkalosis (e.g. tingling, tetany and numbness), but these are not specific to dysfunctional breathing [7].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [7] source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingcitation

    The SEBQ describes two factors reported commonly by patients with dysfunctional breathing: feelings of lack of air and restriction of breathing.

    “The SEBQ describes two factors reported commonly by patients with dysfunctional breathing: the feelings of “lack of air” and “restriction of breathing” [32].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [32] source

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Findingnone given

    There are no data available to estimate the prevalence of other patterns of dysfunctional breathing either in the general population or in people with respiratory disease.

    “There are no data available to estimate the prevalence of other patterns of dysfunctional breathing either in the general population or in people with respiratory disease”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Findingnone given

    Patients' overwhelming symptom is dyspnoea despite exclusion of, or treatment optimisation for, any organic disease.

    “The patients' overwhelming symptom is dyspnoea despite exclusion of, or treatment optimisation for, any organic disease.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingcitation

    There is limited and largely uncontrolled evidence that when dyspnoea is related to an abnormal breathing pattern it may be improved by breathing retraining, but the sensation of dyspnoea may still remain.

    “There is limited and largely uncontrolled evidence that when dyspnoea is related to an abnormal breathing pattern it may be improved by breathing retraining, but the sensation of dyspnoea may still remain [11].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [11] source

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Findingnone given

    Forced abdominal expiration involves patients utilising inappropriate and excessive abdominal muscle contraction to aid expiration.

    “4) Forced abdominal expiration: these patients utilise inappropriate and excessive abdominal muscle contraction to aid expiration.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    The Papworth method has resulted in some symptom relief and increasing carbon dioxide tension using small sample sizes of moderate asthmatics, but data on long-term follow-up are lacking.

    “The Papworth method (where patients are taught diaphragmatic breathing with an emphasis on controlled, slow nasal breathing) has resulted in some symptom relief and increasing carbon dioxide tension using small sample sizes of moderate asthmatics, but data on long-term follow-up are lacking [14, 37].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [14] source
    • cites [37] source

  • May combine two claims.

    Findingnone given

    The Buteyko method has been shown to reduce symptoms in asthmatics and reduce bronchodilator use without changing lung function, although the Buteyko method itself involves active encouragement to reduce use of bronchodilators.

    “This method has been shown to reduce symptoms in asthmatics and reduce bronchodilator use without changing lung function, although the Buteyko method itself involves active encouragement to reduce use of bronchodilators.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Findingnone given

    Thoraco-abdominal asynchrony involves delay between rib cage and abdominal contraction resulting in ineffective breathing mechanics.

    “5) Thoraco-abdominal asynchrony: where there is delay between rib cage and abdominal contraction resulting in ineffective breathing mechanics.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingreasoning

    The patients in this study had asthma and high Nijmegen questionnaire scores, but it was not clear that they had dysfunctional breathing.

    “The patients in this study had asthma and high Nijmegen questionnaire scores, but it was not clear that they had dysfunctional breathing.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingnone given

    The quantity and quality of research varies considerably between dysfunctional breathing subtypes, with hyperventilation syndrome having the largest evidence base.

    “The quantity and quality of research varies considerably between subtypes, with HVS having the largest evidence base.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    Hyperventilation syndrome is the most commonly described and researched form of dysfunctional breathing.

    “This is the most commonly described and researched form of dysfunctional breathing (figure 1b).”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Findingreasoning

    There is significant difficulty in reaching consensus on the epidemiology, comorbidities and management of dysfunctional breathing while there is no clear agreement on the definition of the condition(s).

    “As we have demonstrated, there is a significant difficulty in reaching a consensus on the epidemiology, comorbidities and management of dysfunctional breathing while there is no clear agreement on the definition of the condition(s).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Findingnone given

    Periodic deep sighing is frequent sighing with an irregular breathing pattern.

    “2) Periodic deep sighing: frequent sighing with an irregular breathing pattern.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    One study found a weak relationship between hyperventilation symptoms and breathing pattern in 74% of patients, indicating that a large number of patients with elevated Nijmegen questionnaire score had abnormal breathing patterns.

    “One study found a weak relationship between hyperventilation symptoms and breathing pattern in 74% of patients indicating that a large number of patients with elevated Nijmegen questionnaire score had abnormal breathing patterns [11].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [11] source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    Two common breathing techniques have been used: the Papworth and Buteyko methods.

    “Two common breathing techniques have been used: the Papworth and Buteyko methods.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingnone given

    Periodic deep sighing is characterised by frequent sighing and irregular breathing patterns, sometimes overlapping with hyperventilation.

    “This type of dysfunctional breathing is characterised by frequent sighing and irregular breathing patterns, sometimes overlapping with hyperventilation (figure 1c).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Findingnone given

    Many studies have used the Nijmegen questionnaire as a method of diagnosis and extrapolated its use to different dysfunctional breathing patterns in settings other than exercise-induced hyperventilation syndrome.

    “Many studies have used the Nijmegen questionnaire as a method of diagnosis and extrapolated its use to different dysfunctional breathing patterns in settings other than exercise-induced HVS.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Findingnone given

    Hyperventilation syndrome remains the most extensively studied dysfunctional breathing pattern, although other forms may coexist or appear in isolation.

    “HVS remains the most extensively studied dysfunctional breathing pattern, although other forms may coexist or appear in isolation.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingnone given

    Forced abdominal expiration is the least described breathing pattern in the literature, but can be observed in the clinical setting particularly in patients with COPD.

    “This is the least described breathing pattern in the literature, but can be observed in the clinical setting particularly in patients with COPD.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    Thoracic dominant breathing often occurs in patients with increasing ventilation needs such as cardiac or respiratory disease or decreased abdominal compliance such as morbid obesity, but in their absence it can be termed dysfunctional.

    “This type of breathing often occurs in patients with increasing ventilation needs such as those with cardiac or respiratory disease or those with decreased abdominal compliance such as the morbidly obese, but in their absence it can be termed dysfunctional [11, 48, 49].”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [11] source
    • cites [48] Killian, 1988, Respiratory muscles and dyspnea, Clin Chest Med source
    • cites [49] source

  • May combine two claims.

    Findingreasoning

    Without further diagnostic criteria and with an ongoing lack of awareness of dysfunctional breathing, sample sizes were often low and included mixed breathing patterns.

    “Without further diagnostic criteria and with an ongoing lack of awareness of dysfunctional breathing sample sizes were often low and included mixed breathing patterns.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Findingnone given

    The presentation of varying breathing patterns under the umbrella term 'dysfunctional breathing' appears to be relatively widely appreciated anecdotally, but there is little recognition of this in the literature.

    “The presentation of varying breathing patterns under the umbrella term of “dysfunctional breathing” appears to be relatively widely appreciated (anecdotally), but there is little recognition of this in the literature, and hence the topic presents a significant challenge for clinicians.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Hyperventilation syndrome is the most widely recognised form of dysfunctional breathing.

    “The most widely recognised form of dysfunctional breathing is hyperventilation syndrome (HVS), which was first described over 70 years ago [6].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [6] Kerr, 1938, Physical phenomena associated with anxiety states: the hyperventilation syndrome, Cal West Med

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationreasoning

    Hyperventilation syndrome is just one type of breathing pattern disorder and hyperventilation is not necessarily seen in dysfunctional breathers.

    “This term is often also used synonymously with dysfunctional breathing, whereas in fact it is just one type of breathing pattern disorder and hyperventilation is not necessarily seen in dysfunctional breathers.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Interpretationnone given

    Many dysfunctional breathing patterns may occur as a physiological response to disease, but in the absence of organic abnormalities they can be considered pathological.

    “Many of these breathing patterns may occur as a physiological response to disease, but in the absence of organic abnormalities they can be considered pathological.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Many studies assessing epidemiology use the Nijmegen questionnaire as a method of diagnosis, which may not be valid in some circumstances.

    “Many of the studies assessing epidemiology use the Nijmegen questionnaire as a method of diagnosis, which may not be valid in some circumstances.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationcitation

    Dyspnoea is unlikely to be caused solely by inadequate or inefficient ventilation either due to hyperventilation or an abnormal breathing pattern; additional factors such as poor subjective awareness of breathing are thought to play a role.

    “Dyspnoea is unlikely to be caused solely by inadequate or inefficient ventilation either due to hyperventilation or an abnormal breathing pattern and additional factors, such as poor subjective awareness of breathing by patients, are thought to play a role [10].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [10] van Dixhoorn, 1997, Hyperventilation and dysfunctional breathing, Biol Psychol

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    These factors were said to represent both biomechanical and chemoreceptive factors contributing to dysfunctional breathing, which have often been implicated in other studies.

    “These factors were said to represent both biomechanical and chemoreceptive factors contributing to dysfunctional breathing, which have often been implicated in other studies [33].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [33] source

  • May combine two claims.

    Interpretationreasoning

    Although the Nijmegen questionnaire was developed and validated only in people with exercise induced HVS, its use has since been extrapolated, probably inappropriately, to aid diagnosis of all forms of dysfunctional breathing in many settings.

    “Although this questionnaire was developed and validated only in people with exercise induced HVS its use has since been extrapolated, probably inappropriately, to aid the diagnosis of all forms of dysfunctional breathing in many settings.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationnone given

    Dysfunctional breathing patterns may occur where there is coexistent respiratory disease, in particular asthma, and difficulty arises when trying to untangle which contributes most to symptoms.

    “Dysfunctional breathing patterns may occur where there is coexistent respiratory disease, in particular asthma, and so difficulty arises when trying to untangle which of the two are contributing most to the reported symptoms.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Interpretationreasoning

    The proposed categories include patterns described or observed in isolation as well as coexisting with one another.

    “The proposed categories include patterns described or observed in isolation as well as coexisting with one another.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationnone given

    Hyperventilation syndrome is associated with symptoms both related to respiratory alkalosis and independent of hypocapnia.

    “1) Hyperventilation syndrome: associated with symptoms both related to respiratory alkalosis and independent of hypocapnia.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.

    Interpretationreasoning

    To extrapolate these data to all dysfunctional breathers is difficult and must be interpreted in the context of the studied sample population.

    “To extrapolate these data to all dysfunctional breathers is difficult and must be interpreted in the context of the studied sample population.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Many patterns of dysfunctional breathing are described in the literature and evident in clinical practice, and review of the symptoms and physiology described has enabled classification into the proposed categories.

    “In fact many patterns of dysfunctional breathing patterns are described in the literature (and evident in our clinical practice), and review of the symptoms and physiology described has enabled us to classify each into the following proposed categories (summarised in table 1 and figure 1).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Premisenone given

    Pulmonary rehabilitation has clear benefits in COPD patients and has been trialled in other respiratory conditions.

    “Pulmonary rehabilitation has clear benefits in COPD patients and has been trialled in other respiratory conditions.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationcitation

    Patients with both elevated Nijmegen questionnaire scores and abnormal breathing patterns as assessed by MARM may benefit from breathing retraining to produce more efficient breathing patterns.

    “Patients with both elevated Nijmegen questionnaire scores and abnormal breathing patterns as assessed by MARM may benefit from breathing retraining to produce more efficient breathing patterns [34].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [34] source

  • Probably not a substantial claim: may not pass S4 (based). May combine two claims.

    Interpretationnone given

    Thoracic dominant breathing can often manifest in somatic disease; if occurring without disease it may be considered dysfunctional and results in dyspnoea.

    “3) Thoracic dominant breathing: can often manifest in somatic disease, if occurring without disease it may be considered dysfunctional and results in dyspnoea.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationreasoning

    It is possible that several dysfunctional breathing patterns may coexist.

    “It is possible that several dysfunctional breathing patterns may coexist.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Interpretationnone given

    Treatment for dysfunctional breathing starts with an accurate diagnosis, which in itself can provide significant reassurance and relief of anxiety, and may be enough to reduce the severity and frequency of symptoms.

    “Treatment for dysfunctional breathing starts with an accurate diagnosis, which in itself can provide significant reassurance and relief of anxiety, and may be enough to reduce the severity and frequency of the symptoms.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationcitation

    Thoraco-abdominal asynchrony is sometimes seen as a normal physiological response in upper airway obstruction, neuromuscular disorders and acute respiratory failure, but may be seen in patients without evidence of these, and therefore considered dysfunctional.

    “Thoraco-abdominal asynchrony is sometimes seen as a normal physiological response in upper airway obstruction, neuromuscular disorders and in patients with acute respiratory failure, but may be seen in patients without evidence of these, and therefore considered dysfunctional [52].”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [52] source

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationnone given

    Dysfunctional breathing may present alone, as a somatic manifestation of psychological conditions, or as a manifestation of underlying disease; and in any individual there may be more than one of these factors at play.

    “Dysfunctional breathing may present alone, as a somatic manifestation of psychological conditions or as a manifestation of underlying disease; and in any individual there may be more than one of these factors at play.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning

    There is likely to be a significant publication bias in dysfunctional breathing research.

    “In addition, as for many conditions that lack clear criteria for diagnosis there is likely to be a significant publication bias.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    People with hyperventilation syndrome may also have periodic deep sighing, and the same patient may experience different forms of dysfunctional breathing at different times.

    “For example, people with HVS may also have periodic deep sighing, and indeed the same patient may experience different forms of dysfunctional breathing at different times.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning

    Without defined diagnostic criteria, current research is difficult to interpret.

    “Without defined diagnostic criteria, current research is difficult to interpret.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    Many current breathing retraining methods have yet to be rigorously tested, and without clear definitions for cases and controls linking any improvements seen is difficult.

    “Many current breathing retraining methods have yet to be rigorously tested, and without clear definitions for cases and controls linking any improvements seen is difficult.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    Currently most published treatment proposals are targeted at hyperventilation syndrome, but these may not be appropriate in patients with forced abdominal expiration or thoraco-abdominal asynchrony.

    “Currently most published treatment proposals are targeted at HVS, but these may not be appropriate (and in our experience do not work) in patients with, for example, forced abdominal expiration or thoraco-abdominal asynchrony.”
    Quote in the paperSubstantial claim
68 of 68

  • The paper relies on this without support.

    Dysfunctional breathing patterns occur in some patients with COPD and interstitial lung disease.

    “A clear link between dysfunctional breathing and other respiratory diseases has not been made in the literature, but in our experience dysfunctional breathing patterns do occur in some patients with diseases such as chronic obstructive pulmonary disease (COPD) and interstitial lung disease.”

  • The paper relies on this without support.

    Efficient breathing requires coordination between the diaphragm, abdominal muscles and muscles of the rib cage.

    “Efficient breathing requires coordination between the diaphragm, abdominal muscles and muscles of the rib cage.”
2 of 2

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • The treatment of HVS involves an educational approach, exercises for ventilatory control through voluntary hypoventilation, and specific therapeutic elements according to the patient's symptoms, such as exercise training or relaxation.

    “The treatment of HVS involves an educational approach, exercises for ventilatory control through voluntary hypoventilation, as well as specific therapeutic elements, according to the patient's symptoms, such as exercise training or relaxation.9,12,13,27,36,37”

    From Physiotherapy Education and Breathing Retraining for Patients With Hyperventilation Syndrome: An Observational Study (2026) · cites this paper as [9]

    The Treatment section describes reassurance after diagnosis and breathing retraining, including controlled pauses intended to reduce hyperventilation. It does not describe exercise training or relaxation as symptom-specific HVS treatments; it says no literature exists on pulmonary rehabilitation for dysfunctional breathing. Page numbers are unavailable in our copy. (LLM, conf=0.87)

    Experimental — accuracy not yet measured

  • The clinical community acknowledges physiotherapy as an effective treatment for HVS and, more broadly, for chronic dysfunctional breathing.

    “However, the clinical community acknowledge physiotherapy as an effective treatment for HVS and, more broadly, for chronic dysfunctional breathing.”

    From Physiotherapy Education and Breathing Retraining for Patients With Hyperventilation Syndrome: An Observational Study (2026) · cites this paper as [9]

    The Treatment section says physiotherapy-directed breathing techniques may relieve symptoms and describes follow-up with a respiratory specialist physiotherapist. But the Discussion says most published treatments target HVS, may not work for other breathing patterns, and have not been rigorously tested. The source therefore does not establish physiotherapy as an effective treatment for chronic dysfunctional breathing broadly. (LLM, conf=0.87)

    Experimental — accuracy not yet measured

  • DB is often ill-defined, with considerable ambiguity surrounding its definition, diagnosis and optimal management.

    “This has also led to DB being often ill-defined, with considerable ambiguity surrounding its definition, diagnosis and optimal management (9,10).”

    From How is dysfunctional breathing characterised in the clinical literature? A scoping review (2026) · cites this paper as [10]

  • Four classification systems for DB have been proposed.

    “Four classification systems for DB have been proposed, as referenced in sources (4,7,8,10), with further details provided in Supplementary Materials 2.”

    From How is dysfunctional breathing characterised in the clinical literature? A scoping review (2026) · cites this paper as [10]

  • There is an absence of a universally accepted diagnostic instrument for assessment of DB.

    “A further consequence of this lack of consensus is the absence of a universally accepted diagnostic instrument for assessment (9,10).”

    From How is dysfunctional breathing characterised in the clinical literature? A scoping review (2026) · cites this paper as [10]

Cites

Flagged first, then by citations

Research works printed but not linked: 1

  1. van Dixhoorn, 1997, Hyperventilation and dysfunctional breathing, Biol Psychol, 46, 90

Cited by

Sorted by citations

Related

Authors
Boulding, R., Stacey, R., Niven, R., & Fowler, S. J.
Affiliations
Lancashire Teaching Hospitals NHS Foundation Trust (GB)
ORCID
Venue
European Respiratory Review
Publisher
European Respiratory Society (ERS)
Published
2016-08-31
Volume
25
Issue
141
Pages
287-294
ISSN
  • 0905-9180 (ISSN-L)
  • 1600-0617
DOI
10.1183/16000617.0088-2015
PMC
PMC9487208
OpenAlex
W2510142779
Semantic Scholar
cdf601a50ef9aaf1c91c7e46ee7639e329b01194
Cited by
372
References
67
Citations by year
2026: 46 · 2025: 59 · 2024: 40 · 2023: 51 · 2022: 46 · 2021: 44 · 2020: 28 · 2019: 22 · 2018: 21 · 2017: 9 · 2013: 1
FWCI
13.76
Type
journal article
Language
en
Open access
Licence
cc-by-nc
Locations
  • European Respiratory Review (publishedVersion, cc-by-nc)
  • PubMed (publishedVersion)
  • Research Explorer (The University of Manchester) (publishedVersion, cc-by-nc)
  • PubMed Central (submittedVersion, cc-by-nc)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
Topics
  • Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Respiratory and Cough-Related Research
  • Health Sciences › Medicine › Psychiatry and Mental health › Psychosomatic Disorders and Their Treatments
  • Health Sciences › Medicine › Physiology › Asthma and respiratory diseases
Keywords
dysfunctional breathing, hyperventilation syndrome, dyspnea, respiratory alkalosis, hypocapnia, Nijmegen questionnaire, breathing pattern classification, breathing disorders
MeSH terms
Dyspnea, Humans, Lung, Terminology as Topic, Predictive Value of Tests, Respiration Disorders, Risk Factors, Respiratory Mechanics, Comorbidity

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-22.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-22.

Cited sources are checked by gpt-6-sol.

Statistics and arithmetic are recomputed, not judged.

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