Dysfunctional breathing and hyperventilation complaints

For how many hyperventilation patients are the complaints due to Dysfunctional Breathing ?

Van Leeuwen, Van Dixhoorn, 1993

Dysfunctional breathing and hyperventilation complaints

Three year follow-up of breathing therapy

What is the longterm outcome for patiënts with and without Dysfunctional Breathing?

76 patiënts, referred for breathing therapy in 1989-90

with a diagnosis of hyperventilation or an elevated score on Nijmegen Questionnaire

Follow-up questionnaire in 1993

response by 54 (71%)

19 men and 35 women

35.5 ± 15 years of age

No difference between respondents and non-respondents

Respn=54

non-Resp.n=22

Nijmegenquestionnaire

29.1 29.7

Medicaldiagnosis

7 (13%) 4 (18%)

Psychosocialstressors

30 (55%) 10 (45%)

Number ofsessions

16.6 17.0

Change in maincomplaint

Resp.n=54

non-Resp.n=22

worse 2 (4%) 0

unchanged 12 (22%) 6 (32%)

improved 18 (33%) 5 (26%)

Much improved 22 (41%) 6 (42%)

Response tobreathingtherapy

Resp.n=54

non-Resp.n=22

no positiveresponse

17 (32%) 9 (47%)

positive +mixed feelings

16 (29%) 4 (21%)

positive +managingtension

21 (39%) 6 (32%)

Constructing the role ofDysfunctional Breathing

in the etiology of thecomplaints out of

response in breathingand change in complaint

Although studies of breathing therapy for hyperventilation complaints have positive outcomes, the response in breathing is rarely included

Change in maincomplaints

Response tobreathingtherapy

yes nono positiveresponse DB- DB-

positiveresponse DB+ DB-

Constructing the role of DB out ofresponse to breathing therapy and change in complaint

response tobreathing th

change incomplaints

n (%) role of DB category

absent no improvement 10 (18.5) improbable/unknown

2

improved 6 (11) improbable/unknown

2

much improved 1 (2) none 1

positive no improvement 4 (7.5) none 1

improved 12 (22) possible, secondary 3

much improved 21 (39) probable, major 4

DB not n=5

DB improbableunknown

n=16

DB secondary n=12 n=33 61%

DB major n=21 95 % C.I.

48%-74%

Thus, dysfunctional breathing plays a role in the etiology of hyperventilation complaints in 61% of the patiënts,

in between half and threequarters of the patients

What characteristics are associated with DB?

Is it dependent upon medical or psychological factors or does it play an independent role?

Cardiacdisease

Lungdisease

DB not

DB improbableunknown

DB secondary 1 1

DB major 2 1

Psycho-therapy

Stressors

DB not 2 (40%) 4 (80%)

DB improbableunknown

6 (38%) 10 (63%)

DB secondary 3 (25%) 4 (33%)

DB major 3 (14%) 12 (57%)

ns ns

Dysfunctional breathing is an independent factor

absence of medical diagnosis is not required

psychological problems may partly obscure its role

NijmegenQuestionnaire

DB not 24.5

DB improbableunknown

34.4

DB secondary 29.7

DB major 25.4

F(3,48) =3.0p<0.05

When there is no response to breathing therapy and little or no change in main complaints, the score in Nijmegen Questionnaire is elevated; there is probably psychopathology that dominates the role of dysfunctional breathing

Three year follow-up of breathing therapy

What is the longterm outcome for patiënts with and without Dysfunctional Breathing?

What interventions occurred in the 3 - 4 years of follow-up because of the initial complaints?

medicaltherapy

psycho-therapy

breath

DB not 1 (20%) 1

DB improbable 9 (56%) 1

DB secondary 1 3 (25%) 1

DB major 3 (14%) 1

p < 0.05

One cardiac patiënt received a PTCA for chest pain,

16 patiënts received psychological treatment

4 patiënts followed a second round of breathing therapy

Does the effect on Nijmegen questionaire differ between categories of DB?

Before Follow-up

DB not 24.5 32.8 n=4

DB improbable 33.3 31.8 n=15

DB secondary 29.7 23.1 n=12

DB major 25.8 17.2 n=19

Total 29.2 24.2 p<0.001

MANOVA, TIMExDB, F(3,46)=5.99, p < 0.02

Changes in Nijmegen Questionnaire

15

20

25

30

35

Before Follow-up

DB notDB improbableDB secondaryDB major

Effect sizes (Cohen's d)

-1

-0,5

0

0,5

1

DB notDB improbableDB secondaryDB major

When the complaints are probably due to DB, there is a lasting effect. The average score at follow-up is normal or slightly elevated.

When DB does not play a role, the changes are small and the score at follow-up is high.

The NQ score at follow-up is highly predictable (MR=0.80)

by two predictors:

NQ score: beta = 0.60

DB: beta= -0.42

Thus, a low score and high probability of DB predict low scores after 3-4 years

Does the effect on Nijmegen questionaire differ between DB and subsequent psychotherapy?

n Before Follow-up

DB notPT not

10 29.4 33.5

DB notPT yes

9 35.4 30.3

DB yesPT not

26 26.6 18.9

DB yesPT yes

5 30.6 22.4

MANOVA, TIMExDBxPT, F(1,44)=2.80, p<0.10

Changes in Nijmegen Questionnaire for DB and PT

15

20

25

30

35

Before Follow-up

DB- PT-DB- PT +DB+ PT-DB+ PT+

When the complaints are not due to DB, psychotherapy tends to make a difference: with PT there is improvement, without PT the complaints worsen.

When the complaints are due to DB, psychotherapy does not make a difference,

with PT the initial complaints are a little higher than without PT

The occurrence of PT is moderately predictable (MR=0.52):

response to breathing therapy: beta = -0.33

PT at entry: beta= 0.32

Patients who receive PT and do not respond to breathing therapy will have subsequent PT.

To conclude

When hyperventilation complaints are due to dysfunctional breathing, breathing therapy is sufficient to a high degree.

When the role of dysfunctional breathing is not clear, there is probably psychopathology.

Psychological treatment is helpful, but the complaints remain high.

Thus, based on the response to breathing therapy, hyperventilation complaints can be differentiated into

a disorder of ‘dysfunctional breathing’ and

a more complex psychopathological disorder.

This differentiation can probably be made early in breathing therapy, after for instance four sessions.

When dysfunctional breathing plays an important role the initial response to breathing therapy is already positive to some degree. This needs future investigation.