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. 2001 Sep 15;323(7313):631.

Dysfunctional breathing and asthma

Panic disorder needs to be considered

Simon J C Davies 1,2, Peter R Jackson 1,2, Lawrence E Ramsay 1,2
PMCID: PMC1121193  PMID: 11575318

Editor—Thomas et al report an appreciable prevalence of dysfunctional breathing in adults with asthma and discuss the scope for wider use of breathing therapy.1 Neither Thomas et al nor Keeley and Osman in their editorial2 consider whether such symptoms might occur equally often in the normal population or represent panic attacks and panic disorder, well defined entities common in otherwise healthy people. Without a control group their study is incapable of identifying the prevalence of dysfunctional breathing associated specifically with asthma.

Dysfunctional breathing and the hyperventilation syndrome are by no means the same as panic syndromes, but overlap between them may be considerable. Thomas et al acknowledge limitations of the Nijmegen questionnaire.3 This instrument cannot differentiate the “chimeric” hyperventilation syndrome from panic attacks and panic disorder. The 16 items in the Nijmegen questionnaire include “anxiety,” “feeling tense,” and nine of the 13 panic attack symptoms listed in the Diagnostic and Statistical Manual of Mental Disorders, third edition, revised (DSM-III-R). The questionnaire was not defined to attempt to make this distinction. A 23% lifetime prevalence of spontaneous panic attacks has been reported in patients with asthma.4 This figure is not dissimilar to the 29% of asthmatic patients labelled by Thomas et al as having experienced dysfunctional breathing and again suggests appreciable overlap. The lifetime prevalence of asthmatics meeting DSM-III-R criteria for panic disorder in the same study was 9.7%4.

We reported a significant excess of panic attacks and panic disorder among primary care and hospital patients with hypertension compared with matched normotensive people, and 202 of 287 people who had experienced panic attacks related “shortness of breath” or “difficulty catching breath” as symptoms in their worst panic attack.5 The relation of history of panic attacks to a patient's sex in our sample was strikingly similar to that reported for dysfunctional breathing1, with a significant excess in female patients of around 15% in both studies.

The importance of considering panic disorder in a discussion of dysfunctional breathing lies in the availability of treatment of proved efficacy. Thomas et al limit their consideration of therapeutic intervention to breathing therapy. In a patient with recurrent difficult breathing and history suggestive of panic disorder, a much broader range of treatment, from tricyclic antidepressants and selective serotonin reuptake inhibitors to cognitive therapy, may be effective. Failure to identify panic attacks or panic disorder may deprive patients of valuable treatment options, some of which can be instigated in primary care.

References

  • 1.Thomas M, McKinley RK, Freeman E, Foy C. Prevalence of dysfunctional breathing in patients treated for asthma in primary care: cross sectional survey. BMJ. 2001;322:1098–1100. doi: 10.1136/bmj.322.7294.1098. . (5 May.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Keeley D, Osman L. Dysfunctional breathing and asthma. BMJ. 2001;322:1075–1076. doi: 10.1136/bmj.322.7294.1075. . (5 May.) [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 3.van Dihoorn J, Duivenvoorden HJ. Efficacy of Nijmegen questionnaire in recognition of the hyperventilation syndrome. J Psychosom Res. 1985;29:199–206. doi: 10.1016/0022-3999(85)90042-x. [DOI] [PubMed] [Google Scholar]
  • 4.Carr RE, Lehrer PM, Rausch LL, Hochron SM. Anxiety sensitivity and panic attacks in an asthmatic population. Behav Res Ther. 1994;32:411–418. doi: 10.1016/0005-7967(94)90004-3. [DOI] [PubMed] [Google Scholar]
  • 5.Davies SJC, Ghahramani P, Jackson PR, Noble TW, Hardy P, Hippisley-Cox J, et al. Association of panic disorder and panic attacks with hypertension. Am J Med. 1999;107:310–316. doi: 10.1016/s0002-9343(99)00237-5. [DOI] [PubMed] [Google Scholar]
BMJ. 2001 Sep 15;323(7313):631.

Trial shows benefits of Buteyko breathing techniques

Dick Kuiper 1

Editor—Keeley and Osman in their editorial say that there is no good evidence that breathing therapy benefits patients with asthma.1-1 A medical trial, however, run in 1994 at the Mater Hospital, Brisbane, Australia, clearly showed that asthma patients derive great benefits from learning the Buteyko breathing techniques.1-2

For example, usage of reliever medication in the Buteyko group was reduced by an average of 90% after six weeks, and usage of steroid preventer medication was reduced by an average of 49% after three months (with no significant changes in medication usage in the control group). The 39 asthma patients who participated in this double blind trial were not selected on the basis of dysfunctional breathing but merely on the basis that they all used reliever and preventer medication. The fact that this research has not lead to dozens of follow up studies, but instead was followed by dead silence, raises many questions in my mind. One of the problems is that the Buteyko approach is “foreign” in the true sense of the word to most asthma specialists. It is a new approach to asthma, and we need a new approach as the current approach does not seem to offer anything that even slightly resembles a “cure” for the ever growing number of patients with asthma. Let's be honest: many patients end up on a lifelong regimen of drug treatment.

The second issue is that Buteyko cannot be sold over the counter of a pharmacy, which is why pharmaceutical companies are not interested—and as a consequence, it seems, neither are many medical practitioners. The third issue is that the method actually helps many patients with asthma to lead a life free of symptoms and medication. I agree, there is not much continuing profit in such an approach, but there is an enormous benefit to the patient—and was that not what medicine was all about?

References

BMJ. 2001 Sep 15;323(7313):631.

Author's reply

Mike Thomas 1

Editor—We reported a high prevalence of symptoms compatible with dysfunctional breathing in patients diagnosed and treated for asthma in the community and suggested that this may offer a therapeutic opportunity to improve outcomes of care in these patients. We agree with Davies et al that the prevalence of dysfunctional breathing in the general population needs to be established, although previous studies from the Netherlands have quoted a prevalence of symptomatic hyperventilation of 6-10% in general practice, much lower than the prevalence that we found in patients with asthma.2-1

We agree that there is likely to be an overlap between asthma, anxiety, panic disorder, and hyperventilation, and we believe that further studies are needed to clarify this relation. Such studies will need to measure anxiety and panic indices, and investigate physiological measures of respiration and severity of asthma. The 23% prevalence of spontaneous panic attacks quoted by Davies et al is, however, a lifetime prevalence,2-2 whereas the 29% prevalence of symptoms compatible with dysfunctional breathing that we reported is a cross sectional prevalence at a single moment in time and so is likely considerably to underestimate the lifetime prevalence of such symptoms.

Davies et al raise the possibility that different types of therapeutic intervention, such as antidepressant drugs and cognitive therapy, may improve outcomes in these symptomatic patients. We agree that studies investigating the effectiveness of appropriate interventions are warranted and believe that simple and safe non-pharmacological treatments that have been shown to be effective for dysfunctional breathing in other populations are a particularly attractive option for investigation.2-3

Kuiper raises the possibility that the Buteyko breathing technique may be generally beneficial to patients with asthma. Although this method has received considerable lay publicity, it has so far had very limited scientific scrutiny. The single published study that he quotes has important methodological flaws, both in the blinding of treatment and in the outcome measure2-4; using reduction in inhaled drugs as an end point is of dubious validity because the Buteyko method strongly encourages patients not to use such treatment. We agree, however, that most therapeutic trials for asthma are currently concerned with pharmacological interventions and that there is considerable lay interest in non-pharmacological approaches. We agree with the authors of the Cochrane review of breathing therapy for asthma that controlled studies of breathing exercises for asthma are needed to clarify the effectiveness of such interventions and the characteristics of patients who respond to them.2-5 Our study raises rather than answers questions and points to a potentially important area for further research.

References

  • 2-1.Vansteenkiste J, Rochette F, Demedts M. Diagnostic tests of hyperventilation syndrome. Eur Respir J. 1991;4:393–399. [PubMed] [Google Scholar]
  • 2-2.Carr RE, Leher PM, Rausch LL, Hochron SM. Anxiety sensitivity and panic attacks in an asthmatic population. Behav Res Ther. 1994;32:411–418. doi: 10.1016/0005-7967(94)90004-3. [DOI] [PubMed] [Google Scholar]
  • 2-3.Grossman P, De Swart JC, Defares PB. A controlled study of a breathing therapy for treatment of hyperventilation syndrome. J Psychosom Res. 1985;29:49–58. doi: 10.1016/0022-3999(85)90008-x. [DOI] [PubMed] [Google Scholar]
  • 2-4.Bowler SD, Green A, Mitchell CA. Buteyko breathing techniques in asthma: a blinded randomised controlled trial. Med J Aust. 1998;169:575–578. doi: 10.5694/j.1326-5377.1998.tb123422.x. [DOI] [PubMed] [Google Scholar]
  • 2-5.Holloway E, Ram FSF. Cochrane library. Issue 3. Oxford: Update Software; 2000. Breathing exercises for asthma (Cochrane review) [DOI] [PubMed] [Google Scholar]

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