Respiratory Conditions

There are many reasons why we feel breathless; it may be due to conditions such as COPD (Chronic Obstructive Pulmonary Disease), asthma, heart problems, or anaemia, but sometimes there is no evidence of disease being responsible. The lack of a diagnosis can be frustrating to some, and this frustration can make things worse.

A breathing pattern disorder means not breathing most efficiently for your body. When we develop unhelpful patterns of breathing, it may lead to a continuous sensation of not being able to fill our lungs or get enough breath, or the feeling of a lack of oxygen (sometimes described as air hunger). Clients often complain of being short of breath going uphill or even at rest. Breathing may feel restricted, or you may have chest pain.

A breathing pattern disorder may manifest as breathing too fast, too slow, taking bigger breaths than necessary, breathing through your mouth, breathing at the top of your chest, or having an erratic rhythm.

There are many reasons why we develop unhelpful patterns; pneumonia, pain, sinus problems, and pregnancy being a few physical causes, while stress and anxiety can also be a trigger to ‘altered breathing’. If we over-breathe (known as hyperventilation), we alter some of the chemical balances in our body, which may lead to some very unpleasant symptoms.

Some classic symptoms of over-breathing include:

• Dizziness
• Blurred vision
• Pins and needles in the hands or feet
• Palpitations
• Anxiety
• Bloating
• Muscle tension
• Headaches
• Mouth breathing
• Fatigue
• Sighing
• Yawning

Treatment for Breathing Pattern Disorders

• Breathing Retraining
• Upper Airways Management
• Strengthening and Stretching

Getting out of breath is normal. It’s a natural response when your body needs more oxygen and energy after doing something physical such as running for a bus.

Some people get out of breath even when they’re not being active. Their breathing feels difficult or uncomfortable, and they may feel like they can’t control their breath.

In the UK, 1 in 10 people experience breathlessness and 1 in 5 people who visit A&E are there because of breathlessness.

Chronic Breathlessness

Chronic means long-term. Chronic breathlessness affects the daily lives of many people with long-term health conditions, like COPD, bronchiectasis, interstitial lung disease, or heart disease. Sometimes people also cough, bring up phlegm, or feel wheezy. It can be a disabling and frightening symptom and often persists despite the best possible treatment of any underlying condition. It can be a difficult symptom to live with, but there are ways you can reduce its impact on your life.

An important first step is to understand what is happening. This will help you find ways to improve your breathing. Specialist respiratory physiotherapists are skilled in providing this support.

Acute Breathlessness

Acute means getting suddenly or unexpectedly out of breath. Acute breathlessness needs to be assessed and appropriately treated straight away, as it can be a sign of a new medical condition.

Breathlessness Symptoms

Breathlessness is not just physical. It’s also a feeling that affects the way we think and act. We each feel it differently.

• You may feel hot, panicky, or overwhelmed
• Your chest might feel tight,t like there is a tight band around it
• You might feel that breathing is very hard work and exhausting

Causes of Breathlessness

If you are feeling breathless when you wouldn’t normally, you should see your GP straight away.

The most common causes of breathlessness are:

• lung conditions like COPD ( chronic obstructive pulmonary disease)
• heart conditions
• anxiety
• being overweight
• smoking

What affects breathlessness

Evidence suggests lung function tests and scans don’t always show how breathless you feel. This is because how you breathe, your lifestyle, and how you think about breathing also affect breathlessness.

An important first step is to make sense of what is happening, which will help you find ways to improve your breathing.

Respiratory physiotherapy can help improve breathing efficiency and conserve energy, improving quality of life and reducing unpleasant symptoms.

ACPRC/BTS Guidelines for the physiotherapy management of the adult, medical, spontaneously breathing patient, May 2009, Thorax

Treatment for Breathlessness

• Cough Management
• Breathlessness Management

A cough is a natural protective response that helps us clear foreign objects that irritate our lungs or throat, either to clear mucus or stop us from choking. It can be voluntary or involuntary.

Different types of cough

Most coughs are caused by colds or flu and only last a couple of weeks. For people with long-term lung conditions such as bronchiectasis, a cough productive of mucus is a main symptom, and regular airway clearance techniques are necessary to keep the lungs clear and healthy.

A cough may become habitual and unhelpful, dry and irritating, a hypersensitive reflex.

A cough that lasts more than 8 weeks is labeled as chronic.

Causes of Chronic Cough

Gastro-Oesophageal Reflux Disease (GORD) and laryngopharyngeal reflux (LPR): acid from your stomach rises up the oesophagus and tips over onto the vocal cords, irritating the back of the throat.

Post-Nasal Drip: excess mucus from your nose /sinuses drips down the back of your throat.

Asthma: cough variant asthma can present with cough as the main symptom

Infections: a cough can remain even after other symptoms of a cold, throat infection or chest infection have gone.

Medications: angiotensin-converting enzyme (ACE) inhibitors, commonly prescribed for high blood pressure and heart failure, can cause a chronic cough as a side effect.

If you have a chronic cough …

Your GP may have carried out basic investigations and looked into ‘treatable traits’ or potential causes such as reflux, post-nasal drip, and allergic airways disease. You may have had a short trial of suitable medication to see if the cough settles.

Airways clearance

Specialist respiratory physiotherapists are trained to work with you to find the best method of clearance in a productive cough. This includes exercises, airway clearance and guidance on medication to make mucus easier to clear. Retained mucus increases risk of infection, increases shortness of breath and in turn impacts on health and quality of life.

Cough Suppression

Physiotherapy has proven benefit in people with cough hypersensitivity where the cough is persistent and underlying causes have been ruled out.

The BTS Guideline for Bronchiectasis in Adults recommends that a respiratory physiotherapist teach patients with airway clearance techniques ,which can include ACBT, postural drainage, positive expiratory pressure, inspiratory muscle training,g inhaling saline and mucolytic agents.

In the BTS Clinical Statement Chronic cough in adults, non-pharmacological treatment for a chronic cough includes ‘A complex intervention…delivered by physiotherapists based on techniques that actively suppress coughing.’

Treatment for Cough

• Cough Management
• Upper Airways Management
• Breathing Retraining

Long COVID is generally defined as symptoms persisting for 3 months or more after an acute COVID-19 infection that cannot be explained by another condition. You do not need to have been seriously ill with COVID-19 to develop Long COVID, and even those who experienced mild symptoms can be affected. Symptoms vary from person to person adding to the complexity of its management. As the physio lead for the Torbay and South Devon Long Covid Rehab Program in 2023, I have been able to share and add to the knowledge gained from working with Long COVID sufferers since they first presented in my virtual clinic in October 2020.

Fatigue and breathing difficulties go hand in hand and can improve with specialist physiotherapy input.

Breathing Difficulties

Many Long COVID sufferers experience persistent breathing difficulties.

Symptoms of Long COVID

• pressure in the chest (the COVID squeeze)
• shallow breathing,
• breathlessness,
• the sense of needing to work harder to take a breath, 
• air hunger.

Your GP will have excluded other causes of exertional breathlessness.

Fatigue  

Many people with Long COVID experience fatigue.

Symptoms of fatigue

• low exercise tolerance
• post-exertional symptom exacerbation (may feel unwell, have poor sleep or pain)
• may crash if they have done too much

Specialist physiotherapy can aid your recovery using strict physiological parameters to reduce the chance of relapse.

Your GP will have carried out blood tests and looked into other causes of fatigue.

Long COVID: a clinical update, The Lancet, August 2024
‘Specialist physiotherapy is recommended if there is no improvement in symptoms after practicing breathing control exercises using online or printed resources.’

Breathing difficulties after COVID-19: a guide for primary care, BMJ, June 2023
‘Breathing difficulties are common sequelae of Covid-19 […] specialist physiotherapy should be considered when symptoms are not improving.’

COVID-19 rapid guideline: managing the long-term effects of COVID-19, NICE, January 2024
‘Healthcare professionals should have a range of specialist skills and expertise in managing fatigue and breathlessness. The core team could include physiotherapy.’

Treatment for Long Covid

• Breathing Retraining
• Cough Management
• Fatigue Management

Specialist respiratory physiotherapists work closely with Ear, Nose and Throat (ENT) doctors, GPs, and speech and language therapists in managing upper airway issues. Unpleasant upper airway symptoms such as rhinitis, sinusitis and exercise-induced laryngeal obstruction (EILO) and snoring are often compounded by disordered breathing. There may be an underlying respiratory condition or structural difference.

Habitual mouth breathing often goes hand in hand with these problems, which adversely affect the health of our ears, nose, mouth, and lungs, and impair brain function, sleep, athletic performance and posture. Getting back to nose-breathing is usually the aim as it has so many health benefits. Did you know that the nose has 30 different functions?

Rhinitis

Rhinitis can be allergic or non-allergic

Allergic rhinitis can be caused by allergens such as pollen, house dust mites, animal dander/saliva, mould, wood dust , flour and latex.

Symptoms of allergic rhinitis:

• sneezing
• an itchy, runny or blocked nose
• a cough
• itchy, red, and watery eyes
• an itchy roof of the mouth

Non-allergic Rhinitis

Non-allergic rhinitis can be caused by having a cold, changes in the weather, exercising, smoke, perfume and paint fumes, alcohol and spicy food, hormone changes or certain medications, certain medical conditions, using decongestant and nasal sprays too often.

Symptoms of non-allergic rhinitis

In addition to the above, there may also be a loss of sense of smell.

Sinusitis

Sinusitis is swelling of the sinuses, usually caused by an infection. It’s common,n especially after a cold or flu, and usually clears up on its own after 4 weeks.

Symptoms of Sinusitis

• pain, swelling, and tenderness around your cheeks, eyes or forehead
• blocked or runny nose
• a reduced sense of smell
• green or yellow mucus from your nose
• a high temperature
• a headache or toothache
• bad breath
• a cough
• a feeling of pressure in the ears
• you may also snore at night and sound nasal when you talk

Exercise-induced laryngeal obstruction (EILO)

Exercise-induced laryngeal obstruction (EILO) is a narrowing of the upper airway that happens when you exercise. It can cause breathing difficulties. EILO is common in young athletes but it can also affect pre-teens and adults.

Symptoms of EILO

• Shortness of breath or breathlessness
• Noisy breathing, such as gasping sounds or wheezing
• A feeling of choking or suffocation
• Feeling like there is a lump in the throat
• Throat or chest tightness

Specialist physiotherapy assessment and targeted treatment help to alleviate these symptoms and improve your quality of life.

Functional Nasal Breathing Rehabilitation: a feasible and effective modality for reducing mouth breathing and improving nasal obstruction symptoms in patients with nasal obstruction. Courtney et al (2022) International Journal of Orofacial Medicine

Treatment of Nose, Sinus, and Throat Problems

• Breathing Retraining
• Upper Airways Management
• Breathing Techniques
• Strengthening and Stretching

Most people experience stress and anxiety at some point in their lives. Stress is usually a response to an external cause, such as a tight deadline at work or having an argument with someone, and usually disappears or reduces once the situation has been resolved.

Anxiety is typically described as a feeling of apprehension or dread in situations where there is no actual real threat and is disproportionate to the problem faced. Unlike stress, anxiety persists even after a concern has passed.

Burnout is a state of physical, mental, and emotional exhaustion. It can occur when one experiences long-term stress and feels under constant pressure.

Stress, anxiety, and burnout cause breathing to alter so that we are ready for action: fight, flight, or freeze. Unless there is an immediate and real danger, this change in breathing is unhelpful and can cause unpleasant symptoms if it continues and becomes the new normal.

Symptoms of Stress and Anxiety

• butterflies in the stomach
• shortness of breath
• headaches and /or dizziness
• hot flushes
• increased heartbeat
• increased perspiration
• dry mouth
• the sensation of a tight band across the chest area
• wanting to use the toilet more often
• feeling sick/shaking
• loss or gain of appetite
• choking sensation and/or palpitations

Disordered breathing is seen in around 40% of people who have anxiety and depression.

Breathing exercises are widely used to help us feel calmer and are now easily available on apps or YouTube. Unfortunately, if there is an underlying breathing pattern disorder, the breathing exercise may perpetuate the problem by encouraging breaths that are too big or using the wrong muscles. Sometimes, focusing on breathing can make people who struggle with anxiety feel more anxious.

A specialist respiratory physiotherapist can work alongside you to correct your breathing pattern, look at triggers for symptoms, and work on ways to manage these more effectively to help you feel more like yourself.

Treatment of anxiety

• Breathing Retraining
• Breathing Techniques

How we breathe during exercise significantly affects overall performance.

It is influenced by many factors such as your habitual breathing pattern, strength, tightness and imbalance of different muscles, posture and  limb movement during activity , upper airway anatomy and stress.

Recent studies have shown inspiratory muscle weakness lower than age-related normal, even in sub-elite and Olympic athletes! *

By thorough assessment, both at rest and during your chosen activity, simple changes to improve breathing efficiency can be made, which may include:

• better regulation of breathing during different stages of exercise
• deciding when and how to breathe through your nose or mouth
• optimising posture
• coordinating breath with movement
• strengthening of the often-neglected respiratory muscles

*unpublished data in sub-elite under water hockey, Olympic female rowers, and professional rugby players