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Understanding Dysfunctional Breathing
Discover personalised physiotherapy solutions designed to improve your respiratory health and overall well-being.
What is Dysfunctional Breathing?
Breathing is essential of course. But not all breathing is good – sometimes it’s downright dysfunctional! Specifically, dysfunctional breathing is when people breathe more than their body requires. They may use the upper part of the chest rather than the diaphragm or take intermittent gulping breathes. Dysfunctional breathing can even arise from an over reliance on the mouth for respiration.
Most people will suffer a bout of over breathing at some time or other, sometimes breathing twice as much as is required. Periods of stress or anxiety commonly cause a brief attack of over breathing. However, for some people this type of breathing can become persistent and occurs most of the time. Often they’re not even aware they´re doing it and the condition is then known as Chronic Hyperventilation Syndrome.
Sufferers may say they feel very breathless or that the chest feels tight or wheezy (symptoms that can easily be mistaken for or exaggerated in asthma). They can feel quite dizzy and as though their heart is racing. Often people tell us that “they are worried they aren’t getting enough oxygen.” But it isn´t the oxygen that causes the problems – over breathing lowers the carbon dioxide (CO2) in our blood and that´s what leads to these scary symptoms.
Far from being a waste product of breathing CO2 plays a number of important physiological roles in our bodies. The gas influences many enzyme reactions and controls the constriction or relaxation of blood vessels and airways. It acts to help speed up the release of oxygen from red blood cells into muscle and even plays a part in muscle contraction itself. Pretty important stuff!
CO2 levels are controlled by breathing. Breathe more than needed, by taking deeper or faster breaths and CO2 levels in the blood fall. Hold your breath and CO2 levels rise again. Sometimes a person´s breathing can be quite regular but then a yawn, sigh, or coughing bout brings on symptoms, as CO2 is reduced. Talking too quickly without pausing for breath lowers the blood CO2 and that´s why people sometimes tell us they feel worse when chatting on the phone.
Chronic Hyperventilation Syndrome
Chronic Hyperventilation Syndrome is a condition that mimics many others so investigations are needed to rule out other possible causes. But once a diagnosis is made specialised physiotherapy can help.
Breathing is controlled by the Autonomic Nervous System, this has two branches: the Parasympathetic Nervous System which slows the breathing, reduces cortisol levels and lowers heart rate, and the Sypathetic Nervous System which increases breathing rate, heart rate, blood pressure and cortisol. Often, particularly after a viral illness or if you have an underlying respiratory disease, the Sympathetic Nervous System becomes dominant.
How can physiotherapy help?
Respiratory physiotherapy helps you correct dysfunctional breathing by first assessing your breathing pattern and then teaching breathing techniques to re-educate your breathing muscles and encouraging slower, reduced volume breathing.
With physiotherapy breathing and stretching exercises we can help calm the body, improve your breathing pattern and ultimately cure this uncomfortable sensation of “air hunger”. Just like changing and improving your posture, with time and practice you can re-educate your breathing so that you breathe slowly, efficiently and effectively and no long feel like you have to “gulp the air in:”
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Are you fatigued?
If you have Chronic Obstructive Pulmonary Disease (COPD), other respiratory disease, Long COVID or ME/CFM, then you probably also suffer with fatigue. In medicine we describe fatigue as a “sensation of overwhelming tiredness, lack of energy, and feeling of exhaustion that is not relieved by rest and interferes with usual functioning.” Fatigue is a multi-component symptom, one questionnaire, the Multidimensional Fatigue Inventory (MFI-20) describes subjective fatigue as encompassing five different components; general fatigue, physical fatigue, reduced activity, reduced motivation and mental fatigue, such as having difficulty concentrating.
Many conditions are accompanied by fatigue but it is particularly profound in respiratory disease. There are different reasons for this, the obvious one being a lack of oxygen to the cells, but we now also know that in COPD, and other conditions, the immune system is chronically elevated which causes the “flight or fight” response to remain permanently raised. The damaged lungs release pro-inflammatory cytokines (such as TNF-alpha and Interleukin-6) into the bloodstream. These inflammatory chemicals can cross the blood-brain barrier where they trigger something known as “sickness behavior." This is a coping mechanism - your brain wants to help you heal and it manifests as a profound lack of motivation.
This is all good if the inflammation is short lived (like having a cold that recovers in a week or so) but if the inflammation is chronic and persistent, as it is in COPD, then the “sickness behaviour” can in fact make us sicker.
What can help treat this fatigue? A review paper published last year in Respiratory Medicine by Zhang and colleagues (2025) looked at 35 studies that considered fatigue in COPD and found four things that were effective in significantly reducing it. Pulmonary rehabilitation, aerobic exercise, progressive muscle relaxation and acupressure (although the confidence of this data was lower than the others).
Exercise and pulmonary rehabilitation work by improving the cardiovascular system, building strength in the peripheral and respiratory muscles and helping improve respiratory patterns. Pulmonary rehabilitation is effective for people with high initial levels of fatigue and lower levels and even appears to improve quality of life most in those with high levels of fatigue (Maarten Van Herck et al, 2019).
In one study from my team, we showed improvements in General Fatigue, Physical Fatigue and Reduced Activity after a seven-week pulmonary rehabilitation programme (Lewko et al, 2013). Whilst there were no changes in the Motivation or Mental Fatigue we would argue that seven weeks may be too short a period to achieve change in these areas of fatigue.
In fact, motivation is an interesting concept as we often “wait for the right motivation” to start a new plan or hobby, but motivation is triggered by activity - once we start doing the activity and see results we are more likely to feel motivated to continue.
If you are fatigued, and waiting for the motivation to get started with an exercise programme you’d be better off starting, and perhaps, when the benefits kick in then so will the motivation to continue. Click on the link below to find out more about my online pulmonary rehabilitation programme.
https://betterbreathingphysio.com/pulmonary-rehab-programme/
References
Lewko A, Bidgood PL, Jewell A, Garrod R. Evaluation of multidimensional COPD-related subjective fatigue following a pulmonary rehabilitation programme. Respir Med. 2014 Jan;108(1):95-102. doi: 10.1016/j.rmed.2013.09.003. Epub 2013 Sep 14. PMID: 24084060. https://pubmed.ncbi.nlm.nih.gov/24084060/
Van Herck M, Antons J, Vercoulen JH, Goërtz YMJ, Ebadi Z, Burtin C, Janssen DJA, Thong MSY, Otker J, Coors A, Sprangers MAG, Muris JWM, Prins JB, Spruit MA, Peters JB. Pulmonary Rehabilitation Reduces Subjective Fatigue in COPD: A Responder Analysis. J Clin Med. 2019 Aug 20;8(8):1264
https://pmc.ncbi.nlm.nih.gov/articles/PMC6722504/
Xiaona Zhang, Jiali Xue, Yan Chang, Rui Zhang, Jie Zhao, Xindan Li, Hongyan Lu, Xirui Jiang, Fang Yu, Pengfei Yang. Non-pharmacological interventions for fatigue in patients with chronic obstructive pulmonary disease: a systematic review and network meta-analysis,
Respiratory Medicine, Volume 248, 2025. https://doi.org/10.1016/j.rmed.2025.108409.
Do you suffer from fatigue?
If you have Chronic Obstructive Pulmonary Disease (COPD), other respiratory disease, Long COVID or ME/CFM, then you probably also suffer with fatigue. In medicine we describe fatigue as a “sensation of overwhelming tiredness, lack of energy, and feeling of exhaustion that is not relieved by rest and interferes with usual functioning.” Fatigue is a multi-component symptom, one questionnaire, the Multidimensional Fatigue Inventory (MFI-20) describes subjective fatigue as encompassing five different components; general fatigue, physical fatigue, reduced activity, reduced motivation and mental fatigue, such as having difficulty concentrating.
Many conditions are accompanied by fatigue but it is particularly profound in respiratory disease. There are different reasons for this, the obvious one being a lack of oxygen to the cells, but we now also know that in COPD, and other conditions, the immune system is chronically elevated which causes the “flight or fight” response to remain permanently raised. The damaged lungs release pro-inflammatory cytokines (such as TNF-alpha and Interleukin-6) into the bloodstream. These inflammatory chemicals can cross the blood-brain barrier where they trigger something known as “sickness behavior." This is a coping mechanism - your brain wants to help you heal and it manifests as a profound lack of motivation.
This is all good if the inflammation is short lived (like having a cold that recovers in a week or so) but if the inflammation is chronic and persistent, as it is in COPD, then the “sickness behaviour” can in fact make us sicker.
What can help treat this fatigue? A review paper published last year in Respiratory Medicine by Zhang and colleagues (2025) looked at 35 studies that considered fatigue in COPD and found four things that were effective in significantly reducing it. Pulmonary rehabilitation, aerobic exercise, progressive muscle relaxation and acupressure (although the confidence of this data was lower than the others).
Exercise and pulmonary rehabilitation work by improving the cardiovascular system, building strength in the peripheral and respiratory muscles and helping improve respiratory patterns. Pulmonary rehabilitation is effective for people with high initial levels of fatigue and lower levels and even appears to improve quality of life most in those with high levels of fatigue (Maarten Van Herck et al, 2019).
In one study from my team, we showed improvements in General Fatigue, Physical Fatigue and Reduced Activity after a seven-week pulmonary rehabilitation programme (Lewko et al, 2013). Whilst there were no changes in the Motivation or Mental Fatigue we would argue that seven weeks may be too short a period to achieve change in these areas of fatigue.
In fact, motivation is an interesting concept as we often “wait for the right motivation” to start a new plan or hobby, but motivation is triggered by activity - once we start doing the activity and see results we are more likely to feel motivated to continue.
If you are fatigued, and waiting for the motivation to get started with an exercise programme you’d be better off starting, and perhaps, when the benefits kick in then so will the motivation to continue. Click on the link below to find out more about my online pulmonary rehabilitation programme.
https://betterbreathingphysio.com/pulmonary-rehab-programme/
References
Lewko A, Bidgood PL, Jewell A, Garrod R. Evaluation of multidimensional COPD-related subjective fatigue following a pulmonary rehabilitation programme. Respir Med. 2014 Jan;108(1):95-102. doi: 10.1016/j.rmed.2013.09.003. Epub 2013 Sep 14. PMID: 24084060. https://pubmed.ncbi.nlm.nih.gov/24084060/
Van Herck M, Antons J, Vercoulen JH, Goërtz YMJ, Ebadi Z, Burtin C, Janssen DJA, Thong MSY, Otker J, Coors A, Sprangers MAG, Muris JWM, Prins JB, Spruit MA, Peters JB. Pulmonary Rehabilitation Reduces Subjective Fatigue in COPD: A Responder Analysis. J Clin Med. 2019 Aug 20;8(8):1264
https://pmc.ncbi.nlm.nih.gov/articles/PMC6722504/
Xiaona Zhang, Jiali Xue, Yan Chang, Rui Zhang, Jie Zhao, Xindan Li, Hongyan Lu, Xirui Jiang, Fang Yu, Pengfei Yang. Non-pharmacological interventions for fatigue in patients with chronic obstructive pulmonary disease: a systematic review and network meta-analysis,
Respiratory Medicine, Volume 248, 2025. https://doi.org/10.1016/j.rmed.2025.108409.
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