Dyspnea as a Functional Disorder in Children

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67R.D. Anbar (ed.), Functional Respiratory Disorders: When Respiratory Symptoms

Do Not Respond to Pulmonary Treatment,Respiratory Medicine,

DOI 10.1007/978-1-61779-857-3_4, Springer Science+Business Media, LLC 2012

Abstract Dyspnea, or shortness of breath, frequently accompanies cardiopulmo-

nary disease in both pediatric and adult patients. However, the sensation of breath-

lessness can also accompany anxiety with somatic symptoms that are troublesome

and sometimes disabling. Symptoms are often out of proportion to physical findings,

test results often normal, and may decrease substantially when the patient is asleep

or distracted. The most common presentations of functional dyspnea include vocal

cord dysfunction, hyperventilation, sighing dyspnea, and overbreathing or hyper-

ventilation during exercise. These symptoms are most often confused with poorly

controlled asthma resulting in overtreatment with asthma medications, includingcorticosteroids. After a judicious workup for organic cardiopulmonary disease,

specific testing may help differentiate these disorders. These include specialized

cardiopulmonary testing, provocation tests, and standardized and validated ques-

tionnaires. Identification of functional dyspnea can then facilitate short-term inter-

vention and/or psychological evaluation and treatment.

Keywords Dyspnea Functional respiratory disorders Hyperventilation Sighing

Vocal cord dysfunction

Introduction

Dyspnea is defined as difficult or labored breathing or shortness of breath, and

patients often complain that I cant get enough air. The word is derived from the

Greek dys meaning bad or difficult and pnoia meaning breathlessness.

D.N. Homnick (*)

Department of Pediatrics, Michigan State University, Kalamazoo Center for Medical Studies,

1000 Oakland Drive, Kalamazoo, MI 49008, USA

e-mail: [email protected]

Chapter 4

Dyspnea

Douglas N. Homnick


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68 D.N. Homnick

Dyspnea is often a nonspecific but troubling sensation prompting patients to read-

ily and regularly seek medical help. Dyspnea represents a complex psychophysi-

ologic sensation occurring in a variety of cardiorespiratory and metabolic

disorders. It is expected in demonstrable cardiopulmonary disease, or normal with

exertion during exercise, but when disproportionate to findings on the physical

examination or the level of exertion, should lead the examiner to consider a func-

tional etiology.

A careful history and physical examination and judicious laboratory testing are

always indicated to rule out treatable organic causes of dyspnea or to rule in those

of psychogenic or functional etiologies. The physical examination usually will not

reveal specific abnormalities in patients with functional dyspnea except for rapid

and deep respirations during an acute episode. Of considerable more difficulty is

diagnosing chronic dyspnea as a subtle increase in breathing frequency that may not

be as evident (see testing below) and the complaint of the patient may be simply thatof air hunger.

Acute, psychogenic, or functional dyspnea usually resolves within minutes with-

out specific therapy, in contrast to that associated with cardiopulmonary or meta-

bolic disease. Functional causes of dyspnea, classified as dysfunctional breathing

disorders, are clinically evident with observable deep and rapid respirations, noisy

breathing, or are simply perceived by the patient. These include vocal cord dysfunc-

tion (VCD), hyperventilation (often associated with panic attack/disorder), and

those conditions probably related to hyperventilation, including sighing dyspnea,

and some exertional dyspnea [1]. VCD is a common cause of functional dyspnea,particularly in, but not limited to, adolescents. This condition is thoroughly dis-

cussed in Chap. 6 and will not be reviewed here. The other conditions are discussed

below with illustrative cases.

Hyperventilation

Hyperventilation is defined as respirations in excess of metabolic demands and isoften, but not invariable, associated with reduction in arterial pCO

2(PaCO

2) with

subsequent increase in pH (alkalosis). It can occur chronically or in response to a

provoking stimulus such as sudden fright or other acute stressor. It was originally

described associated with tetany in 1922 by Goldman [2] and later as the hyperven-

tilation syndrome associated with anxiety by Kerr [3] in 1937. The exact prevalence

of hyperventilation is unknown but thought to occur in 610% of adults [46]. Even

less is known about the prevalence of dyspnea associated with hyperventilation in

children; however, the age distribution suggests it is more common in adolescence.

Enzer and Walker [7] reviewed the records of 44 children and adolescents admittedto the hospital with symptoms associated with hyperventilation. The majority were

greater than 12 years (range 516) with a 2 : 1 female ratio (Fig. 4.1). In another

study of children and adolescents with hyperventilation, 53% of patients were

between 13 and 15 years with an equal gender distribution [8]. It is most frequently
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694 Dyspnea

misdiagnosed as acute or chronic asthma leading to ineffective treatment with

asthma medications. However, asthma as a trigger for hyperventilation or vice versa

occurs, particularly when mild asthma is undiagnosed [9].

Relationship to Anxiety or Other Psychological Disturbance

The relationship of hyperventilation to psychological states is well established. Of

the 44 children and adolescents that Enzer and Walker [7] reviewed, 23 were referred

for psychiatric evaluation. Of these, 13 were diagnosed with anxiety disorder, 3 with

depression, 1 with psychosis, 4 with conversion reaction, and 2 refused the referral.

Issues over sexuality were the most common factors in these conditions. This is also

true in adults. In another study, 50% of patients with symptomatic hyperventilation

were described as suffering from psychiatric disturbance characterized by anxiety,

panic, and phobic symptoms [10]. Hyperventilation has significant overlap rateswith known psychiatric conditions. De Ruiter et al. [11] found hyperventilation

rates of 48% among patients with panic disorder, 83% for panic disorder with ago-

raphobia, and 82% with generalized anxiety disorder.

This has spawned debate as to the very existence of the hyperventilation syn-

drome or whether hyperventilation is a symptom [1218]. Those believing hyper-

ventilation is a symptom of an underlying psychological disturbance point out the

similarity of symptoms to panic attacks (Table 4.1). Also, symptoms of hyperventi-

lation such as chest tightness or discomfort, paresthesias, dizziness, blurred vision,

rapid heart rate, sweating, and confusion or feelings of unreality may be reproducedwith a stressful mental load without hypocapnia [20]. They also may be reproduced

in susceptible individuals during voluntary hyperventilation while maintaining nor-

mocapnia. Also patients who experience panic attacks at home show little decrease

in transcutaneous CO2levels (tcCO

2) [15].

Fig. 4.1 Age and gender distribution of children and youth presenting with hyperventilationReprinted from [1]. With permission from Elsevier


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70 D.N. Homnick

That is not to say that the symptoms associated with hyperventilation do not

have physiological explanations. When hypocapnic alkalosis occurs, the symp-

tom of derealization may be due to hypocapnic-induced decrease in cerebralblood flow and paresthesias can occur as a result of increased neuronal excitabil-

ity [21, 22]. Chest wall pain and discomfort may be due to hypocapnia-induced

chest wall muscle spasm, esophageal spasm, or gastroesophageal reflux disease

[23, 24].

Clinical

As dyspnea is a common presenting sign of significant cardiopulmonary or met-

abolic disease (Table 4.2), the clinician must be cautious in making a diagnosis

of functional disease. A complete and careful history can often hone the differ-

ential diagnosis and provide for judicious testing. Functional respiratory disor-

ders are often diagnosed as asthma, and overtreatment and ineffective treatment

are common. However, dysfunctional breathing and asthma are not mutually

exclusive, and, in one study, 29% of adults with asthma screened positively for

hyperventilation versus 8% of those without asthma [6]. Niggemann [25] points

out several important questions that can help differentiate organic from func-tional respiratory disease (Table 4.3). In a child or teen with a functional respi-

ratory disorder, the possibility of child sexual or physical abuse should always

be considered [26].

The physical examination may reveal an anxious and distracted patient and

abnormalities in depth of respirations, and breathing frequency and use of accessory

Table 4.1 Criteria for panic attack

Note:A panic attack is not a codable disorder. Code the specific diagnosis in which the panic attack

occurs (e.g., 300.21 panic disorder with agoraphobia [p. 441])

A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms

developed abruptly and reached a peak within 10 min:(1) Palpitations, pound heart, or accelerated heart rate

(2) Sweating

(3) Trembling or shaking

(4) Sensations of shortness of breath or smothering

(5) Feeling of choking

(6) Chest pain or discomfort

(7) Nausea or abdominal distress

(8) Feeling dizzy, unsteady, light-headed, or faint

(9) Derealization (feelings of unreality) or depersonalization (being detached from oneself)

(10) Fear of losing control or going crazy(11) Fear of dying

(12) Paresthesias (numbness or tingling sensations)

(13) Chills or hot flashes

Reprinted with permission from [19] (Copyright 2000)


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714 Dyspnea

muscles are important signs. Careful chest and neck examination and auscultation

are important, as is the examination of the nose for signs of nasal obstruction.

A careful neurologic examination may reveal hyperreflexia associated with anxiety,

and skin evaluation can demonstrate hyperhidrosis or self-mutilation.

Table 4.2 Causes of dyspnea

Upper airway

Obstruction foreign body

Angioedema

Epiglottitis Diphtheria

Bacterial tracheitis

Tonsillar abscess

Lower airway

Asthma

Pneumonia

Croup (laryngotracheobronchitis)

Bronchiolitis

Pulmonary contusion

Adult respiratory distress syndrome

Infant respiratory distress syndrome

Chronic obstructive pulmonary disease

Cystic fibrosis

Pneumoconiosis

Interstitial lung disease

Hypersensitivity pneumonitis

Thermal trauma

Chest

Pneumothorax

Pleural effusion, hemothorax, empyema

Trauma

Rib fractures

Flail chest

Congenital thoracic malformations

Diaphragmatic hernia

Cardiac

Congestive cardiac failure

Acute pulmonary edema

Acute myocardial infarction Cardiac arrhythmias

Congenital heart disease

Vascular

Pulmonary embolus

Pulmonary hypertension

Arteriovenous malformation

Others

Psychogenic hyperventilation (panic)

Toxigenic, e.g., carbon monoxide, cyanide, salicylates

Metabolic acidosis Anemia


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72 D.N. Homnick

Table 4.3 History that suggests a functional breathing disorder

Question Response

How do you exactly characterize your

symptoms?

e.g., during inspiration and/or expiration, being out of

breath, heavy breathing, dyspnea, pain, etc.; the

wording of patients is often consistent, differentfrom organic complaints, and may already allow

an assignment

Can any breath sounds be heard during

the episodes?

e.g., wheezing, stridor, or no breath sounds at all; can

bystanders hear it? Usually, no specific sounds can

be heard by the surroundings, except in VCD

Is there a typical time point during the

day? Circadian rhythm?

e.g., daytimes or at night, morning, evening, or at any

time; usually there is no defined time of the day

Do you awake at night because of the

symptoms?

Asking for symptoms at night is not exactly enough,

because many patients exhibit symptoms when

lying in bed but still awake, but not during sleep;

this question is one of the most important ones and

allows differentiation to at least bronchial

hyperreactivity and asthma, which mostly show

nocturnal symptoms

Did the symptoms start in the context

of a respiratory tract infection?

Or after any other event?

Especially psychogenic cough and throat clearing

mostly start with a common cold or bronchitis,

then patients lower the threshold to cough, and

finally they cough without any reason. Other

causes include psychological events such as

divorce of parents

What typically acts as a trigger? e.g., physical exercisealthough this can occur bothwith organic and psychogenic or functional

disorders, psychosocial stress, etc., or no typical

trigger factors at all

Are sport activities possible or limited? e.g., usual sport lessons at school, private sporting

activities in sporting associations; sport sometimes

possible, sometimes not?

How long do episodes last? e.g., minimum, maximum duration; average in

seconds, minutes, or hours; very variable duration?

How long does it take you to recover? While asthmatic symptoms usually resolve within

1020 min, psychogenic dyspnea may disappear

within only a few minutesDo you suffer from the symptoms? e.g., in psychogenic cough, the surrounding (such as

teachers, schoolmates, or family) suffers more than

the patients; do the surroundings develop even

aggressive feelings?

Where is the feeling of breathing

difficulty localized?

e.g., let the patient localize with one finger; roughly,

psychogenic dyspnea is more often located to the

throat than thorax

Did you get any medications for your

symptoms? Were they effective?

To what extent?

e.g., antiasthmatic therapy in forms of short-acting

beta-agonists or inhaled corticosteroids; usually,

there is no or only little improvement by drugs,

except from the placebo effect strength

Did you ever have clinical signs such

as tingling of lips or fingers?

e.g., if hyperventilation is suspected

(continued)


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74 D.N. Homnick

The HVPT has been long held to be the gold standard of tests designed to

reproduce the symptoms of and therefore diagnose hyperventilation. However,its sensitivity and specificity to determine whether symptoms occur as a result of

hypocapnic alkalosis or the stress of the procedure has been called into question.

Hornsveld et al. [30] studied 115 patients with suspected hyperventilation in

terms of their ability to recognize symptoms during a HVPT versus a placebo test

consisting of isocapnic overbreathing. Thirty patients with a positive HVPT then

underwent ambulatory tcCO2 monitoring to determine hyperventilation during

spontaneous symptom attacks at home. Of the 115 patients, 85 (74%) reported

symptoms during the HVPT. However, 56 of those also reported symptoms dur-

ing isocapnic overbreathing (false positive), while 29 did not report symptoms

under this condition (true positive). Fifteen false-positive and 15 true-positive

patients underwent the home tcCO2 monitoring and experienced 22 symptom

attacks. tcCO2decreased in only 7, was slight, and followed the onset of hyper-

ventilation, suggesting that hyperventilation was a consequence rather than cause

of the symptoms. In another study, patients with hyperventilation symptoms

underwent a HVPT and a mental load task [20]. About the same number of

patients recognized symptoms during the mental load (52%) versus the HVPT

(61%). Both HVPT and a mental load (word-color conflict test) with measure-

ment of ETCO2 have been shown to have some usefulness in discriminating

patients with asthma-like symptoms associated with negative tests for asthma

and hyperventilation from true asthmatics [31]. Although the HVPT is theoreti-

cally a quick and easy test to do in the office, in our pediatric pulmonology

Table 4.4 The Nijmegen questionnairea score over 23/64 indicates hyperventilation

Symptoms

Never

0

Rarely

1

Sometimes

2

Often

3

Very often

4

Chest pain

Feeling tenseBlurred vision

Dizzy spells

Feeling confused

Faster or deeper breathing

Short of breath

Tight feelings in chest

Bloated feeling in stomach

Tingling fingers

Unable to breathe deeply

Stiff fingers or armsTight feelings around mouth

Cold hands or feet

Palpitations

Feeling of anxiety

Reprinted from [27]. With permission from Elsevier


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76 D.N. Homnick

causes of dyspnea including asthma. These can include pulmonary function testing,

bronchial challenge with methacholine, chest X-ray, serum pH, glucose, electro-

lytes, and a thyroid screen.

A frequent complaint is that of a sense of suffocation accompanied by a feeling

of chest restriction or heaviness [37]. The patient may undertake environmental

manipulation such as running to an open window in an attempt to get enough air

[34]. As with other functional respiratory disorders, a history of life stressors should

be sought.

The typical patient presents with a series of deep, sighing respirations with nor-

mal respiratory frequency, often using accessory muscles. When distracted, the

sighing may decrease spontaneously and when faced with a stressful situation

becomes more frequent and pronounced. Although sighing dyspnea has been

described most commonly associated with psychological stress, including anxiety,

this has not been invariable. Wong et al. [33] showed similar personality profiles inchildren with sighing dyspnea as compared to normal children in terms of anxiety,

somatic complaints, and internalizing behavior.

Testing for Sighing Dyspnea

There are no physiological tests that distinguish sighing dyspnea, and the laboratory

workup is the same as for hyperventilation. Inconsistent pulmonary function abnor-malities have been described including higher residual volume (RV) and residual

volume to total lung capacity (TLC) ratio (RV/TLC%) but with normal TLC and

functional residual capacity (FRC) measured with the body plethysmograph [38].

Aljadeff et al. [39] showed normal TLC and increased RV in adults with sighing

dyspnea. In another study, office spirometry was normal in children with sighing

dyspnea [33]. The significance of these pulmonary function findings is unknown.

With treatment, including simple reassurance, the prognosis appears to be good for

this condition.

Exertional Dyspnea

Dyspnea with exercise is often an early manifestation of cardiopulmonary disease

including both restrictive and obstructive pulmonary disease. In healthy children

and adolescents, exercise-induced dyspnea is most commonly thought to be associ-

ated with exercise-induced asthma [40]. It is also present when patients are poorly

conditioned for the attempted activity and frequently accompanies obesity. Whensymptoms are out of proportion to the patients level of conditioning and the his-

tory, physical examination, and appropriate testing do not suggest an underlying

cardiopulmonary disorder, a functional respiratory diagnosis should be considered.

These include VCD and exercise-induced hyperventilation. VCD is extensively

discussed in Chap. 6.


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774 Dyspnea

Clinical

A typical presentation of exercise-induced hyperventilation (EIHV) as a functional

cause of exertional dyspnea consists of often abrupt onset of shortness of breathassociated with a sense of extreme air hunger occurring much earlier in exercise

than one would expect based on the patients level of conditioning. The patient

appears anxious but can talk through the episode and may have associated symp-

toms such as paresthesias of the extremities, light-headedness or dizziness, a sensa-

tion of being hot or cold, diaphoresis, and chest discomfort, among others. If stridor

or wheezing is heard, another functional or organic diagnosis needs to be consid-

ered. Typically, the episode resolves quickly with rest but reoccurs with new onset

of activity. As performance anxiety may drive the symptoms, these may occur more

commonly or severely with competition rather than practice. Upon careful historytaking, other somatic complaints may be elicited and other psychological dysfunc-

tion or trauma uncovered. A family pattern of anxiety-associated symptoms may be

present.

The physical examination is generally normal, although the patient may show

signs of anxiety such as hyperreflexia, sinus tachycardia, or hyperhidrosis. Other

causes of cardiopulmonary or metabolic diseases, as outlined in Table 4.2, should

be considered based on the history and physical examination before making a func-

tional diagnosis.

Testing for Exercise-Induced Functional Dyspnea

Exercise testing with or without measurement of expired gases is useful in trying to

discriminate those with underlying physiologic abnormalities associated with dysp-

nea and normal physiologic limitation. Abu-Hassan et al. [40] reviewed the records

of 142 children and adolescents (621 years) referred to a pediatric pulmonary

clinic for exercise-induced dyspnea to determine the etiologies of the exercise-induced dyspnea with no signs and symptoms of asthma and no response to inhaled

beta-adrenergic agents. Ninety-eight had had a primary diagnosis of exercise-

induced asthma (EIA) made by their referring provider. During exercise testing,

symptoms of dyspnea were reproduced in 117. However, only 11 (8%) had evidence

of EIA defined by a decrease on forced expiratory volume over 1 s (FEV1) of at least

15%. Seventy-four patients (52%) had normal physiological limitations, 15 (11%)

had restrictive pulmonary function due to minor thoracic cage abnormalities, 13

(9%) had VCD, 2 (1%) had exercise-induced laryngomalacia, and one patient

demonstrated exercise-induced primary hyperventilation (EIHV). Selecting patientsfor chest discomfort (frequently associated with hyperventilation/panic) and no evi-

dence of exercise-induced decrease in FEV1appears to be more selective in diag-

nosing EIHV. Hammo [41] studied 32 patients (818 years) presenting to their

pediatric pulmonary clinic with a history of EIA and chest discomfort with exercise.

Patients underwent treadmill exercise with monitoring of ETCO2, oxygen saturation


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78 D.N. Homnick

(SPO2), and postexercise spirometry. Eleven patients experienced chest discomfort

during the test with minimal decrease in SPO2and spirometry. However, this group

showed an average decrease in ETCO2of 23% versus 9.8% for the rest of the group

(17 with no reproducible symptoms and no significant drop in FEV1and 4 diag-

nosed with EIA).

The value of measuring ETCO2during exercise testing for cardiopulmonary dis-

ease has also been shown in adults with typical and atypical chest pain [42]. Among

a group of 113 adults with exercise-induced chest pain, 92 did not show significant

ST depression, i.e., evidence of coronary artery disease. These were divided in a

group (n= 30) with history compatible with hyperventilation and without (n= 62).

Hypocapnia was demonstrated in 21/30 of those with a positive history of hyperven-

tilation, but also in 25/62 of the negative history group. Hypocapnia also occurred

in 3 patients with ST depression and in one control. Fourteen of the 49 patients also

had borderline or mild reductions in postexercise peak flow measurements. Theauthors felt that measurement of ETCO

2as an adjunct to cardiopulmonary exercise

testing was a useful tool to assess symptoms associated with hyperventilation. They

also felt that mild lung disease may also be responsible for triggering overbreathing

during exercise in some subjects.

Ventilatory equivalents during exercise testing have been used as a provocative

test to differentiate those patients who hyperventilate versus normal controls (see

specific testing for hyperventilation above) [32]. However, they have also been

used to assess the relationship between mild lung disease and hyperventilation.

Twenty-two mild asthmatics (11 males, 11 females), 11 patients with hyperventila-tion, and 22 (11 males, 11 females) controls underwent exercise testing with gas

exchange measurement [43]. VE/VO2and VE/VCO

2were no different between the

controls and mild male asthmatics but were significantly elevated in those previ-

ously determined to hyperventilate and in female asthmatics. Although postexer-

cise spirometry was positive in 50% of asthmatics (>15% decrease), it did not

correlate with the ventilatory equivalents. From this study, exercise-induced hyper-

ventilation in female mild asthmatics did not appear to be related to EIA, although

there was no immediate explanation for this other than possible psychological fac-

tors. Of note is a similar female preponderance in hyperventilation withoutasthma.

Specific Treatment for Functional Dyspnea

Treatment for functional dyspnea is generally the same as for other functional respi-

ratory disorders and is outlined in detail in several chapters of this text. Several

specific treatments for functional dyspnea have been studied, and some are dis-cussed below. Our general approach to psychological evaluation and treatment of

patients with any functional disorder is outlined in Table 4.5. This approach includ-

ing psychological testing has not infrequently uncovered psychological disturbance

requiring further intervention as in case #1 presented below.


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794 Dyspnea

Although not well documented in the medical literature, patients have tradition-

ally used a paper bag for rebreathing during an acute episode of hyperventilation.

Although, in theory, this can reduce hypocapnia in association with the hyperventi-

lation, it also offers the opportunity for the patient to observe the depth and fre-

quency of their respirations in order to make a conscious effort to slow them.

Suggestion and expectation of relief of symptoms also has been shown to be a factor

in bag rebreathing under experimental conditions [44]. However, bag rebreathing

also has some risks. Callaham [45] reported three cases where bag rebreathing erro-

neously applied to patients with myocardial ischemia resulted in death. A subse-quent experiment in normal volunteers showed significant hypoxia associated with

hypercapnia in some individuals depending on length of rebreathing therapy.

Simple reassurance has also been used successfully to relieve symptoms of

hyperventilation. In the case study of Enzer and Walker [7], reassurance was stated

as the primary treatment, although all patients employed bag rebreathing to abort

acute attacks. Nine of the 44 subjects studied also receive sedative medications for

varying period of times, and several underwent cognitive-behavioral therapy.

Extensive discussions of cognitive-behavioral and pharmacologic therapies are

found in Chaps. 9 and 14.Acupuncture has also been shown to be an effective treatment for hyperventila-

tion in one study. In a pilot, randomized, crossover trial of 4 weeks of acupuncture

therapy versus breathing retraining, Gibson et al. [46] showed a statistically

significant decrease in Nijmegen scores and in the Hospital Anxiety and Depression

Table 4.5 Psychological evaluation and treatment of functional disorders

Screening EvaluationPremorbid functioning

Current functioningFamily history

Psychological traumaComorbid disordersSomatic symptoms

Psychological Intervention

(may involve more than

one type of intervention)

Psychoeducation

Relaxation therapyBreathing therapy

BiofeedbackPsychotherapy (individual,

group or family)Psychological Testing and

Mental Status Exam(to identify specific issues

or disorders)Personality, intellectual,achievement, projective,behavioral, family functioning,

medication side effect,substance abuse.

Brief Intervention

Psycho-education, relaxationtherapy, breathing exercises,

hypnosis, speech therapy

No problems

identified

Not

better

Nopsychopathology

Problems

identified

Psychopathology

identified

Resolution

Psychopharmacology

Reprinted from [28]. With permission from Elsevier
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80 D.N. Homnick

Scale in subjects with hyperventilation. Use of acupressure may yield similar benefit

(Chap. 15).

Self-hypnosis has also been shown to be effective in reducing chronic dyspnea in

children and teens (Chap. 12). Anbar [47] studied 17 youths (ages 818) who were

taught hypnotic self-induction techniques and imagery related to their dyspnea.

Sixteen of the patients had resolution or improvement of their symptoms within one

month of practicing the techniques and experienced no recurrences during follow-

up of up to 15 months.

Others have used biofeedback, breathing techniques, and breathing retraining

to reduce or eliminate functional dyspnea associated with panic attacks/disorder

[4850]. Biofeedback, breathing techniques, and speech therapy techniques are

thoroughly reviewed in Chaps. 10, 11, and 13.

Case Studies

Case 1

YS is a 14-year-old girl seen in emergency department for severe respiratory dis-

tress. This included rapid and deep respirations with slight increase in respiratory

rate, chest pressure, blurring of vision, headache, diaphoresis, rapid heart rate, and

normal cardiopulmonary auscultation. She is able to verbally describe her symp-

toms during an episode. This is the third trip to the emergency department in

2 months. Workup in the ED has included an electrocardiogram, electroencephalo-

gram, computerized tomography of her head, serum electrolytes, bicarbonate, cal-

cium, magnesium, thyroid screen, sedimentation rate, arterial blood gas, and chest

X-ray. The ED workup has been negative except for a slightly abnormal ABG show-

ing pH 7.51, pCO232, and pO

299 in room air.

Further history shows that these episodes have occurred spontaneously: once

during Spanish class, twice while home alone in the afternoon after school, and

never at night. YS was able to call a neighbor and subsequently her mother for thetwo episodes at home and was transported by paramedics all three times. She also

complains of frequent headaches and stomach aches and has had other episodes of

shortness of breath which she has been able to relieve by sitting in front of a fan. She

has not responded to albuterol prescribed in the ED and, in fact, states that the

inhaler makes her shaky and more short of breath. The exam in the office is normal

except for mild tachycardia, mild diaphoresis, and slightly increased respiratory

rate. She appears anxious and complains of shortness of breath during the examina-

tion, but her respiratory rate is normal and there is no clinical evidence of respira-

tory distress. Spirometry is normal.You obtain further history that reveals she is missing school at least 1 day per

week because of headache and stomach ache. The history and workup suggests a

functional respiratory disorder and she is referred to psychology for evaluation.

During the subsequent psychological testing and interview, it is revealed that she
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814 Dyspnea

has been the victim of bullying at school that has been going on for about 6 months.

The testing is suggestive of an ongoing anxiety disorder.

Questions:

1. Items from the medical history that would suggest a functional respiratory disor-

der include which of the following:

(a) Symptoms are not occurring at night.

(b) Urgent, repeated visits to the emergency department.

(c) She is able to verbalize her symptoms during an episode of respiratory

distress.

(d) a and c.(e) a, b, and c.

2. The arterial blood gas done in the emergency department probably represents

which of the following conditions:

(a) Acidosis secondary to renal disease

(b) Undiagnosed bulimia

(c) Chronic hyperventilation

(d) Acute airway obstruction

(e) Acute hyperventilation

3. From the history, clinical presentation, and psychological evaluation, the most

likely diagnosis is dyspnea secondary to:

(a) Schizophrenia

(b) Hypercarbia

(c) Panic attack/disorder with hyperventilation

(d) Hyperventilation syndrome

(e) None of the above

Answers:

1. (d): The majority of patients with functional causes of dyspnea demonstrate

disappearance of their symptoms during sleep and during the day when dis-

tracted. They are also able to talk through an episode where patients with

organic causes of dyspnea such as acute asthma are not able to verbalize more

than a word or two at a time. Repeated ED visits occur with acute attacks of

anxiety-driven functional disorders as well as true cardiorespiratory disease.

2. (e): A mild, uncompensated respiratory alkalosis is not unusual in a recovering

acute episode of hyperventilation. The workup in the ED is negative, and the

patients symptoms resolve spontaneously. Additionally, there has been no airway

noise detected during the examination and no response to albuterol, suggesting

the absence of acute airway obstruction. Normal electrolytes are against renal


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disease or bulimia, and blood gases in chronic hyperventilation are usually normal

or show a mild compensated respiratory alkalosis.

3. (c): Hyperventilation is a sign with symptoms most consistent with panic attack

often as part of panic disorder or chronic anxiety; although controversial, it is

now thought not to be a distinct syndrome. Bullying has likely led to the anxiety

disorder with understandable school phobia as psychological testing has not

shown evidence of psychosis. Hypercarbia is a result of underventilation.

Case 2

AJ is a 15-year-old boy brought to your office for evaluation by his mother with the

complaint that he feels that he cant get enough air. This consists of intermittent deepsighing respirations occurring up to 20 per minute, lasting for several minutes and occur-

ring up to ten times per day or more, and beginning about one month before his visit. He

appears distressed during these episodes, uses accessory respiratory muscles, complains

of chest heaviness, and often becomes light-headed. Turning a fan on and sitting in its

stream or going outside house for a few minutes helps relieve the symptoms, which

eventually resolve spontaneously. He makes no respiratory noises during the episodes,

and intermittent use of an inhaled beta-adrenergic inhaler has only made him shaky.

His past medical history is generally unremarkable except for frequent migraine head-

aches and occasional stomach aches. His physical examination and spirometry are nor-

mal. He demonstrates occasional deep sighs during the examination. Of note in the

social history is the death 1 year ago of his father, recent decrease in his academic per-

formance, and frequent missed days of school due to his breathing problems.

Subsequent workup including a chest X-ray, metabolic screen, drug screen, and

complete pulmonary functions is normal.

Questions:

1. AJs symptoms are most consistent with which of the following condition:

(a) Metabolic acidosis

(b) Sighing dyspnea

(c) Vocal cord dysfunction

(d) Asthma

(e) None of the above

2. True statements about this condition include all of the following EXCEPT:

(a) Pulmonary functions can reliably diagnose this condition.(b) Most patients with this condition have underlying anxiety.

(c) Manipulation of the environment is a typical finding.

(d) With treatment, the prognosis is good.

(e) Patients may have other somatic complaints.


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Answers:

1. (b): Sighing dyspnea. A normal metabolic screen and intermittent increased

respiratory distress are inconsistent with a metabolic acidosis such as might

occur in diabetic ketoacidosis. Normal pulmonary functions and lack of noise

during breathing and normal auscultation would be against VCD. Normal lung

functions and lack of response to a short-acting beta-adrenergic inhaler make

asthma unlikely.

2. (a): It is true that most patients with sighing dyspnea have underlying anxiety and

they may also manipulate the environment by, for example, sitting in front of a

fan or running to an open window to help relieve their symptoms. The prognosis

appears to be good in this condition. There are no consistent pulmonary function

abnormalities found.

Case 3

LW is a 16-year-old girl who comes to the office with mother complaining of short-

ness of breath associated with her extensive sports activities. LW, a straight A stu-

dent, plays varsity soccer on the high school team and is also involved in club soccer

with an extensive travel schedule. She has attained a high level of skill and is antici-

pating being recruited by colleges after high school.

However, during this season, she has periodically experienced acute shortness of

breath occurring about 10 min into play and worse during games versus practices.

Her primary physician suspects exercise-induced bronchospasm, but she has had no

relief using a short-acting beta-adrenergic agent prior to exercise or with symptom

onset, with daily use of an inhaled corticosteroid and a leukotriene modifier. Her

episodes come on quickly; she complains of light-headedness, tingling in her hands

and feet, and chest discomfort. These disappear within a few minutes after stopping

her activity, although upon resumption of the activity, the symptoms often return.

Both her coach and mother have observed these episodes, and other than deep, rapid

breathing, no respiratory noise or other symptoms have been noticed. Her examina-

tion in the office is entirely normal except from some hyperhidrosis of the palms.

Spirometry done in the office is normal.

Questions:

1. The clinical history and signs are compatible with?

(a) Vocal cord dysfunction(b) Poorly controlled and undiagnosed exercise-induced asthma

(c) Exercise-induced tracheomalacia

(d) Hyperventilation

(e) All of the above


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84 D.N. Homnick

2. What additional history would be useful in helping differentiate a functional

respiratory disorder from an organic disorder?

(a) Do symptoms occur at times other than exercise?

(b) Is there a history of stomach or headache complaints?(c) Have there been any family disruptions, i.e., divorces, new babies, family

illnesses, deaths, etc.?

(d) b and c

(e) All of the above

3. What test(s) would be most useful to utilize first in distinguishing functional

respiratory disorder from an organic disorder?

(a) Flexible bronchoscopy

(b) Flexible bronchoscopy while undergoing exercise testing on a treadmill(c) Cardiorespiratory metabolic testing on a bicycle ergometer

(d) Simple exercise testing on a treadmill with cardiac monitoring and postexer-

cise spirometry

(e) Complete lung functions

Answers:

1. (d): Patients with acute upper airway obstruction due to VCD or lower airway

obstruction due to tracheomalacia will often demonstrate noisy breathing, i.e.,

inspiratory stridor or expiratory, monophonic wheezing. Undiagnosed exer-

cise-induced asthma is most often a feature of poorly controlled persistent

asthma and, assuming good adherence to therapy, should get better. The fact

that there is no noisy breathing and the symptoms resolve within minutes sug-

gests a functional respiratory disorder other than VCD, most likely over-

breathing due to performance anxiety. Complete lung functions without a

challenge of exercise are often unrevealing unless significant organic dis-

ease is present.

2. (e): All of the above pieces of historical information can lead the examiner in the

direction of a functional respiratory disorder as all are compatible with anxiety

or other psychological disturbance. Similar symptoms occurring at times other

than exercise as during test taking in school, etc., strongly point to a functional

etiology.

3. (d): The simplest and most comprehensive way to screen for cardiorespiratory

disease due to an organic etiology is exercise testing on a treadmill with car-

diac monitoring and postexercise spirometry. The pattern of the flow volume

loop and ratios of inspiratory to expiratory flows can distinguish between exer-

cise-induced upper airway obstruction and lower airway bronchoconstriction

(see Chap. 6). Also, when deep and frequent respirations out of proportion to

level of conditioning and amount of work are observed during the test, this can

be helpful in making a functional diagnosis.


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854 Dyspnea

Conclusions

Functional dyspnea is represented by VCD, acute and chronic hyperventilation,

sighing dyspnea, and exertional dyspnea. The prognosis for these conditions remainsguarded with variable success in attaining long-term remission or cure. In long-term

follow-up of children and adolescents with hyperventilation, it was found that 40%

still had symptoms of hyperventilation as adults. This often occurred with signs and

symptoms of chronic anxiety [8, 51]. However, many techniques have been useful

for at least short- to moderate-term improvement in symptoms. These combined

with a thorough medical evaluation to rule out organic disease and psychological

testing and intervention, when appropriate, have the best chance of providing for

long-term benefit.

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Dyspnea as a Functional Disorder in Children

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