What Causes a Breathing Pattern Disorder?

One of the first questions people ask after being diagnosed with a breathing pattern disorder is:

"Why has this happened to me?"

The honest answer is that there is rarely one simple cause.

Research suggests that breathing pattern disorders usually develop when several factors come together. An illness, injury or stressful event may first change the way you breathe. For most people, breathing gradually returns to normal. For others, the altered pattern persists and begins to contribute to ongoing breathlessness.

Understanding these contributing factors can help explain why symptoms develop and why they sometimes continue long after the original trigger has resolved.

It often begins with a genuine trigger

Breathing patterns usually change for a good reason.

During a chest infection, an asthma attack, severe pain or a frightening episode of breathlessness, your body naturally adapts the way you breathe. These changes help you cope with the increased demands placed on your lungs and body.

In many people, breathing gradually returns to its previous pattern once the trigger has resolved.

Sometimes, however, that altered pattern continues even after the original problem has improved.

Researchers are still trying to understand exactly why this happens, but it appears to be one of the key steps in the development of a breathing pattern disorder.

Respiratory illness

Many people can identify a clear point at which their breathing changed.

Common examples include:

• a viral chest infection
• pneumonia
• influenza
• a prolonged cough
• another respiratory illness

During these illnesses it is completely normal for breathing to become faster, shallower or more effortful.

For some people, breathing does not completely return to its previous pattern once they have recovered.

This does not mean the infection is still present. Instead, the breathing pattern itself may have changed and continue to contribute to symptoms.

Long COVID

Persistent breathlessness is one of the most common symptoms reported after COVID-19.

Research has shown that some people with Long COVID develop altered breathing patterns even when scans, oxygen levels and routine lung tests appear reassuring.

At present, researchers do not fully understand why this occurs.

Several explanations have been proposed, including changes in breathing mechanics, altered control of breathing by the nervous system and the effects of prolonged illness. No single explanation has yet been proven.

For many people, a breathing pattern disorder appears to be one important contributor to ongoing breathlessness after COVID-19.

Asthma and other lung conditions

Breathing pattern disorders frequently occur alongside asthma and other respiratory diseases.

This does not mean that asthma causes a breathing pattern disorder, nor that everyone with asthma will develop one.

Instead, asthma can create circumstances in which breathing changes.

During an asthma flare-up it is normal to breathe differently because narrowed airways make breathing more difficult. If that altered pattern persists after the asthma is under better control, it may continue to contribute to breathlessness even when lung function has improved.

This helps explain why some people continue to feel breathless despite receiving appropriate treatment for their asthma.

Pain and physical illness

Pain can also influence the way we breathe.

Pain in the chest, neck, back or abdomen often causes people to breathe more cautiously or use different muscles to protect the painful area.

Similarly, recovering from surgery or another significant illness may temporarily alter breathing.

Most people gradually return to their usual breathing pattern as they recover.

Occasionally, however, the altered pattern becomes established and continues after the original problem has resolved.

Anxiety and stress

Stress and anxiety affect everyone's breathing.

You may have noticed your breathing become faster before an interview, while giving a presentation or during an upsetting situation.

These are completely normal responses.

For some people, periods of prolonged stress or anxiety appear to contribute to the development or worsening of a breathing pattern disorder. Equally, living with unexplained breathlessness can understandably increase anxiety.

The relationship works in both directions.

Rather than thinking of anxiety as "the cause", it is more accurate to think of it as one factor that can interact with breathing alongside physical health, previous illness and other influences.

Reflux

Some people notice that reflux symptoms seem to make their breathing feel worse.

Although reflux is commonly reported by people with breathing pattern disorders, current evidence has not shown that reflux directly causes the condition.

It may, however, aggravate cough, throat irritation or other symptoms that influence breathing in some individuals.

Deconditioning

Breathlessness often changes behaviour.

When physical activity repeatedly makes breathing uncomfortable, it is understandable that people begin avoiding situations that trigger symptoms.

Over time this reduction in activity can lead to a loss of fitness, known as deconditioning.

As fitness falls, everyday activities require more effort and breathlessness occurs sooner.

This creates another factor that can reinforce symptoms, even though it was not the original cause.

How breathing patterns become established

One of the most important ideas in current research is that breathing patterns can become established over time.

A breathing strategy that was initially helpful during illness or stress may continue after it is no longer needed.

Researchers are still investigating exactly how this happens, but breathing appears to be highly adaptable. Patterns that are repeated frequently may become increasingly automatic.

This does not mean you have consciously changed the way you breathe.

Instead, your body may simply continue using a breathing strategy that was once helpful but is no longer the most effective way of breathing.

Why several factors often occur together

One of the reasons breathing pattern disorders can be difficult to understand is that several influences often overlap.

For example, someone may:

• develop asthma
• experience a chest infection
• become worried by persistent breathlessness
• reduce their physical activity
• lose confidence in exercise

None of these factors alone explains all of their symptoms.

Together, however, they may reinforce one another, making breathlessness feel increasingly persistent.

This is why clinicians usually look at the whole picture rather than searching for one single cause.

How the cycle develops

Once breathlessness becomes frightening or unpredictable, it can begin to reinforce itself.

A simplified version of the cycle looks like this:

1. A trigger changes breathing↓
2. The altered breathing pattern continues↓
3. Breathlessness and other symptoms develop↓
4. Symptoms become worrying or uncomfortable↓
5. Activity decreases and breathing receives more attention↓
6. Fitness and confidence fall↓
7. Breathlessness occurs more easily↓
8. The cycle continues

Not everyone experiences every stage, and the cycle may begin at different points for different people. However, understanding this process helps explain why symptoms sometimes continue long after the original illness has resolved.

Understanding the causes

One of the most helpful things about understanding a breathing pattern disorder is recognising that there is rarely one single cause.

Instead, symptoms usually develop through the interaction of several physical and psychological factors. Identifying the factors contributing to your breathlessness helps your clinician decide which treatments are most likely to help.

In the next article, we'll explain how clinicians assess a breathing pattern disorder and why diagnosis depends on combining lots of pieces of information rather than one single test.

Remember: If you develop new, severe or rapidly worsening breathlessness, chest pain, coughing up blood, or feel faint or unwell, seek urgent medical assessment.