Dysfunctional breathing is a term describing breathing disorders where chronic changes in breathing pattern result in dyspnoea and other symptoms in the absence or in excess of the magnitude of physiological respiratory or cardiac disease. We reviewed the literature and propose a classification system for the common dysfunctional breathing patterns described. The literature was searched using the terms: dysfunctional breathing, hyperventilation, Nijmegen questionnaire and thoraco-abdominal asynchrony. We have summarised the presentation, assessment and treatment of dysfunctional breathing, and propose that the following system be used for classification. 1) Hyperventilation syndrome: associated with symptoms both related to respiratory alkalosis and independent of hypocapnia. 2) Periodic deep sighing: frequent sighing with an irregular breathing pattern. 3) Thoracic dominant breathing: can often manifest in somatic disease, if occurring without disease it may be considered dysfunctional and results in dyspnoea. 4) Forced abdominal expiration: these patients utilise inappropriate and excessive abdominal muscle contraction to aid expiration. 5) Thoraco-abdominal asynchrony: where there is delay between rib cage and abdominal contraction resulting in ineffective breathing mechanics.This review highlights the common abnormalities, current diagnostic methods and therapeutic implications in dysfunctional breathing. Future work should aim to further investigate the prevalence, clinical associations and treatment of these presentations. @ERSpublications A review of common abnormalities, current diagnostic methods and therapeutic implications in dysfunctional breathing http://ow.ly/ZTzK6
Hypercalcemic crisis is a rare but life-threatening condition defined by decompensation of hypercalcemia with significant disturbance to cardiac, renal, gastrointestinal and neurological function. Here we document the case of a 74-year-old gentleman with a parathyroid adenoma who presented to hospital after bloods revealed severe hypercalcemia (5.58 mmol/L). Rehydration with diuretics and bisphosphonate infusions failed to revert the hypercalcemia over 42 hours (5.58 mmol/L). Low calcium hemodialysis rapidly reduced calcium levels and allowed for further investigations. Computerised tomography (CT) scan and magnetic resonance cholangiopancreatography revealed associated acute pancreatitis. A parathyroid adenoma was discovered by ultrasound and removed surgically. Parathyroidectomy led to resistant hypocalcemia requiring multiple calcium infusions. Hypercalcemia may lead to nausea and vomiting, decrease oral fluid intake and nephrogenic diabetes insipidus. This in turn leads to volume depletion and hypovolemic acute kidney injury. In patients severe acute kidney injury leading to renal failure, aggressive fluid replacement may be detrimental and these patients may require correction by dialysis. Literature review returned 13 case reports/case series totalling 68 patients undergoing dialysis for hypercalcemia. These case reports found a rapid decrease in serum calcium levels post calcium free hemodialysis (CFHD). Mortality was observed in only one case report which was attributed to sepsis. 1 Hemodialysis reportedly clears 682 mg/hr of calcium vs 82 mg/hr in saline diuresis. 2 It offers a safe way of treatment in patients with cardiac and renal comorbidities and results in rapid reduction in calcium levels and improvement in cognition. 1,3,4
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