Breathlessness and dysfunctional breathing in patients with postural orthostatic tachycardia syndrome (POTS): The impact of a physiotherapy intervention

Abstract

Postural orthostatic tachycardia syndrome (POTS) is a chronic, multifactorial syndrome with complex symptoms of orthostatic intolerance. Breathlessness is a prevalent symptom, however little is known about the aetiology. Anecdotal evidence suggests that breathless POTS patients commonly demonstrate dysfunctional breathing/hyperventilation syndrome (DB/HVS). There are, however, no published data regarding DB/HVS in POTS, and whether physiotherapy/breathing retraining may improve patients' breathing pattern and symptoms. The aim of this study was to explore the potential impact of a physiotherapy intervention involving education and breathing control on DB/HVS in POTS. A retrospective observational cohort study of all patients with POTS referred to respiratory physiotherapy for treatment of DB/HVS over a 20-month period was undertaken. 100 patients (99 female, mean (standard deviation) age 31 (12) years) with a clinical diagnosis of DB/HV were referred, of which data was available for 66 patients prepost intervention. Significant improvements in Nijmegen score, respiratory rate and breath hold time (seconds) were observed following treatment. These data provide a testable hypothesis that breathing retraining may provide breathless POTS patients with some symptomatic relief, thus improving their healthrelated quality of life. The intervention can be easily protocolised to ensure treatment fidelity. Our preliminary findings provide a platform for a subsequent randomised controlled trial of breathing retraining in POTS.

Chronic fatigue and post-exertional malaise in people living with long COVID

“…In the absence or in excess of the magnitude of physiological respiratory or cardiac disease, long COVID may involve chronic changes in breathing patterns that result in this breathing discomfort [82]. Respiratory physiotherapy and breathing retraining may be helpful for people with breathing discomfort, considering improvements in symptoms in people living with postural orthostatic tachycardia syndrome and asthma [82][83][84][85]. Currently, there is limited information about whether exercise is beneficial for people living with long COVID, especially considering the heterogeneous range of symptoms.…”

Management of Postural Orthostatic Tachycardia Syndrome in the Absence of Randomized Controlled Trials

“…In a retrospective observational cohort study of 100 patients, 99 of whom were female, the authors studied the effects of breathing. 14 The physiotherapy intervention included education on proper breathing techniques with breathing retraining exercises and frequent meetings with a specialized respiratory physiotherapist. 14 The breathing retraining exercises involved attempting to achieve nasal breathing, normal respiratory rates, normal tidal volume, proper inspiratory/expiratory ratios, and proper thoraco-abdominal excursion, which are mechanisms that are naturally compromised in the setting of inappropriate tachycardia and during the feeling of breathlessness.…”

“… 14 The physiotherapy intervention included education on proper breathing techniques with breathing retraining exercises and frequent meetings with a specialized respiratory physiotherapist. 14 The breathing retraining exercises involved attempting to achieve nasal breathing, normal respiratory rates, normal tidal volume, proper inspiratory/expiratory ratios, and proper thoraco-abdominal excursion, which are mechanisms that are naturally compromised in the setting of inappropriate tachycardia and during the feeling of breathlessness. 14 Of the 66 patients who remained committed to the physiotherapy intervention, 97% reported improvements in symptom burden with improved respiratory rates and improved breath-hold times after a mean of just three sessions.…”

“… 14 The breathing retraining exercises involved attempting to achieve nasal breathing, normal respiratory rates, normal tidal volume, proper inspiratory/expiratory ratios, and proper thoraco-abdominal excursion, which are mechanisms that are naturally compromised in the setting of inappropriate tachycardia and during the feeling of breathlessness. 14 Of the 66 patients who remained committed to the physiotherapy intervention, 97% reported improvements in symptom burden with improved respiratory rates and improved breath-hold times after a mean of just three sessions. 14 However, further investigation is warranted to rule out a placebo effect as this small retrospective cohort study had no control group.…”

Platypnea-orthodeoxia syndrome mimicking postural orthostatic tachycardia syndrome

“…Atypical features of our patient with respect to POTS were the male sex and mature age. Breathlessness that worsens in the upright position is a common symptom in patients with POTS and may be related to dysfunctional breathing/hyperventilation syndrome [ 12 ]. Orthodeoxia, however, is not a feature of POTS and the unusual severity of the respiratory symptoms during orthostatic challenge in our patient prompted further testing.…”