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Stefan Chmelik and New Medicine Group on Breathing Pattern Disorder

You can’t go more than three weeks without eating or three days without drinking. But just three minutes is the most you can probably manage without breathing.

Poor breathing patterns are a habit, just like posture, not a disease. That’s good because it means you can change it, as with any habit.

Stefan Chmelik, founder of New Medicine Group, uses traditional Chinese medical expertise combined with the latest technology and understanding to assess and treat what may be the most under-diagnosed epidemic of modern living, Breathing Pattern Disorder

Note: shortness of breath, wheezing, chest pain and suchlike can indicate a serious medical condition, and people should seek medical attention.

Most people have some idea of what an anxiety or panic attack is, and that’s called acute hyperventilation. Breathing Pattern Disorder (BPD) can be a bit like a chronic, long drawn out panic attack, perhaps lasting years, but often never properly assessed or diagnosed as such. We talk about Overbreathing, as people with BPD are breathing in too much, or Hypocapnia, literally low carbon dioxide, as this is what happens to the body’s chemistry as a result of Overbreathing.

But the implications of Breathing Pattern Disorder are more far reaching than just anxiety, devastating as that can be, with virtually every aspect of health potentially effected by changes in breathing.

Basically, most people breath upside down. You can test this for yourself: imagine and picture yourself in your mind walking to the top of a hill and you take a deep breath in as a reward……. Did you puff out your chest and maybe even fling your arms back? Chances are you did, and by doing so stopped yourself from doing exactly what you had intended i.e. being able to take a deep breath.
Here’s the thing: the chest and lungs have a lot less to do with breathing than you might think. It’s actually all about the abdomen, specifically the diaphragm and the pelvic floor. This is confusing to many people, so further explanation is needed.

What are people doing wrong?

From a good breathing function point of view, the lungs should be a largely passive in the breathing process, receiving air as a result of a difference in pressure between the abdomen and the chest created as the diaphragm contracts downwards. The diaphragm forms the top of a balloon like structure that encases all our abdominal organs, the bottom of which is what is generally referred to as the pelvic floor. This balloon-like piece of our anatomy has muscle fibres that enable it to contract, and it also has memory so that when these muscle fibres are released on relaxation, it returns to its at resting shape.

The start of the inhalation process therefore, is in the abdomen, not the top of the chest and not the collarbones. When the muscles connected to the pelvic floor and diaphragm start to contract and move downwards, increasing pressure in the abdomen and thus creating a relative vacuum in the chest, allowing air at atmospheric pressure to rush in, filling up the lungs and expanding the ribcage. If you then simply relax, or literally do nothing (in a Zen sort of way), the muscle fibres holding the diaphragm down will release and the diaphragm will slowly spring back to its resting place nestling underneath the lungs.

For almost everybody who gets agitated and says they can’t get enough air, including many people diagnosed with asthma, exactly the opposite is true. In fact they have too much air, as they are breathing in, rapidly and from the upper chest, but not breathing out. We tend to think of oxygen (O2) as being ‘good’ and carbon dioxide (CO2) as ‘bad’, but like most things in the body, they are part of a balancing act, and a great example of a Yin-Yang relationship from the Chinese Medicine point of view.

Oxygen is stimulating and makes muscles contract, carbon dioxide relaxes muscles, airways and blood vessels. In simple terms, how can you breath in properly unless you relax and breathe out?
When you fill a jug with water, it fills from the bottom up, and it’s just the same with the lungs. You may be filling the lungs from the top, but you can’t pour air into a lung that is not empty, or unless you start from the bottom and fill upwards. The diaphragm draws air down into the spacious, lower chest in a more relaxed and efficient way than chest muscles can when they pull air into the smaller volume of the upper chest.

So breathing with the upper chest is inefficient and tiring. And it tends to make us feel less relaxed than when breathing with the belly. This breathing-effect is two-way: when we feel stressed we breath faster. But breathing faster can make you feel more stressed.

Breathing with the diaphragm encourages a calmer mind. It triggers some muscle relaxation too, which in turn helps the mind settle down. When you practice breathing this way, you create a virtuous circle as the mind and body calm one another down.

Letting your diaphragm do your breathing for you helps you maintain physical and emotional balance. This is why yoga and martial arts training, as well as athletic and artistic performance techniques all emphasise the use of the diaphragm.

How does the ‘most natural thing in the world’ go so wrong?

The thing about breathing is that it is pretty much the only autonomic (subconscious) nervous system function that we can easily decide to override. Very few people can control their heartbeat or gut peristalsis at will, but even a child can hold their breath or breathe too fast. And that’s the key issue in fact – most people develop their poor breathing habits at an early age. Anything which is stressful, anxiety provoking, fear inducing or shocking will cause a child to change the way he/she is breathing, as threat perception is directly linked to the fight-fight-freeze response, and the diaphragm is associated with this. Over time, this becomes habitual, and the body posture even moulds around this breathing pattern, making it more concrete. It is not uncommon for the experiences that have shaped someone’s breathing pattern to be pre-memory, that is before conception, during birth or in infancy.

Your subconscious will kick in and create a breathing pattern if you let it, which is why it’s impossible to kill yourself by holding your breath (you will simply faint and start breathing again).

Interestingly, I have found that many people who have been trained to breath, such as wind musicians, singers, actors etc, have a dysfunctional breathing pattern i.e. they breath poorly. This seems to be because the training involves controlling the out breathe and release of the diaphragm, whereas natural relaxed breathing is about allowing the breath to happen without effort.

Breathe and be happy

In fact, breathing goes beyond being simply essential for health. Research demonstrates that certain types of breathing have a direct result on actual happiness levels. Breathing at a rate of six breaths per minute (inhaling for 4 seconds, exhaling for 6 seconds) induces what is called cardiac coherence, which is a reflection of a healthy heart rate variability (HRV). This condition is known to be consistent with a sense of increased wellbeing, and interestingly, Bach fugue’s, Gregorian chants, Buddhist meditation all tend to be based around a six breaths per minute rhythm.

HRV is a measure of how much your heart rate fluctuates in response to life and it’s stresses. It reflects the ability of your heart to adapt and recover from normal fluctuations.

Poor HRV has been linked to many mind-body disorders such as heart disease, fibromyalgia, chronic fatigue syndrome, depression and chronic stress.

Respiratory Sinus Arrhythmia (RSA) may sound like a worrying disease, but it is in fact a good thing. RSA occurs in the tract from heart to brain, in the aorta and carotid arteries sinuses and the respiratory centers in the brain stem. This tract involves monitoring and regulation of the mechanisms related to heart activity and blood circulation.

The bigger the RSA, the better it is for your heart function and blood pressure. Reduced breathing, that is slow and relaxed breathing focusing on the exhalation, induces a greater RSA.

Poor breathing patterns (Breathing Pattern Disorder, BPD) the extreme of which is hyperventilation (Hyperventilation Syndrome, HVS) are frequently involved or indicated in:

• Anxiety and mood changes including PMT
• Pain – including muscle pain, migraine, IBS, fibromyalgia
• Pelvic pain, including interstitial cystitis, prostate and genital pain in men
• Asthma and shortness of breath
• A significant proportion of chest pain patients
• Allergies and sensitivities
• Trauma

People who over-breathe often complain of symptoms that include

• Light headiness
• Head neck and upper body aching
• Giddiness/Dizziness
• Shortness of breath
• Heart palpitations
• Numbness
• Chest pains
• Dry mouth
• Clammy hands
• Difficulty swallowing
• Tremors
• Sweating
• Weakness
• Fatigue

Breathing is usually helpful for people who:

• Feel depressed
• Feel exhausted
• Feel tense or achy
• Have difficulty sleeping
• Have difficulty concentrating
• Feel agitated or anxious

 

How is BPD diagnosed or assessed?

I use a machine that measures the amount of carbon dioxide you are breathing out, so we know exactly what your breathing function is like. I also test using a well-tested questionnaire and by taking a full medical history, including analysis of all signs and symptoms. A postural and functional breathing assessment is used to check the mechanics of breathing and I will finally combine Traditional Chinese Medical pulse and tongue analysis to provide a totally holistic overview of breathing as it relates to your overall health.
This assessment accurately covers everything: the structural and functional aspects of breathing, the stress and emotional components, the biochemical aspects.

So how do I learn to breath properly again?

Changing a dysfunctional breathing pattern can be quite simple, but not necessarily easy. Long ingrained habits of any kind can take some time to unlearn, but it’s very possible to do so with good guidance and mentoring. In essence, the skill of relaxed and easy functional breathing comes from doing nothing and allowing your body’s intelligence to fall into a normal breathing pattern. But for many people living busy, goal orientated lives, doing nothing is surprisingly difficult.

Breathing rehabilitation generally consists of breathing exercises tailored to the personality of the individual, perhaps using one of a number of biofeedback devices, DVD’s or Apps.

Some level of bodywork is often required to alter postural habits.

Learning stress-management and anxiety control techniques is important for many people.
Acupuncture and relaxation techniques can be very helpful in changing bad habits.

Sometimes nutritional deficiencies, allergies or sensitivities are involved and may need to be addressed.

In severe cases, where early developmental memory or Post Traumatic Stress Disorder (PTSD) may be involved, trauma-resolution processes will most likely be required.

BPD Facts

Hyperventilation Syndrome and Breathing Pattern Disorder

• Hyperventilation syndrome is a breathing pattern disorder
• Dysfunctional breathing does not imply you have a problem with your lungs
• It affects many otherwise healthy people
• Symptoms include unexplained shortness of breath
• Sometimes rapid breathing and heart rate are obvious too but not always.
• Hyperventilation may be a response to emotional or environmental factors
• The condition causes changes to blood chemistry. These are reversible.
• Treatment involves breathing retraining (and medication is some cases).

What is it?

Hyperventilation syndrome (HVS) is a common result of prolonged stress, which often holds the key to a wide range of health problems.

HVS is increasingly recognized as a significant cause of ill-health, although remains widely under-diagnosed.

Hyperventilation syndrome/Breathing Patterns Disorders are defined simply as moving more air through the chest than the body can deal with.

It may be caused by breathing faster than normal (usually more than 15 breaths a minute) mouth breathing, sighing or yawning frequently.

Most people have experienced short episodes of acute over breathing during stressful or frightening events and it is very easy to spot.

But more subtle chronic hyperventilation is characterized by a whole array of symptoms, which can be baffling to both sufferer and doctor alike.

We breathe in oxygen-rich air and breathe out the carbon-dioxide our body constantly produces. But if too much carbon dioxide is flushed out of the system, it alters the body’s normal pH (acid/alkaline balance). This in turn produces physiological changes.

Even slight falls in carbon dioxide levels will directly affect nerve cells, as well as blood flow to the heart and brain, producing a wide variety of symptoms in many system in the body.

In HVS the normal pattern of breathing often moves from being abdominal to upper chest breathing, often through the mouth. This constant overuse of upper body muscles often causes more pain and tension in chest, neck, shoulders and head as well.

Understandable anxiety over symptoms tends to cause further over-breathing, thereby creating a vicious circle.

Boring but important – technical and academic stuff

• Inappropriate breathing patterns (O’Sullivan & Beales 2007)

• BPD appears linked to Central sensitization. Central sensitisation is defined as ‘an augmentation of responsiveness of central pain-signalling neurons to input from low-threshold mechanoreceptors’ (Nijs 2009)
• The evolution of chronic pain has been shown to have strong association with the process of central sensitization, in which there is enhanced sensitivity to various modes of painful and non-painful stimuli (Buchgreitz et al 2006).
• Staud (2006) has described the ways in which peripheral pain impulses can lead to central sensitization. In many chronic pain states, including chronic migraine, irritable bowel syndrome, fibromyalgia syndrome, repetitive, persistent or recurrent peripheral nociceptive features can lead to neuroplastic changes in the spinal cord and brain, that results in central sensitization and consequent pain.

The autonomic nervous system (ANS) is an extensive neural network whose main role is to regulate the milieu intérieur by controlling homeostasis and visceral functions. Although most functions regulated by the ANS are out of conscious control, emotions and somatosensory inputs profoundly influence the ANS. Observing the marked vasomotor and sudomotor changes after traumatic nerve injury, it became apparent long ago that the ANS plays an important role in pain modulation and perception. Despite the debate on whether the role of the sympathetic nervous system in generating and sustaining certain pain syndromes is significant, specialists in pain management have sought tools for investigating the ANS.
Paola Sandroni MD

Additional contributions from Professor David Peters

What does poor breathing lead to?

Definitions:

• It might almost be easier to list what breathing is not involved in, so integral is it to basic human health and happiness.
• BPD: Breathing Pattern Disorder
• HVS: Hyperventilation Syndrome
• Hypocapnia: Deficiency of CO2 in the blood, resulting from hyperventilation, leading to respiratory alkalosis

 

How common is HVS/BPD?

As many as 10% of patients in general internal medicine practices are reported to have HVS as their primary diagnosis. BPD is far more prevalent than HVS however, so the numbers will be greater.
(Lum L. 1987 Hyperventilation syndromes in medicine and psychiatry: ?a review. J. R Soc Med. 80:229-231)

Much more common in women – HVS/BPD is female dominated, ranging from a ratio of 2:1 to 7:1 (peak ages 15-55 years)

(Damas-Mora J et al 1980 Menstrual Respiratory Changes and Symptoms. British Journal of Psychiatry. 136, 492-497)

Breathing properly makes you happy:
Mindfulness based meditation techniques have been proved highly effective in enabling people to become happier, to improve quality of life and reduce symptoms such as chronic pain. There has now been more than 25 years of modern research into Mindfulness. The studies report:

• Dramatic reductions in pain levels and an enhanced ability to cope with pain that may not go away
• Dramatic decreases of anxiety, depression, hostility and the tendency to somatise
• More effective skills in managing stress
• An increased ability to relax
• Greater energy and enthusiasm for life
• Improved self-esteem
• An ability to cope more effectively with both short and long-term stressful situations

 

Chest pain:

In up to 85% A&E admissions for chest pain, no physical reason for the pain can be found.
(Katon W Walker E. 1998 J Clin Psychiatry. 59(Suppl 20):15-21)

“Stress and fear often cause rapid breathing or hyperventilation. This usually occurs in young adults and although the hyperventilating patient often complains of chest pain, this is rarely a manifestation of cardiac disease.”
(Garfunkel et al 2002 Chest pains in the dental environment. Refuat Hapeh Vehashinayim.19:51-59)

Breathing and Fibromyalgia (FMS)
Hyperventilation reduces CO2 leading to pain and stiffness, common features of fibromyalgia syndrome (FMS). FMS often follows a fluctuant course, affected by the menstrual cycle, during which pain sensitivity varies, even in healthy women.
(Naschitz, J. et al 2006. Patterns of hypocapnia in patients with fibromyalgia, chronic fatigue syndrome. American Journal of Medical Science 331 (6), 295-303)

Naschitz JE, et al 2006 Patterns of hypocapnia on tilt in patients with fibromyalgia, chronic fatigue syndrome, nonspecific dizziness, and neurally mediated syncope. Am J Med Sci. 331:295-303.

Overbreathing causes PMS and menstrual pain:
Research shows that as progesterone levels rise during the second half of the menstrual cycle, the breathing rate accelerates—and the pain threshold drops.
(Cimino R et al 2000 Does the ovarian cycle influence the pressure-pain threshold of the masticatory muscles in symptom-free women? J Orofac Pain. 14:105-111)
Most PMS symptoms may be caused directly by overbreathing. “It has been known for more than 100 years that women hyperventilate during the second half of the menstrual cycle …… [and] symptoms of the chronic hyperventilation syndrome are remarkably similar to the symptoms observed in some women with PMS.”? “In women with PMS the sensitivity of the respiratory center to CO2 is increased more than normal by progesterone, or some other secretory product of the corpus luteum, resulting in pronounced hyperventilation with the associated clinical signs and symptoms.”
(Ott H et al 2006 Symptoms of premenstrual syndrome may be caused by hyperventilation Fertility and Sterility 86(4):1001e17-19)

Pain threshold is significantly lowered and perception of pain greatly increased in people with BPD:
(Sackner M Gummels E Adams J. 2004 Med Hypotheses. 63:118–123)

Reduced mental capacity and memory:

Under-oxygenation of the Brain (Litchfield P. 2003 A Brief overview of the chemistry of respiration and the breathing heart wave)

In this image, O2 availability in the brain is reduced by 40% as a result of about a minute of overbreathing (HVS). In addition, glucose critical to brain functioning is markedly reduced as a result of cerebral vasoconstriction.

Almost all anxiety and panic attacks are due to BPD:
It is in effect physiologically impossible to have a panic attack or asthma attack if respiratory CO2 levels are normal.
(Nardi A et al 2001 Hyperventilation challenge test in panic disorder and depression with panic attacks. Psychiatry Research 105(1-2):57-65)

Hammo A-H et al 1999 Exercise-induced hyperventilation: a pseudo-asthma syndrome, Ann Allergy Asthma Immunol 82:574-578
HVS, the extreme of breathing pattern disorders (BPD), produces far-ranging physiological effects via its alteration of pH and depletion of CO2, resulting in respiratory alkalosis, acute or chronic
Gilbert C 1999 Hyperventilation and the body. Accident and Emergency Nursing. 7:130-140.

Poor breathing and back pain:
Back pain is the most common ailment on the planet. Diaphragm and abdominal muscles tone are key providers of spinal stability. Poor breathing related muscle function is indicated in much clinical back pain.
(Panjabi M. 1992 J Spinal Disord. 5:383-389)

Reduced spinal support was noted during combined load challenge to ?the low back and during breathing challenge (e.g. digging and breathing poorly at the same time)
(McGill S et al.1995 Ergonomics. 38:1772-1792)

A randomized controlled study showed that patients with moderate chronic low back pain, average 1-year duration, improved significantly (pain and function) after either breathing rehabilitation or physical therapy for 8 weeks (12 x 45-minute sessions)
(Mehling W et al. 2005 Randomized, controlled trial of breath therapy for patients with chronic low-back pain. Altern Ther Health Med. 11:44-52)

Breathing and IBS:
Hyperventilation is very common among patients with irritable bowel syndrome, as reduced CO2 causes smooth muscle spasm.
(Ford M Camilleri M Hanson R 1995 Hyperventilation, central autonomic control, and colonic tone in humans. Gut 37:499-504)

Breathing and Pelvic Floor Dysfunction, inc incontinence:
Numerous studies indicate that pelvic floor dysfunction is frequently related to altered breathing patterns –

• Lee D Lee L J McLaughlin L 2008 Stability, continence and breathing: The role of fascia following pregnancy and delivery. Journal of Bodywork and Movement Therapies 12:333–348
• Pool-Goudzwaard A van Dijke G van Gurp M 2004. Contribution of pelvic floor muscles to stiffness of the pelvic ring. Clinical Biomechanics 19 (6), 564–571
• Smith M Russell A Hodges, P 2006. Disorders of breathing and continence have a stronger association with back pain than obesity and physical activity. Australian Journal of Physiotherapy 21(52):11-16

Pelvic pain:
Chronic pelvic pain (involving the, perineum, testicles and penis) associated with chronic prostatitis involving nonbacterial urinary difficulties has been shown, in a 2005 study at Stanford University School of Medicine, to be capable of being effectively treated using trigger point deactivation, together?with relaxation and breathing techniques.
(Anderson R et al. 2005 Integration of myofascial trigger point release and paradoxical relaxation training treatment of chronic pelvic pain in men. Jnl. Urol.174:155-160)

Chronic Pelvic Pain Syndrome – the full list of AKA’s:

• Interstitial cystitis (IC)
• Pelvic Floor Dysfunction (PFD)
• Vestibulitis, vulvodynia, clitorodynia, vaginismus, prostatodynia
• Non-bacterial cystitis or prostatitis
• Reproductive pelvic pain
• Dyspareunia
• Bladder pain syndrome/interstitial cystitis (BPS/IC)
• Overactive Bladder Syndrome (OBS)
• Irritable Pelvis Syndrome (IPS)
• Urgency-Frequency Syndrome (UFS)
• Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS)
• Prostate Pain Syndrome (PPS)
• Painful Bladder Syndrome (PBS)
• Endometriosis Associated Pain Syndrome
• Urethral Pain Syndrome
• Penile Pain Syndrome
• Scrotal Pain Syndrome
• Vaginal Pain Syndrome
• Vulvar Pain Syndrome
• Pudendal Pain Syndrome
• Vestibular Pain Syndrome
• Clitoral Pain Syndrome
• Epididymal Pain Syndrome
• Post-vastectomy Pain Syndrome
• Perpetual Arousal Syndrome (PAS)

 

For Interstitial Cystitis:

In a study of 19 interstitial cystitis patients with pelvic floor dysfunction who underwent relaxation therapy utilizing diaphragmatic breathing and progressive relaxation techniques there was a significant decrease in pain and urgency scores after 3 months of therapy
(Mendelowitz F Moldwin R 1997 Complementary therapies in the management of interstitial cystitis. In: Sant G, ed. Interstitial Cystitis. Philadelphia, Pa: Lippincott-Raven; 235–239)

Summary of breathing effects and benefits

BPD: Breathing Pattern Disorder
HVS: Hyperventilation Syndrome
Hypocapnia: Deficiency of CO2 in the blood, resulting from hyperventilation, leading to respiratory alkalosis

Poor breathing habits may be indicated in or the cause of:

• Chest pain
• Fibromyalgia (FMS) and other chronic pain
• PMS and menstrual pain
• Reduced mental capacity and memory
• Anxiety and panic attacks, breathing issues
• Back pain
• IBS
• Pelvic Floor Dysfunction, inc incontinence
• Pelvic pain
Chronic Pelvic Pain Syndrome – the full list of AKA’s:
• Interstitial cystitis (IC)
• Pelvic Floor Dysfunction (PFD)
• Vestibulitis, vulvodynia, clitorodynia, vaginismus, prostatodynia
• Non-bacterial cystitis or prostatitis
• Reproductive pelvic pain
• Dyspareunia
• Bladder pain syndrome/interstitial cystitis (BPS/IC)
• Overactive Bladder Syndrome (OBS)
• Irritable Pelvis Syndrome (IPS)
• Urgency-Frequency Syndrome (UFS)
• Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS)
• Prostate Pain Syndrome (PPS)
• Painful Bladder Syndrome (PBS)
• Endometriosis Associated Pain Syndrome
• Urethral Pain Syndrome
• Penile Pain Syndrome
• Scrotal Pain Syndrome
• Vaginal Pain Syndrome
• Vulvar Pain Syndrome
• Pudendal Pain Syndrome
• Vestibular Pain Syndrome
• Clitoral Pain Syndrome
• Epididymal Pain Syndrome
• Post-vastectomy Pain Syndrome
• Perpetual Arousal Syndrome (PAS)

Summary of BPD effects
Breathing Pattern Disorders influence health due to:
• Altered blood pH, creating respiratory alkalosis
• Increased sympathetic arousal, altered neuronal function (including motor control)
• Sense of apprehension, anxiety, affecting balance (and possibly panic)
• Depleted Ca and Mg ions, enhancing sensitization, encouraging spasm, reducing pain thresholds
• Smooth muscle cell constriction, leading to vasoconstriction (and possibly altering fascial tone)
• Smooth muscle constriction can also lead to colon spasm and pseudo-angina
• Reduced oxygen release to cells, tissues, brain (Bohr effect) – encourages ischemia, ‘brain-fog’, fatigue & pain
• Evolution of myofascial trigger points
• Biomechanical overuse stresses that compromise core stability and posture, and cause pain

Benefits of breathing properly include:
• Dramatic reductions in pain levels and an enhanced ability to cope with pain that may not go away
• Dramatic decreases of anxiety, depression, hostility and the tendency to somatise
• More effective skills in managing stress
• An increased ability to relax
• Greater energy and enthusiasm for life
• Improved self-esteem
• An ability to cope more effectively with both short and long-term stressful situations

Nervous system signs & symptoms of Respiratory Alkalosis due to BPD:
Yee A Rabinstein A 2010 Neurologic Presentations of Acute Metabolic Disorders. Neurol Clin. 28:1–16
Central Nervous System Symptoms
• Lightheadedness
• Vertigo
• Confusion
• Headache
• Tinnitus
• Blurred vision
• Syncope

Peripheral Nervous System Symptoms
Circumoral/limb paresthesias
Cramps
Tremor

CNS Signs
• Ataxia
• Chvostek’s sign
• Tremor
• Encephalopathy
• Coma
• Seizure manifestations

PNS Signs
• Myoclonus
• Tetany

People who over-breathe often complain of symptoms that include:
• Light headiness
• Head neck and upper body aching/pain
• Giddiness/Dizziness
• Anxiety
• Shortness of breathe
• Heart palpitations
• Numbness
• Chest pains
• Dry mouth
• Clammy hands
• Difficulty swallowing
• Tremors
• Sweating
• Weakness
• Fatigue

Breathing is usually helpful for people who:
• Feel depressed
• Feel exhausted
• Feel tense or achy
• Have difficulty sleeping
• Have difficulty concentrating
• Feel agitated or anxious