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Educational Capnography
DYSFUNCTIONAL BREATHING
Effects of Compromised Respiration
on Physiology and Psychology
Peter M. Litchfield, Ph.D.
Graduate School of Breathing Sciences
Tel: 307.633.9800 Cell: 505.670.2874
www.breathingsciences.bp.edu
pl@breathingsciences.bp.edu
Copyrighted 2012-2013

MISSION
Our mission is to help people
improve health and performance
through the application
of behavioral learning principles
to breathing physiology.
2

PROBLEM
Self-defeating learned breathing behaviors
compromise physiology, psychology, health,
and performance.
Learned dysfunctional breathing has a major impact
on multiple physiological systems, resulting in
symptoms and deficits, usually attributed to other causes,
by clients and their health practitioners, rather than to learned
behaviors and responses that may account for them.
3

OBJECTIVE
Clients learn new breathing habits,
and related behaviors, that are consistent
with healthy physiology and psychology.
4

SOLUTION
Practitioners offer client-centered learning solutions,
based on the principles of:
● behavioral counseling
● behavioral analysis
● behavior modification
● cognitive learning
● awareness training
● applied psychophysiology
● phenomenological exploration (consciousness)
5

RESPIRATION AND BREATHING
are not the same thing.
Respiratory physiology is reflexive.
Breathing mechanics of gas exchange (external respiration)
Biochemistry of gas distribution to and from tissues (internal respiration),
Utilization of oxygen by the mitochondria of cells (cellular respiration).
Breathing physiology is behavioral.
Breathing, as a behavior, is subject to the same principles of learning as any
other behavior, including the role of motivation, emotion, attention,
perception, and memory.
6

EFFECTS OF BREATHING HABITS
The reconfiguration principles of physiology, i.e., learning principles, point to
the most fundamental, practical, and profound factors that account for:
(1) the far-reaching effects of dysfunctional breathing habits (e.g., deregulated
plasma pH, chronic contraction of muscles in the jaw), as well as for
(2) the surprising benefits of self-regulatory breathing habits (e.g., improved
cerebral blood flow for improved attention, learning, and performance, or
muscle reeducation that supports jaw realignment).
7

BREATHING OBJECTIVES
Breathing as a set of behaviors serves physiological, psychological,
and social needs and motivations. Here is a list of some of them:
● Delivery and utilization of oxygen (respiration)
● pH regulation, electrolyte balance
● Vascular regulation, e.g., cerebral and coronary
● Buffering metabolic acids, e.g., lactic acid
● Non respiratory lung functions (filtering metabolic functions)
● Muscle regulation, e.g., triggering and dysponesis
● Defensive posturing, e.g., coping with stress and anxiety
● Speech and singing
● Psychological state changes (dissociation), disconnecting
8

DYSFUNCTIONAL BREATHING
Dysfunctional breathing is defined as behavior that
compromises physiology and/or psychology, acutely
and/or chronically.
9

BREATHING BEHAVIORS
Breathing behaviors are considered dysfunctional based
on their relationship with other behaviors and how
together they impact physiological and psychology.
Here are examples of some breathing behaviors:
● Aborted exhale ● Accessory muscle breathing ● Breath holding
● Deep/shallow breathing ● Disruptive thoughts ● Dysponesis
● Effortful breathing ● Fast/slow breathing ● Forced exhalation
● Gasping, sighing, coughing ● Intentional manipulations
● Interpretation of symptoms ● Mouth/nasal breathing ● Overbreathing
● Underbreathing ● Reverse breathing ● Self-talk ● Transition time
10

COMPROMISED MECHANICS
Dysfunctional habits not only seriously compromise
respiration, but may also directly disturb physiology and
psychology on many levels.
Breathing habits may be dysfunctional as a result of triggering:
● PHYSICAL CHANGES in local physiology
● SOMATIC CHANGES (muscles) and their associated effects
● AUTONOMIC CHANGES and their associated effects
● CENTRAL CHANGES (cerebral) and effects on motivation, emotion, and cognition
11

RESPIRATORY FITNESS
The fundamental objective
Respiratory fitness is about reflex-regulated gas exchange based on:
● extracellular pH,
● extracellular partial pressure carbon dioxide (PCO2), and
● blood plasma PO2.
It is about moment to moment regulation of:
● extracellular pH,
● electrolyte balance,
● blood flow,
● hemoglobin chemistry, and
● kidney function.
12

COMPROMISED RESPIRATION
When respiration is disturbed by breathing habits it may
result in an unbalanced extracellular acid-base chemistry
and failure to meet metabolic requirements.
13

BREATHING & RESPIRATION
Respiratory fitness is vital to health and performance, and must be regulated
despite the breathing acrobatics of talking, emotional encounters, and
professional challenges. Respiratory fitness needs to be in place regardless of
whether or not one is relaxed or stressed, excited or bored, active or inactive,
working or playing, focused or distracted.
The “respiratory chemical axis” of breathing, i.e., acid-base regulation, needs to
remain relatively stable despite significant changes in breathing mechanics, e.g.,
changes in rate, that may be serving parallel objectives.
14

MEDIATED CONSEQUENCES
The impact of dysfunctional breathing on physiology is far reaching.
Dysfunctional breathing habits can cause, trigger, exacerbate, and perpetuate
symptoms and deficits of all kinds , ones that typically go “unexplained” or are
mistakenly attributed to other causes, e.g., stress. From a learning perspective
these breathing mediated outcomes become behavioral consequences, rather than
the effects of external factors.
15

RELEVANCE
Dr. Robert Fried comments as follows:
“There are varying reports of its [dysfunctional breathing] frequency in
the population at large, ranging between 10 percent and 25 percent. It
has been estimated to account for roughly 60 percent of emergency
ambulance calls in major US city hospitals.”
(Fried, Robert Breathe Well, Be Well. 1999, p 45)
16

RELEVANCE
Dr. Robert Fried comments further:
“Fewer than 1 in 100 of my clients show normal PCO2. It has long been
known that it is rare among persons with seizure disorders, heart
disease, asthma, anxiety, stress, panic disorder with or without
agoraphobia, other phobias, hyperthyroidism, migraine, chronic
inflammatory joint disease with chronic pain, and so on, NOT to
hyperventilate. We’re probably looking at half the U.S. population.”
(The Psychology and Physiology of Breathing. 1993, pp. 43-44.)
17

PHASES OF RESPIRATION
● External respiration: the breathing mechanics of gas exchange.
● Internal respiration: the chemistry of moving gases to/from cells
● Cellular respiration: O2 utilization for synthesis of ATP molecules
ATP is adenosine triphosphate, the molecule broken down by cells for energy.
18

EXTERNAL RESPIRATION
External respiration is about the mechanics of breathing, moving
gases (air) in and out of the lungs. Specifically, it is about oxygen
acquisition and proper carbon dioxide (CO2) allocation.
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INTERNAL RESPIRATION
● Transport of O2 in the blood from lungs to tissue cells
● Distribution of O2 to cells based on their metabolic requirements
● Transport of metabolic CO2 from tissue cells to the lungs
● Excretion of excess CO2
● Reallocation of CO2 for acid-base balance regulation.
20

CHEMICAL AXIS OF BREATHING
pH = [HCO3
‾] ÷ PCO2
The Henderson-Hasselbalch (H-H) equation,
describes pH regulation in extracellular fluids.
PCO2 is partial pressure carbon dioxide,
regulated by moment to moment breathing.
[HCO3
‾] is bicarbonate concentration,
regulated by the kidneys (8 hours -5 days)
21

CRITICAL pH VALUES
Normal plasma pH levels are 7.36 to 7.44 (7.4 the magic number)
When pH values drop below 7.36, acidemia is the consequence.
When values rise above 7.44, alkalemia is the consequence.
Plasma pH shifts up or down as a function of changes in:
1. PCO2 (denominator of the H-H equation), and
2. bicarbonate concentration (numerator of the H-H equation).
22

PCO2
Denominator of the Equation
Arterial levels of PCO2, i.e., PaCO2,
must remain between 35 and 45 mmHg (or 4.7 and 6.0 kPa)
to keep plasma pH within its normal pH range of 7.36 to 7.44, slightly alkaline.
Respiratory acidosis (pH < 7.36)
is the result increased levels of PaCO2.
Respiratory alkalosis (pH > 7.44)
is the result of reduced levels of PCO2.

CHEMO-REGULATORY REFLEXES
Balancing the H-H equation is achieved through
the presence of receptor sites in
● the brainstem, sensitive to interstitial pH and PCO2
● the arterial system (aorta & carotid arteries)
sensitive to plasma pH, PCO2 and O2
Many patients have learned breathing habits that preempt these reflexes.
24

HYPOCAPNIA
is a PaCO2 deficit.
When PaCO2 is too low (below 35 mmHg),
with deeper and/or faster breathing,
the denominator of the H-H equation is smaller.
Thus, the extracellular pH rises (above 7.44)
with resulting respiratory alkalosis,
a condition identified as hypocapnia.
25

BEHAVIORAL HYPOCAPNIA
is the result of learned overbreathing behavior.
When hypocapnia is a consequence of dysfunctional
breathing habits it is known as behavioral hypocapnia.
Behavioral hypocapnia (respiratory alkalosis,)may have profound immediate and
long-term effects that may trigger, exacerbate, perpetuate, and/or cause a wide
variety of symptoms that may seriously impact health and performance.
26

HYPERCAPNIA
is excessive PaCO2.
When PaCO2 is too high with shallower and/or slower breathing, extracellular pH
falls (below 7.36) with resulting respiratory acidosis, or hypercapnia.
Behavioral hypercapnia is the consequence of underbreathing, not ventilating off
adequate CO2 by breathing too slowly and/or too shallow. Behavioral hypercapnia
is rare. Hyperinflation is the most likely cause.
27

EFFECTS OF HYPOCAPNIA
From: Laffey, J. & Kavanagh, B. Hypocapnia. New England Journal of Medicine. 2002.
“…extensive data from a spectrum of physiological systems indicate that
hypocapnia has the potential to propagate or initiate pathological
processes. As a common aspect of many acute disorders, hypocapnia
may have a pathogenic role in the development of systemic diseases.”
28

SUMMARY QUOTATIONS
The effects on hypocapnia on physiology are impressive.
“Hypocapnia-induced vasospasm is responsible for reduced cerebral blood flow
and neurological symptoms, for reduced coronary blood flow and chest pain, for
paresthesia of limbs, and circumoral pallor.”
Thomson, Adams, & Cowan, Clinical Acid-Base Balance, 1997
“This disruption in the acid-base equilibrium triggers a chain of systematic
reactions that have adverse implications for musculoskeletal health, including
increased muscle tension, muscle spasm, amplified response to catecholamines,
and muscle ischemia & hypoxia.”
Schleifer, Ley, and Spalding, Journal of Industrial Medicine, 2002
29

UNEXPLAINED SYMPTOMS
Learned breathing behaviors may play an important role in the
appearance of unexplained symptoms as well as their disappearance.
Learned overbreathing results in CO2 deficiency, behavioral hypocapnia, which may
seriously and immediately disturb acid-base balance. Its effects on body chemistry
may mediate changes labeled as “unexplained symptoms,” including misunderstood
performance deficits and “effects of stress,” all of which may be mistakenly
attributed to other causes.
30

Behavioral Hypocapnia
PHYSIOLOGICAL EFFECTS
Hemoglobin chemistry: O2 distribution by Hb is restricted.
● Red blood cell CO2 diminishes while alkalinity increases,
thereby increasing hemoglobin’s affinity for oxygen
and inhibiting its distribution to cells (Bohr Effect).
● The same red blood cell physiology restricts
the amount of nitric oxide (NO) released by hemoglobin,
resulting in significant vasoconstriction.
The net effect is reduced oxygen and glucose resources
for cells that require them.
31

Plasma alkalemia and low PCO2
● Calcium ions are exchanged for hydrogen ions in smooth muscle
resulting in vascular, gut, and bronchial constriction.
● Electrolyte shifts result in muscular calcium-magnesium imbalance.
● Increased pH in muscles increases their resting tension levels.
● Decreased PCO2 suppresses substance P-induced
epithelium- dependent relaxation.
The net effect is reduced oxygen and glucose supply to cells that
require them with possible serious outcomes: ● Cerebral
hypoglycemia ● Ischemia (localized anemia) ● Reversible brain
lesion effects.
32

Interstitial alkalemia and electrolytes
● Muscles: Calcium ions are exchanged for hydrogen ions
in smooth and skeletal muscle and set the stage for
muscle spasm, weakness, stiffness, and fatigue.
● Neurons: Sodium and potassium ions are exchanged
for hydrogen ions in neurons, for example, which
increases their excitability, contractility, and metabolism.
33

Intracellular acidemia
The resulting oxygen deficit combined with
increased cellular excitability, contractility, and metabolism
increases the likelihood of intracellular lactic acidosis
in active tissues, e.g., in neurons and muscles (tetany).
34

Inhibitory and excitatory brain centers
● Reduced oxygen and glucose supply disrupt inhibitory control centers
(e.g., in the limbic system), and depending on the context, may trigger emotions,
such as anger, anxiety, euphoria, and stress.
● Low cerebral PaCO2 levels may disinhibit the hypothalamus
to activate the pituitary-adrenal system and its associated hormones
(e.g., ACTH), resulting in stress symptoms, acute and chronic.
35

Long term effects
Chronic effects include major losses of bicarbonate and sodium ions, electrolytes
that are excreted as a result of CO2 deficit in the nephrons of the kidney.
“The body maintains pH very closely. Even 7.45 or 7.5 over time may have
significant consequences. If proteins don’t fold correctly, membranes may not
function properly. An improperly folded protein is viewed by macrophages as
foreign, and can initiate an immune response which could be involved in everything
from autoimmune disease to Alzheimer’s.”
Jan Newman, M.D.
36

Other Effects
● Dishabituation
● Antioxidant reduction
● Thrombosis (blood clotting)
● Myofacial tissue compromise
● Exacerbation of inflammation
● Red blood cell rigidity
● Extracellular sodium deficiency (hyponatremia)
● Extracellular potassium deficiency (hypokalemia)
37

Exacerbation of health issues and complaints
● Neurological (epilepsy) ● Cognitive: learning disabilities (ADD) ● Emotional
(anger, panic attack, anxiety) ● Psychological (trauma) ● Vascular (hypertension)
● Cardiovascular (angina, arrhythmias) ● Efficacy of drugs (absorption) ● Fitness
issues (muscle strength, fatigue) ● Gastric (IBS) ● Respiratory (asthma)
● Chronic pain (inflammation) ● Pregnancy (symptoms) ● Neuromuscular
(orthodontic) ● Sleep disturbances (apnea) ● Psychophysiological disorders
(headache) ● Behavioral (performance issues) ● Unexplained conditions:
fibromyalgia, chronic fatigue
38

SYMPTOMS AND DEFICITS
RESPIRATORY
● shortness of breath
● breathlessness,
● bronchial constriction and spasm
● airway resistance,
● reduced lung compliance
● asthma symptoms, e.g., wheeze
● unable to breathe deeply
● chest tightness, pressure, and pain
● inflammation
39

PERIPHERAL
● trembling
● twitching
● shivering
● sweatiness,
● coldness
● tingling
● numbness
40

CARDIOVASCULAR
● palpitations
● increased rate
● angina symptoms
● arrhythmias
● nonspecific pain
● ECG abnormalities
41

EMOTIONAL
● anxiety ● anger ● fear ● panic ● apprehension ● worry ● crying,
● low mood ● frustration ● performance anxiety ● phobia
IMPORTANT
Many, perhaps most, of these kinds of “symptoms and deficits” are learned
responses to the effects of hypocapnia, e.g., inability to focus or remember triggers
anxiety, frustration, or anger.
42

STRESS AND AUTONOMIC HYPER AROUSAL
● tenseness ● acute fatigue ● chronic fatigue ● effort syndrome ● weakness
● headache ● burnout ● anxiety ● muscle pain
Virtually most known acute and chronic symptom and deficit
can be triggered by respiratory compromise.
43

SENSORY
● blurred vision ● dry mouth ● dry skin ● sound seems distant
● reduced pain threshold ● Tinnitus ● numbness ● tingling (hands, lips)
● dishabituation
44

CONSCIOUSNESS
● dizziness ● loss of balance ● fainting ● black-out ● confusion
● disorientation ● disconnectedness ● hallucinations ● traumatic memories
● low self-esteem ● personality shifts
45

COGNITIVE
● dishabituation ● attention deficit ● inability to think ● confusion
● disorientation ● poor memory ● learning deficits ● poor concentration
46

Effects of hypocapnia on the brain
Vasoconstriction leads to a 60% reduction of oxygen.
47

SKELETAL MUSCLES
● tetany ● hyperreflexia ● spasm ● weakness ● fatigue ● pain ● chest
pain, pressure, discomfort ● difficult to swallow ● feelings of suffocation
48

SMOOTH MUSCLES
● Reduced cerebral blood flow
● Reduced cerebral blood volume
● Cerebral vasoconstriction
● Coronary vasoconstriction
● Gut smooth muscle constriction
● Reduced placental perfusion
● Bronchiole constriction
● Cerebral and myocardial hypoxia (O2 deficit)
49

Behavioral hypocapnia
ABDOMINAL
● nausea
● cramping
● bloatedness
● exacerbation of sensitivities, disorders
50

MOVEMENT
● coordination
● reaction time
● balance
● eye-hand coordination
● perceptual judgment
51

VASCULAR
● hypertension
● migraine
● digital artery spasm
● compromised placental blood flow
● ischemia (tissue anemia)
● red blood cell rigidity, thrombosis
52

PERFORMANCE
● sleep apnea ● anxiety ● rehearsal ● focus ● endurance ● altitude
sickness ● muscle function ● fatigue ● pain
53

SLEEP
“One of the mechanisms by which application of noninvasive positive airway
pressure reduces central sleep apnea is by increasing hemoglobin oxygen
saturation and increasing the partial pressure of arterial carbon dioxide toward or
above the apneic threshold. In fact, central sleep apnea is predicted by the
presence of hypocapnia during waking hours. Thus, hypocapnia is a common
finding in patients with sleep apnea and may be pathogenic.”
Laffey, J. G., & Kavanagh, B. P. Hypocapnia. New England Journal of Medicine (2002); 347(1): 43-53.
“We conclude that when apnea occurs under conditions in which central PCO2 is
well below the CO2 setpoint, subjects are at risk of developing dangerous
hypoxemia due to absence of a hypoxic ventilatory response.”
Corne, S., Webster, K., Younes, M. Hypoxic respiratory response during acute stable hypocapnia. American
Journal of Respiratory and Critical Care Medicine; 167.9 (May 1, 2003): 1193-9.
54

MECHANICS AND CHEMISTRY
Breathing is acrobatic. It fits all occasions. And, if it is adaptive, it serves
fundamental respiration most of the time.
Maintaining a stable respiratory chemical axis (pH regulation) is vital to health and
performance, and must be regulated despite the breathing acrobatics of talking,
emotional encounters, and professional challenges.
Learned dysfunctional breathing may seriously compromise respiratory function. It
may disturb fundamental biochemistry and physiology that touches all other
physiological systems, and may do so both profoundly and immediately.
55

ASSESSMENT
Applied Behavior Analysis
Behavior analysis is serious detective work, a client-practitioner partnership in
the exploration of physiology, behavior, and experience.
Practitioners and clients work together to uncover the specific learning histories
of maladaptive breathing habits, including the specific behaviors learned and
their triggers, their reinforcements, and their effects.
Clients learn about how and why they breathe the way they do, and how
unconscious habits may be influencing their health and performance. These are
the objectives of applied behavior analysis.
56

CAPNOGRAPHY
Capnography is instrumentation used in surgery, critical care,
emergency medicine, and behavioral assessment.
Capnography provides for real time monitoring of alveolar PCO2; that is,
measurement of CO2 retained in the alveoli, not the amount exhaled.
57

THE CAPNOGRAM
The continuous and real-time presentation of waveform data permits
observation of air flow, including breath-holding, gasping, spasm, sighing,
breathing rate, aborted exhalation, and rhythmicity.
From Levitsky, 2007
58

CLIENT-CENTERED SERVICES
Breathing learning services are client-centered.
● Practitioners are guides, coaches, consultants who assist in learning.
● Breathing learning services do not involve diagnosis or treatment.
● Clients subscribe to, or register for, learning programs, not therapy sessions.
● Clients and practitioners work together in a partnership.
● Clients do most of the work, and they do it the field, at home and at work.
● Emphasis is on what clients learn, not what practitioners do.
62

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