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Thorax 1993;48:809-81 1                                                                                                                809


                             Pattern of lung volumes in patients with sighing
                             breathing
                             Gabriel Aljadeff, Morico Molho, Ido Katz, Shlomo Benzaray, Zippy Yemini,
                             Robert J Shiner




                             Abstract
                             Background-Sighing         breathing    is
                             observed in subjects suffering from anxi-
                             ety with no apparent organic disease.
                             Methods-Lung volumes and expiratory
                             flow rates were measured in 12 patients
                             with a sighing pattern of breathing and in
                             10 normal subjects matched for age, gen-
                             der, and anthropometric data. In both
                             groups the measurements were made by
                             spirographic and plethysmographic tech-
                             niques. In normal subjects functional
                             residual capacity (FRC) and residual vol-
                             ume (RV) were measured during normal
                             breathing and again during simulated
                             sighing breathing to exclude technical
                             artifacts resulting from hyperventilation
                             during measurement by the helium                       E
                                                                                          i:         ,.Y

                             closed circuit method.                                     l,

                                                                                                 .,. 1, 1,
                                                                                                              1,


                             Results-Patients with a sighing pattern                                                                 .i-'i
                                                                                    i
                                                                                    ;            !: .|;                               i.-
                                                                                                                                     -"I.
                             of breathing had a normal total lung                                I, |Time.
                             capacity (TLC) but significantly different             I,I         .,     S:
                                                                                                             .,
                                                                                                             ..

                             partitioning of lung compartments com-
                             pared with normal subjects. The vital                         .:    '''          I'
                             capacity (VC) was lower when measured                Normal respiration pattern on spirometry (A) and sighing
                             by both spirographic and plethysmo-                  breathing pattern (B).
                             graphic methods and RV was higher. The
                             forced expiratory volume in one second
                             (FEV1) was also lower in patients with               patients describe their shortness of breath as
                             sighing breathing. The FEVJIVC and the               an inability to "get enough air into their
                             maximal expiratory flow rates at 50%                 lungs". Most cases suffer from some form of
                             and at 25% of the forced vital capacity              psychoneurosis3 with no apparent organic dis-
                             (V5(, and V2,) were normal and similar in            ease and the diagnosis is easily made on the
                             both groups. In normal subjects there                basis of symptoms and signs.'-10 Typically,
                             were no differences in RV when mea-                  there is no exertional dyspnoea, and these
                             sured during quiet or simulated sighing              subjects usually feel better during exercise
                             breathing.                                           and do not benefit from bronchodilator
                             Conclusions-Subjects with sighing                    therapy. With the exception of hyperven-
                             breathing have a normal TLC with a                   tilation and hypocapnoea, no other clinical
Department of                higher RV and lower VC than normal                   abnormalities have been described in these
Clinical Respiratory                                                              patients.? In our experience a large RV is fre-
Physiology, The              subjects. There was no obvious physio-
Chaim Sheba Medical          logical or anatomical explanation for this           quently present in the absence of lung disease
Center, Affiliated to        pattern.                                             or thoracic cage abnormalities. In one study
the Sackler School of                                                             RV was abnormally high in five of 21 patients
Medicine, Tel-Aviv            (Thorax 1993;48:809-81 1)                           but no reference was made to the significance
University, Israel
G Aljadeff                                                                        of this.3
M Molho                       Many patients are referred for specialist eval-        We have undertaken a study to verify our
I Katz                        uation of shortness of breath. Not infre-           observation with both spirographic and
S Benzaray
Z Yemini                      quently a sighing pattern of breathing is           plethysmographic measurements in patients
R J Shiner                    observed when spirography is recorded on            complaining of sighing breathing and in nor-
Reprint requests to:          graph paper. Sighing breathing, otherwise           mal subjects during normal respiration and
Dr R J Shiner
Received 14 July 1992
                              known as hyperventilation syndrome,' psy-           during simulated sighing breathing.
Returned to authors           chogenic hyperventilation,2 or behavioural
17 November 1992
Revised version received
                              breathlessness,3 is characterised by highly         Methods
11 January 1993               irregular breathing punctuated by deep              Lung volumes and maximal expiratory flow
Accepted 16 March 1993        periodic inspirations (fig). The majority of        rates were measured in 12 patients with a
                        Downloaded from thorax.bmj.com on December 31, 2011 - Published by group.bmj.com
  Al8adeff, Molho, Katz, Benzaray, Yemini, Shiner
810

                             sighing pattern of breathing and in 10 healthy               after deep breaths which may artificially
                             volunteers matched for age, gender, and                      increase FRC.
                             anthropometric values. All subjects under-                      The measurements were made during mid
                             went careful clinical and radiological                       morning in the sitting position and in the
                             examination to exclude lung, heart or neuro-                 same sequence for all subjects. A comput-
                             muscular diseases, thoracic deformities, obe-                erised water spirometer (Godard-Statham BV
                             sity, smoking habits, atopy, recent respiratory              type 15422) and a computerised constant
                             tract infection, or any other condition that                 volume plethysmograph (Jaeger Master Lab
                             could interfere with normal respiratory func-                type MIJB) were used. None of the subjects
                             tions. The radiological examination of normal                were taking any drugs at the time of the
                             subjects was part of the check up. Approval of               study.
                             the ethics committee was not sought as we                       The thoracic gas volume was measured five
                             felt that the tests were consistent with our                 times and an average value was calculated.
                             usual evaluation of patients with dyspnoea.                  The flow-volume curves were recorded with
                             Informed consent was obtained from all sub-                  the same equipment, the flow and volume
                             jects. No formal psychiatric assessment was                  changes being measured at the mouth, and
                             undertaken.                                                  the best curve was automatically integrated
                                A consistent history, the spirographic                    from at least three manoeuvres. The observed
                             recordings, and a low mean (SD) end tidal                    values were compared with the predicted nor-
                             Pco2 of 4 40 (0 27) kPa confirmed the                        mal values in this laboratory.'
                             sighing pattern of breathing.
                                 Lung volumes were assessed by both spiro-                STATISTICAL ANALYSIS
                             graphic (with helium closed circuit technique                Normal distribution goodness of fit test was
                             for FRC) and plethysmographic methods. In                    performed on each variable in each group.
                             normal subjects FRC was measured during                      Since the variables were normally distributed
                             quiet breathing and during artificial sighing                at the 95% confidence level, the hypothesis
                             breathing. Subjects were asked to take one                   test of the means was used to determine sig-
                             deep breath every 30 seconds, except during                  nificant differences in the measurements
                             the last minute, after which they were                       between the two groups. The possibility of a
                             requested to breathe normally to avoid                       type II statistical error (as a small number of
                             changes in the expiratory level. This double                 subjects were involved) is unlikely in view of
                             checking was to avoid spirometric pitfalls; we               the high a (>0 05) and the small variability of
                             suspected that sighing during measurements                   the population.
                             by the helium closed circuit technique could                    Regression analysis of spirometric and
                             lead to artificially high values of FRC. The                 plethysmographic measurements was used to
                             amount of helium absorbed during this tech-                  determine the correlation between them.
                             nique is generally minimal and depends on
                             the duration of the test and the weight of the
                             subject [helium absorbed (ml) = W (kg)/3 x                   Results
                             t (min)]. This volume was subtracted from                    There were no significant differences in age,
                             the observed FRC value. The time correction                  sex distribution, and anthropometric data
                             factor, which is only one component of venti-                between the two groups. The lung volumes
                             lation, may be insufficient to avoid inexact                 measured by both methods were within nor-
                             measurement in the presence of hyperventila-                 mal values. However, all the patients had a
                             tion or sighing. Deep breaths recruit more                   significantly lower VC (p < 0-01 by spirogra-
                             respiratory units and some helium can be                     phy and p < 005 by plethysmography) and a
                              absorbed or trapped in a larger ventilated                  significantly higher RV (p < 0-01 by both
                              area. Spirographic records frequently show an               methods) than the normal subjects, while
                              upward movement of the expiratory level                     TLC and FRC were similar in both groups.
                                                                                          There were no differences between spiro-
                                                                                          graphic and plethysmographic measurements.
                                                                                          The forced expiratory volume in one second
Mean (SD) anthropometric data, spirographic and plethysmographic measurements (%          (FEV,) was significantly lower in the patient
predicted) in normal subjects and patients with sighing breathing.                        group (p < 0-01) but the FEV1/VC ratio and
                      Normal subjects                    Sighing patients                 maximal flow rates at 50% and 25% of forced
                                                                                          VC (Vmax5, and Vmax25) were similar in
Age (y)                 36 (6)                            33 (12)                         both groups (table).
M:F                      8:2                               8:4                               In the normal subjects RV and FRC were
Height (cm)            173 (8)                           170 (11)
Body surface area (m2)   1-85 (0-02)                       1-85 (0 02)                    similar with normal breathing and with artifi-
FEV,                   109 (12)                           97 (9)                          cial sighing when measured with the helium
FEVN/VC                105 (6)                           104 (5)                          closed circuit technique.
V50                    105 (29)                           96 (17)
V25                     99 (28)                           96 (17)
                       Spirographic     Plethysmographic Spirographic Plethysmographic
VG                     105 (12)         108 (12)          93 (10)*     98 (13)**          Discussion
RV                      95 (12)         104 (23)         123 (21)*    138 (37)*           Our results provide convincing evidence that
TLC                    102 (9)          107 (10)         100 (12)     108 (15)
FRC                    109 (11)         119 (16)         107 (17)     121 (17)            patients with a sighing breathing pattern have
                                                                                          different partitioning of lung volumes from
FEV,-forced expiratory volume in     one second; VC-vital capacity; RV-residual vol-      normal subjects, having a smaller VC and
ume; TLC-total lung capacity; FRC-functional residual capacity; V,,-maximal expi-
ratory flow rate at 50% of forced VC; V,5-maximal expiratory flow rate at 25% of forced   larger RV, but a similar TLC and FRC. The
VC. *p < 001; **p < 005.                                                                  fact that there were no differences in the
                           Downloaded from thorax.bmj.com on December 31, 2011 - Published by group.bmj.com
Paern oflung volumes in patients with sighing breathing                                                                                    81

                              measurements of FRC during normal and              RV include changes in the thoracic cage, res-
                              sighing breathing in the normal subjects           piratory muscles, or in lung tissues,'2 but
                              proves that this is not an artifact.               there was no evidence for any of these in our
                                 The different partitioning of lung volumes      patients although they were not specifically
                              in the two groups can be explained by differ-      sought.
                              ences in the shape and compliance of the              We conclude that the pattern of lung
                              thoracic cage.12 Although we cannot entirely       volumes in patients with sighing breathing is
                              exclude this possibility as chest wall compli-     characterised by a lower VC and a higher RV
                              ance measurements were not performed,              than in normal subjects. No obvious physio-
                              thoracic abnormalities were not noted and          logical or anatomical explanation for this
                              there were no differences in age, sex distribu-    pattern could be found.
                              tion, and anthropometric data between the
                              two groups. Anatomical reasons can hardly
                              explain the respiratory symptomatology              1 Rice RL. Symptom patterns of the hyperventilation syn-
                                                                                      drome. Am J Med 1950;8:691.
                              which is characterised by periodic episodes         2 Fraser RG, Pare' JAPP. Diagnosis of diseases of the chest.
                              and not by constant symptoms aggravated by              2nd edn, vol 3. Philadelphia: Saunders, 1979: 1944-5.
                                                                                  3 Howell JBL. Behavioral breathlessness. Thorax 1990;45:
                              exercise.                                               287-92.
                                 The normal expiratory flow rates in the          4 Mechanic D. Social psychologic factors affecting the pre-
                              patients exclude air trapping resulting from            sentation of body complaints. N Engl J Med 1972;
                                                                                      286:1132-9.
                              airway obstruction. Their lower FEV1 is             5 Ker WJ. Some physical phenomena associated with the
                              related to the lower VC since the FEV1NC                anxiety states and their relation to hyperventilation. Ann
                                                                                      Intern Med 1937;2:962.
                              ratio is normal. Moreover, if airflow limita-       6 Comroe JH. Physiology of respiration. 2nd edn. Chicago:
                              tion is the cause of air trapping and of the            Year Book, 1974:232.
                              sighing breathing pattern, remission of             7 Lum JR. Hyperventilation and anxiety states. J R Soc Med
                                                                                      1981;74:1-4.
                              symptoms should result in correction of the         8 Lum JR. Hyperventilation syndromes in medicine and
                              physiological abnormality.                              psychiatry: a review. I R Soc Med 1987;80:229-31.
                                                                                  9 Magarian GJ. Hyperventilation syndromes: infrequently
                                 In a study of patients with chronic hyper-           recognized common expressions of anxiety and stress.
                              ventilation five of 21 patients had an                   Medicine 1982;61:219-36.
                              increased RV yet bronchial responsiveness (as       10 Bass C, Gardner WN. Respiratory and psychiatric abnor-
                                                                                       malities in chronic symptomatic hyperventilation. BMJ
                              determined by histamine challenge) was not               1985;290:1387-90.
                              increased.'0 An increase in RV indicates that       11 Qanjer PH (ed). Standardized lung function testing. BuUl
                                                                                       Eur Physiopathol Respir 1983;19(Suppl 5):1-91.
                              the lung is still hyperinflated after maximal       12 Comroe JH. Physiology of respiration. 2nd edn. Chicago:
                              expiratory effort. Reasons for an increased              Year Book, 1974:172-7.
           Downloaded from thorax.bmj.com on December 31, 2011 - Published by group.bmj.com




                                  Pattern of lung volumes in patients with
                                  sighing breathing.
                                  G Aljadeff, M Molho, I Katz, et al.

                                  Thorax 1993 48: 809-811
                                  doi: 10.1136/thx.48.8.809


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