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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 [email protected] Copyrighted 2012-2013

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Effects of Compromised Respirationon Physiology and Psychology

Peter M. Litchfield, Ph.D.Graduate School of Breathing SciencesTel: 307.633.9800 Cell: 505.670.2874

[email protected]

Copyrighted 2012-2013

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MISSIONOur mission is to help people improve health and performancethrough the application of behavioral learning principles to breathing physiology.


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PROBLEMSelf-defeating learned breathing behaviors compromise physiology, psychology, health, and performance.Learned dysfunctional breathing has a major impacton 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.


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


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SOLUTIONPractitioners 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)


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RESPIRATION AND BREATHINGare 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.


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EFFECTS OF BREATHING HABITSThe 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).


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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


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


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BREATHING BEHAVIORSBreathing 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


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COMPROMISED MECHANICSDysfunctional 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


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RESPIRATORY FITNESSThe fundamental objectiveRespiratory 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.


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


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BREATHING & RESPIRATIONRespiratory 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.


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MEDIATED CONSEQUENCESThe 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.


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RELEVANCEDr. 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)


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RELEVANCEDr. 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.)


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● 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.


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EXTERNAL RESPIRATIONExternal 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.


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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)


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CRITICAL pH VALUESNormal 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).


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PCO2Denominator of the EquationArterial 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.

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CHEMO-REGULATORY REFLEXESBalancing 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.


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HYPOCAPNIAis 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.


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BEHAVIORAL HYPOCAPNIAis the result of learned overbreathing behavior.When hypocapnia is a consequence of dysfunctionalbreathing 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.


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HYPERCAPNIAis 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.


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EFFECTS OF HYPOCAPNIAFrom: 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.”


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SUMMARY QUOTATIONSThe 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


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UNEXPLAINED SYMPTOMSLearned 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.


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Behavioral Hypocapnia

PHYSIOLOGICAL EFFECTSHemoglobin chemistry: O2 distribution by Hb is restricted.● Red blood cell CO2 diminishes while alkalinity increases, thereby increasing hemoglobin’s affinity for oxygenand 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.


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Behavioral Hypocapnia

PHYSIOLOGICAL EFFECTSPlasma alkalemia and low PCO2

● Calcium ions are exchanged for hydrogen ions in smooth muscleresulting 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.


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Behavioral Hypocapnia

PHYSIOLOGICAL EFFECTSInterstitial alkalemia and electrolytes● Muscles: Calcium ions are exchanged for hydrogen ionsin smooth and skeletal muscle and set the stage formuscle spasm, weakness, stiffness, and fatigue.

● Neurons: Sodium and potassium ions are exchangedfor hydrogen ions in neurons, for example, which increases their excitability, contractility, and metabolism.


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Behavioral Hypocapnia

PHYSIOLOGICAL EFFECTSIntracellular 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).


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Behavioral Hypocapnia

PHYSIOLOGICAL EFFECTSInhibitory 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.


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Behavioral Hypocapnia

PHYSIOLOGICAL EFFECTSLong term effectsChronic 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.


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Behavioral Hypocapnia

PHYSIOLOGICAL EFFECTSOther 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)


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Behavioral Hypocapnia

PHYSIOLOGICAL EFFECTSExacerbation 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


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Behavioral Hypocapnia

SYMPTOMS AND DEFICITSRESPIRATORY● 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


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Behavioral Hypocapnia

SYMPTOMS AND DEFICITS PERIPHERAL ● trembling● twitching● shivering● sweatiness,● coldness ● tingling● numbness


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Behavioral HypocapniaSYMPTOMS AND DEFICITS CARDIOVASCULAR● palpitations● increased rate● angina symptoms● arrhythmias● nonspecific pain● ECG abnormalities


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Behavioral Hypocapnia

SYMPTOMS AND DEFICITS EMOTIONAL● anxiety ● anger ● fear ● panic ● apprehension ● worry ● crying, ● low mood ● frustration ● performance anxiety ● phobia

IMPORTANTMany, 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.


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Behavioral Hypocapnia

SYMPTOMS AND DEFICITSSTRESS 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.


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Behavioral Hypocapnia

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


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Behavioral Hypocapnia

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


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Behavioral Hypocapnia

SYMPTOMS AND DEFICITSCOGNITIVE● dishabituation ● attention deficit ● inability to think ● confusion● disorientation ● poor memory ● learning deficits ● poor concentration


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Effects of hypocapnia on the brainVasoconstriction leads to a 60% reduction of oxygen.


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Behavioral Hypocapnia

SYMPTOMS AND DEFICITSSKELETAL MUSCLES● tetany ● hyperreflexia ● spasm ● weakness ● fatigue ● pain ● chest pain, pressure, discomfort ● difficult to swallow ● feelings of suffocation


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Behavioral Hypocapnia

SYMPTOMS AND DEFICITS 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)


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Behavioral hypocapnia

SYMPTOMS AND DEFICITSABDOMINAL● nausea● cramping● bloatedness● exacerbation of sensitivities, disorders


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Behavioral hypocapnia

SYMPTOMS AND DEFICITS MOVEMENT● coordination● reaction time● balance● eye-hand coordination● perceptual judgment


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Behavioral hypocapnia

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


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Behavioral hypocapnia

SYMPTOMS AND DEFICITS PERFORMANCE● sleep apnea ● anxiety ● rehearsal ● focus ● endurance ● altitude sickness ● muscle function ● fatigue ● pain


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Behavioral hypocapnia

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.


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MECHANICS AND CHEMISTRYBreathing 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.


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ASSESSMENTApplied Behavior AnalysisBehavior 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.


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CAPNOGRAPHYCapnography 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.


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THE CAPNOGRAMThe 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


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CLIENT-CENTERED SERVICESBreathing 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.