Rethinking dysfunctional breathing in severe asthma

Published online April 29, 2025

Dysfunctional breathing (DB) is a common but often underrecognized contributor to poor asthma control, particularly in patients with severe asthma. Despite its prevalence, diagnosing DB remains challenging due to the absence of a gold standard. The Nijmegen Questionnaire (NQ) is frequently used in clinical settings, but its validity in asthma populations is debated. In contrast, Cardiopulmonary Exercise Testing (CPET) is emerging as a promising diagnostic modality that offers objective insights into breathing patterns during physical exertion. In a recent study published in The Journal of Allergy and Clinical Immunology: In Practice, Soumagne et al. compared these two approaches to better understand their diagnostic value and implications for managing DB in severe asthma. 

In this prospective study, 138 adults with severe asthma were recruited from three expert centers in France. DB was assessed using two methods: (1) the NQ combined with the hyperventilation provocation test (HVPT), interpreted by a panel of chest physicians, and (2) CPET, evaluated independently by two experienced physiologists. The study aimed to compare the prevalence and characteristics of DB identified by each method and to assess their diagnostic agreement.

The authors found that 44% of patients were diagnosed with DB using NQ/HVPT and 45% using CPET. However, the agreement between the two methods was poor (κ = 0.16), suggesting that they may identify different DB phenotypes. Patients diagnosed via NQ/HVPT were more likely to be female, have poorer asthma control, lower quality of life, and more comorbidities such as anxiety and depression. In contrast, those diagnosed via CPET had better lung function and higher oxygen levels, with no significant differences in asthma control or quality of life compared to those without DB.

The findings suggest that NQ/HVPT may reflect the overall burden of asthma and its comorbidities rather than DB itself, while CPET may more accurately identify physiological patterns of DB. The poor diagnostic agreement between the two methods highlights the need for standardized diagnostic criteria. CPET, with its objective assessment of breathing patterns and exercise capacity, may offer a more reliable approach to diagnosing DB in patients with asthma. However, further research is needed to validate its clinical utility and impact on patient outcomes.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.

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