Introduction

The Association of Chartered Physiotherapists in Respiratory Care (ACPRC) position statement supports using the unified nomenclature for breathing pattern disorder (BrPD) according to the agreed consensus.¹ Additionally, the assessment for individuals suspected of having BrPD has been suggested based on the group of expert clinicians’ recommendations.¹ Having a consensus on these aspects allows us to move forward and initiate important discussions about diagnosis, outcome measures and treatment for BrPD. It also marks an important starting point for facilitating discussions within the physiotherapy community, with patients and the wider multidisciplinary team on further developing the best ways to help with this important condition.

In June 2023, the ACPRC hosted an in-person conversation entitled ‘What next for BrPD?’ with a group of BrPD physiotherapy experts convened to participate in discussions on nomenclature and assessment,¹ and who agreed to continue the dialogue. This provided the opportunity for an open-ended discussion about the opportunities and challenges for BrPD in the future. This commentary aims to summarise (Figure 1) and reflect on these discussions aligned to the ACPRC’s four pillars of practice.² So, what next for BrPD?

Figure 1.A summary of the output from expert discussions “What next for BrPD?”

Sharing Knowledge and Skills

Discussions recognised the importance of ensuring specific education for BrPD from pre-registration level upwards and includes providing courses that support education across all levels of experience. The European Respiratory Society (ERS) Harmonised Education in Respiratory Medicine for European Specialists (HERMES) Respiratory Physiotherapy post-graduate curriculum indicates assessment and management of breathing pattern abnormalities are within the knowledge and skills domains required for specialists in respiratory physiotherapy.³ The assessment guide (see supplementary materials) developed by Grillo et al.¹ may support this by providing a baseline for developing such education with the development of competencies or minimum expected standards. Education about assessment of breathlessness, encompassing BrPD should start at pre-registration level and infiltrate all specialities within physiotherapy since this condition is relevant to respiratory physiotherapy as well as other specialities, including back/neck pain, fibromyalgia, pelvic floor problems and mental health conditions. Therefore, education at all levels should reflect this.

The group also discussed the role of the breathing pattern assessment within wider breathlessness services, and as an important component of a biopsychosocial assessment across many different fields, including (for example) chronic pain, exercise performance and long COVID. Education and awareness of this condition amongst the wider multidisciplinary team (MDT) was also felt to be essential to ensure prompt and effective referrals and accurate diagnosis. Increased knowledge and awareness could lead to preventative education and input in schoolchildren, primary care (for example, newly diagnosed asthmatics), and liaison with musculoskeletal services (e.g. patients with low back pain). Clinical experts in this area should also be supported to develop their specialist skills and continue to extend their knowledge.

Connecting People

It is essential to provide opportunities to develop the patient voice within this field and support opportunities to include patients in the development of clinical services and research opportunities. Moreover, engaging with stakeholders within hospital trusts, community settings and academic institutions will ensure that this condition is recognised and included in service and policy development. Connecting with our international colleagues and experts in other professions will help us to develop our understanding of this condition and share good practice.

Facilitating Research and Best Practice

The proposal of a single name (BrPD), as well as assessment, will provide a clear baseline to support the development of research evidence to inform practice. Clarity of terminology will support recognition of the condition. However, a deeper understanding of the mechanisms underlying this condition is crucial, making further research in this area essential. It is also essential we understand more about how this condition presents across different groups (gender, age, culture, beliefs and socioeconomic groups) as well as hearing from the patient’s voice through qualitative research. Furthermore, the evidence for effective treatment must be developed and supported by reliable and valid outcome measures. In parallel, it is essential we further estimate the workforce needs required to deliver effective services. It is, therefore, crucial to establish effective coding of the diagnosis of BrPD in the UK through both Systematized Nomenclature of MEDicine clinical terms (SNOMED codes)⁴ and the development of a Health Resource Group (HRG) code⁵ to ensure activity can be financially reimbursed. Clinical coding is an essential process for accurately capturing large volumes of data about diagnosis, treatment, and who delivers this activity. These data are vital to ensuring the true level of activity in respiratory departments is known for reimbursement of costs, for future planning, and information gathering about the nature of this condition. With more information, service provision can be more accurately planned. Within this, we need to increase professional opportunities through post-graduate education and the development of advanced specialist roles for clinicians working at an advanced level to help develop our workforce and the leaders within this area and to ensure each service can provide such expertise.

Leadership and Innovation

There are leadership requirements across all the areas currently described. However, this may need to come from both individuals and the different professional groups with which the clinical experts are associated. There are many groups in the UK already at the forefront of promoting best practice for BrPD, including formal groups like the ACPRC, Physiotherapy for Breathing Pattern Disorders and the Buteyko Association, as well as some more informal groups, including singing for breathing groups and those interested in breathing and athletic performance. Additionally, there is the influence of social media and a range of experts with claims about the importance of breathlessness management, with varying expertise. Opportunities need to be created to enable these groups to come together to ensure this area of interest is moving forward collectively. By standardising the name, BrPD as well as assessment, the priorities outlined in this commentary should be more achievable. Service planning and evaluation will be easier, and career pathways can be shaped; collaboration between physiotherapists and other members of the MDT regarding education and research will be streamlined. Ultimately, patient outcomes will be improved.

What next for BrPD?

This commentary highlights many important next steps for BrPD from various perspectives. We hope that by discussing some of these issues, we have provided a clearer sense of direction for leaders, researchers and clinicians working with people living with BrPD.