Q. What can cause sudden forced exhalation?

Answered by
Dr. Vivek Chail
and medically reviewed by iCliniq medical review team.
Published on Sep 23, 2017 and last reviewed on: Aug 13, 2019

Hi doctor,

I am a 45 year old male. A month back, I was diagnosed with sleep apnea. I have enclosed my report here. I feel breathless at night while lying down and I was advised it as because of sleep apnea. I have been trying to use a CPAP. For past two months I am experiencing breathlessness on even slight exertion like walking for a few minutes, bending down, etc. My doctor said it may be due to coronary ischemia. I had a positive TMT and may have to undergo an angiography. My chest physician said it as bronchoconstriction. He prescribed Foracort inhaler, Duolin inhaler, Deriphyllin retard and Montek. The unresolved problem I am facing now is a sudden involuntary exhalation of breath. This happens more often at night, from time to time breath exhales in a sudden explosive spurt that almost throws up my body a bit something like hiccups from the stomach. This happens many times at night and disturbs sleep. It also happens the moment I put on my CPAP full face mask. Earlier it was more while using the CPAP and nowadays it happens even without the CPAP. Also my wife says that even with CPAP sometimes I am absolutely still, not breathing while sleeping.

My father is a heart patient and he also has COPD. My mother suffered with asthma and now got cured of it. I do not smoke or drink alcohol and I am a vegetarian. In addition to the above tests, my chest X-ray was normal. Five months back I had an echo and brain MRI, which are all also normal. Brain MRI was taken because I had some balancing issues which were then diagnosed as uncompensated vestibular lesion. I also have severe cervical spondylosis. What could be the cause of this sudden aggressive exhalation? Could my breathlessness issue be entirely due to lungs? If so should I undergo angiography? Thanks in advance.

Dr. Vivek Chail

Radiodiagnosis Radiology


Welcome to icliniq.com.

I have read through your query and reports (attachment removed to protect patient identity) in detail. Please find my observations below.

There is a probability of having a parasomnia which is defined as sleep disorders that involve abnormal movements and features like aggressive exhalation, partial awakening, arousal with confusion, sleep terror and related symptoms.

This problem is in addition to the obstructive sleep apnea which is there in you. Studies show that 9.5 percent of people with obstructive sleep apnea might have parasomnia.

About 20 percent of patients experience improvement and decrease in episodes of parasomnia after CPAP (continuous positive airway pressure) and it is persisting even with CPAP in you.

  • The chest x-ray and brain MRI are normal therefore there is no serious problem in the lungs and brain.
  • It is understood that you have got necessary breathing tests like spirometry to rule out any abnormality in breathing volumes and therefore variation in peak expiratory flow rate for which you have been given medicine.
  • There are two types of angiography. One is CT angiography and is done using CT machine and office procedure. The other is catheterization laboratory angiography which is done in the cath lab and might require you to stay in hospital for a day.
  • Both are equally good and you might discuss with the cardiologist and then proceed with making a choice.

At 45 years, getting a CT angiography is suggested. It is a low risk procedure comparable with the cath lab angiography.

Doing lipid profile and cardiac enzyme test is also important.

For further information consult a pulmonologist online --> https://www.icliniq.com/ask-a-doctor-online/pulmonologist

Hi doctor,

Thank you for your kind response. Please help me to understand, what is the implication of the parasomnia you mentioned? How to get this diagnosed? And what is the treatment? I get those forced exhalations with body jerks even while I am awake at night. As mentioned, my chest physician did a simple test in his office by asking me to blow into something and the peak expiratory flow rate was 500 and after some walking it became 350. Are these numbers normal? The doctor said bronchoconstriction/bronchospasm. Is this a temporary problem? My father has COPD, is there any chance that my problem related to COPD? As mentioned the main symptom is breathlessness on even slight exertion. In the TMT test, I stopped the test due to a lot of breathlessness; but no significant chest pain. Can only breathlessness be a sign of blocked arteries?

Dr. Vivek Chail

Radiodiagnosis Radiology


Welcome back to icliniq.com.

Features involving the sudden exhalation described by you are essentially a manifestation of obstructive sleep apnea itself but recent research has shown it might be a closely associated behavior termed parasomnia.

These are sleep related disorders and require a detailed investigation including the contribution of the obstructive sleep apnea. I guess your diagnosis has been made after detailed investigation and therefore this might be an extension of your obstructive sleep apnea.

Treatment wise there is a need for to the sleep hygiene with the CPAP treatment which you are taking.

I am unable to get what you mean by the forced exhalations with jerks even when awake. Are you completely awake or half awake? However this need to be discussed with your doctor who made diagnosis of obstructive sleep apnea and then treatment might be modified as required.

It is important to know if you feel sleepy in daytime and this also requires to be treated. This is not a serious condition but might get disturbing and this is happening to you.

  • Your doctor suspects that the peak expiratory flow rate PEFR findings are showing possibility of asthma and is treating you for it.
  • COPD also might have similar findings but there are differences between the two conditions. Diagnosis of asthma versus COPD has to be confirmed after regular follow up.
  • While COPD is seen in smokers, has genetic linkage and worsen over time. Asthma is seen in smokers and non-smokers, due to allergy and improves with medicine and might recur frequently as acute attacks of breathlessness.

Although there is a strong clinical suspicion of asthma, I would like you to get evaluated for any suspected heart condition as a cause of the breathlessness. This is most important because heart problems have become common these days due to stress and lifestyle and those who are overweight.

  • Heart problems are to be evaluated in detail and might be present without chest pain. People who have breathlessness and positive TMT require proper evaluation.
  • The risk for heart disease is calculated from multiple variables including blood serum cholesterol test, which is lipid profile and cardiac enzymes among the blood tests. There are other heart function tests like ECG, TMT, heart perfusion studies and angiography which help in assessment of heart disease.

For further information consult a pulmonologist online --> https://www.icliniq.com/ask-a-doctor-online/pulmonologist

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