What causes fluttering in lung fields when taking a deep breath and how is it treated?

Fluttering in Lung Fields When Taking a Deep Breath

The sensation of fluttering in the lung fields during deep breathing most likely represents diaphragmatic flutter—a rare disorder characterized by rapid, involuntary rhythmic contractions of the diaphragm that can be triggered by increasing the depth of breathing. 1, 2

Understanding the Condition

Diaphragmatic flutter is defined by rapid rhythmic involuntary contractions of the diaphragm, typically occurring at frequencies of 9-15 Hz (high-frequency type) or 0.5-8.0 Hz (classic type), and is often triggered by deep breathing or increased diaphragmatic activity. 1, 2

Key Clinical Features:

• Patients experience dyspnea, thoracoabdominal pain, and visible or palpable epigastric pulsations during episodes 2, 3
• The flutter can be associated with symptoms like belching, hiccups, or retching in high-frequency variants 2
• Deep breathing specifically triggers or worsens the fluttering sensation in documented cases 1

Diagnostic Approach:

• Electromyography (EMG) of the diaphragm, scalene, and parasternal intercostal muscles showing repetitive discharges at 9-15 Hz confirms high-frequency diaphragmatic flutter 2
• Spirographic tracings demonstrate high-frequency oscillations superimposed on normal tidal breathing patterns 2
• The diagnosis requires excluding other respiratory diseases that could cause similar symptoms 2, 3

Treatment Recommendations

First-Line Pharmacological Therapy:

Carbamazepine 200-400 mg three times daily is the recommended initial treatment, as it has demonstrated complete resolution or significant improvement of flutter and associated symptoms in all reported cases. 2

• This anticonvulsant medication appears to suppress the abnormal diaphragmatic contractions effectively 2
• Response to carbamazepine strongly suggests the flutter is causing the symptoms rather than being coincidental 2

Alternative Non-Invasive Approach:

Noninvasive ventilatory support (NVS) using mouthpiece or nasal ventilation can instantaneously halt diaphragmatic flutter by resting the diaphragm, and should be considered when medical therapy fails. 1

• Manual resuscitator bag, mouthpiece ventilation, or nasal NVS can stop flutter episodes immediately 1
• This approach works by reducing diaphragmatic activity, which is a known trigger 1
• NVS has been successful for sustained periods (16+ months) with no adverse effects 1

Invasive Options for Refractory Cases:

• Phrenic nerve crush has provided optimal outcomes with resolution of symptoms and return of normal diaphragmatic function in cases where medical therapy failed 3
• This should be reserved for severely disabling cases unresponsive to conservative measures 3
• Diaphragm pacer stimulation has been attempted but was ineffective in at least one documented case 1

Important Clinical Pitfalls

Do not confuse diaphragmatic flutter with hyperventilation syndrome, which presents with similar respiratory symptoms but is characterized by hypocapnia and psychological mechanisms rather than involuntary diaphragmatic contractions. 4

• Hyperventilation syndrome involves breathing in excess of metabolic needs with low PaCO2, whereas diaphragmatic flutter shows normal blood gases with abnormal EMG findings 4, 2
• The flutter pattern on spirography and EMG distinguishes these conditions 2

Avoid dismissing the complaint as anxiety-related without proper diagnostic workup, as diaphragmatic flutter is a distinct neurological disorder requiring specific treatment. 2

• High-frequency diaphragmatic flutter appears to be a distinct disease entity separate from chronic hiccups or other respiratory complaints 2
• The condition responds specifically to carbamazepine, confirming its neurological basis 2

Monitoring and Follow-up

• Assess symptom resolution and frequency of episodes after initiating carbamazepine 2
• If using NVS, monitor for breakthrough episodes and adjust duration/frequency of ventilatory support as needed 1
• Watch for rare episodes that may occur with position changes (e.g., getting out of bed) which typically resolve with 30-40 minutes of NVS 1