Hyperventilation syndrome

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Hyperventilation syndrome.
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Hyperventilation syndrome (HVS), also known as chronic hyperventilation syndrome (CHVS), dysfunctional breathing hyperventilation syndrome, cryptotetany, [1] [2] spasmophilia, [3] [4] [5] latent tetany, [4] [5] and central neuronal hyper excitability syndrome (NHS), [3] is a respiratory disorder, psychologically or physiologically based, involving breathing too deeply or too rapidly (hyperventilation). HVS may present with chest pain and a tingling sensation in the fingertips and around the mouth (paresthesia) and may accompany a panic attack.

Contents

People with HVS may feel that they cannot get enough air. In reality, they have about the same oxygenation in the arterial blood (normal values are about 98% for hemoglobin saturation) and too little carbon dioxide (hypocapnia) in their blood and other tissues. While oxygen is abundant in the bloodstream, HVS reduces effective delivery of that oxygen to vital organs due to low-CO2-induced vasoconstriction and the suppressed Bohr effect.

The hyperventilation is self-promulgating as rapid breathing causes carbon dioxide levels to fall below healthy levels, and respiratory alkalosis (high blood pH) develops. This makes the symptoms worse, which causes the person to breathe even faster, which then, further exacerbates the problem.

The respiratory alkalosis leads to changes in the way the nervous system fires and leads to the paresthesia, dizziness, and perceptual changes that often accompany this condition. Other mechanisms may also be at work, and some people are physiologically more susceptible to this phenomenon than others. [6]

The mechanism for hyperventilation causing Paresthesia, lightheadedness, and fainting is: hyperventilation causes increased blood pH (see Respiratory alkalosis for this mechanism), which causes a decrease in free ionized calcium (Hypocalcaemia), which causes paresthesia and symptoms related to hypocalcaemia.

Causes

Hyperventilation syndrome is believed to be caused by psychological factors. [7] It is one cause of hyperventilation with others including infection, blood loss, heart attack, [8] hypocapnia or alkalosis due to chemical imbalances, decreased cerebral blood flow, and increased nerve sensitivity. [9]

In one study, one third of patients with HVS had "subtle but definite lung disease" that prompted them to breathe too frequently or too deeply. [10]

A study, found that 77% of patients with empty nose syndrome have hyperventilation syndrome. [11] Empty nose syndrome can appear in people having done nose surgery like cauterization, turbinectomy, turbinoplasty, etc. [12]

Many people with panic disorder or agoraphobia will experience HVS. However, most people with HVS do not have these disorders. [6]

Diagnosis

Hyperventilation syndrome is a remarkably common cause of dizziness complaints. About 25% of patients who complain about dizziness are diagnosed with HVS. [9]

A 1985 study, Efficacy of Nijmegen Questionnaire [13] in recognition of the hyperventilation syndrome, stated: "It is concluded that the questionnaire is suitable as a screening instrument for early detection of HVS, and also as an aid in diagnosis and therapy planning." [14]

Treatment

One review of research, published in 2013, concluded "The results of this systematic review are unable to inform clinical practice, based on the inclusion of only 1 small poorly reported RCT [randomised controlled trial] ... Therefore, no recommendations for clinical practice can be made." [15]

While traditional intervention for an acute episode has been to have the patient breathe into a paper bag, causing rebreathing and restoration of CO₂ levels, this is not advised. [16] The same benefits can be obtained more safely from deliberately slowing down the breathing rate by counting or looking at the second hand on a watch. This is sometimes referred to as "7-11 breathing", because a gentle inhalation is stretched out to take 7 seconds (or counts), and the exhalation is slowed to take 11 seconds. This in-/exhalation ratio can be safely decreased to 4-12 or even 4-20 and more, as the O₂ content of the blood will easily sustain normal cell function for several minutes at rest when normal blood acidity has been restored.

It has also been suggested that breathing therapies such as the Buteyko Breathing method may be effective in reducing the symptoms and recurrence of the syndrome.

Benzodiazepines can be prescribed to reduce stress that provokes hyperventilation syndrome. Selective serotonin reuptake inhibitors (SSRIs) can reduce the severity and frequency of hyperventilation episodes. [17]

History

The original traditional treatment of breathing into a paper bag to control psychologically based hyperventilation syndrome (which is now almost universally known and often shown in movies and TV dramas) was invented by New York City physician (later radiologist), Alexander Winter, M.D. [1908-1978], based on his experiences in the U.S. Army Medical Corps during World War II and published in the Journal of the American Medical Association in 1951. [18] Because other medical conditions can be confused with hyperventilation, namely asthma and heart attacks, most medical studies advise against using a paper bag since these conditions worsen when CO2 levels increase. [19]

Related Research Articles

<span class="mw-page-title-main">Panic attack</span> Period of intense fear

Panic attacks are sudden periods of intense fear and discomfort that may include palpitations, sweating, chest pain or chest discomfort, shortness of breath, trembling, dizziness, numbness, confusion, or a feeling of impending doom or of losing control. Typically, symptoms reach a peak within ten minutes of onset, and last for roughly 30 minutes, but the duration can vary from seconds to hours. Although they can be extremely frightening and distressing, panic attacks themselves are not physically dangerous.

<span class="mw-page-title-main">Respiratory system</span> Biological system in animals and plants for gas exchange

The respiratory system is a biological system consisting of specific organs and structures used for gas exchange in animals and plants. The anatomy and physiology that make this happen varies greatly, depending on the size of the organism, the environment in which it lives and its evolutionary history. In land animals the respiratory surface is internalized as linings of the lungs. Gas exchange in the lungs occurs in millions of small air sacs; in mammals and reptiles these are called alveoli, and in birds they are known as atria. These microscopic air sacs have a very rich blood supply, thus bringing the air into close contact with the blood. These air sacs communicate with the external environment via a system of airways, or hollow tubes, of which the largest is the trachea, which branches in the middle of the chest into the two main bronchi. These enter the lungs where they branch into progressively narrower secondary and tertiary bronchi that branch into numerous smaller tubes, the bronchioles. In birds the bronchioles are termed parabronchi. It is the bronchioles, or parabronchi that generally open into the microscopic alveoli in mammals and atria in birds. Air has to be pumped from the environment into the alveoli or atria by the process of breathing which involves the muscles of respiration.

<span class="mw-page-title-main">Buteyko method</span> Alternative physical therapy for asthma

The Buteyko method or Buteyko Breathing Technique is a form of complementary or alternative physical therapy that proposes the use of breathing exercises primarily as a treatment for asthma and other respiratory conditions.

Hyperventilation is irregular breathing that occurs when the rate or tidal volume of breathing eliminates more carbon dioxide than the body can produce. This leads to hypocapnia, a reduced concentration of carbon dioxide dissolved in the blood. The body normally attempts to compensate for this homeostatically, but if this fails or is overridden, the blood pH will rise, leading to respiratory alkalosis. The symptoms of respiratory alkalosis include dizziness, tingling in the lips, hands, or feet, headache, weakness, fainting, and seizures. In extreme cases, it may cause carpopedal spasms, a flapping and contraction of the hands and feet.

Hypoventilation occurs when ventilation is inadequate to perform needed respiratory gas exchange. By definition it causes an increased concentration of carbon dioxide (hypercapnia) and respiratory acidosis. Hypoventilation is not synonymous with respiratory arrest, in which breathing ceases entirely and death occurs within minutes due to hypoxia and leads rapidly into complete anoxia, although both are medical emergencies. Hypoventilation can be considered a precursor to hypoxia and its lethality is attributed to hypoxia with carbon dioxide toxicity.

Alkalosis is the result of a process reducing hydrogen ion concentration of arterial blood plasma (alkalemia). In contrast to acidemia, alkalemia occurs when the serum pH is higher than normal. Alkalosis is usually divided into the categories of respiratory alkalosis and metabolic alkalosis or a combined respiratory/metabolic alkalosis.

<span class="mw-page-title-main">Hypocalcemia</span> Low calcium levels in ones blood serum

Hypocalcemia is a medical condition characterized by low calcium levels in the blood serum. The normal range of blood calcium is typically between 2.1–2.6 mmol/L while levels less than 2.1 mmol/L are defined as hypocalcemic. Mildly low levels that develop slowly often have no symptoms. Otherwise symptoms may include numbness, muscle spasms, seizures, confusion, or cardiac arrest.

The control of ventilation is the physiological mechanisms involved in the control of breathing, which is the movement of air into and out of the lungs. Ventilation facilitates respiration. Respiration refers to the utilization of oxygen and balancing of carbon dioxide by the body as a whole, or by individual cells in cellular respiration.

Hypoparathyroidism is decreased function of the parathyroid glands with underproduction of parathyroid hormone (PTH). This can lead to low levels of calcium in the blood, often causing cramping and twitching of muscles or tetany, and several other symptoms. It is a very rare disease. The condition can be inherited, but it is also encountered after thyroid or parathyroid gland surgery, and it can be caused by immune system-related damage as well as a number of rarer causes. The diagnosis is made with blood tests, and other investigations such as genetic testing depending on the results. The primary treatment of hypoparathyroidism is calcium and vitamin D supplementation. Calcium replacement or vitamin D can ameliorate the symptoms but can increase the risk of kidney stones and chronic kidney disease. Additionally, medications such as recombinant human parathyroid hormone or teriparatide may be given by injection to replace the missing hormone.

<span class="mw-page-title-main">Respiratory arrest</span> Medical condition

Respiratory arrest is a sickness caused by apnea or respiratory dysfunction severe enough it will not sustain the body. Prolonged apnea refers to a patient who has stopped breathing for a long period of time. If the heart muscle contraction is intact, the condition is known as respiratory arrest. An abrupt stop of pulmonary gas exchange lasting for more than five minutes may permanently damage vital organs, especially the brain. Lack of oxygen to the brain causes loss of consciousness. Brain injury is likely if respiratory arrest goes untreated for more than three minutes, and death is almost certain if more than five minutes.

<span class="mw-page-title-main">Hypocapnia</span> State of reduced carbon dioxide in the blood

Hypocapnia, also known as hypocarbia, sometimes incorrectly called acapnia, is a state of reduced carbon dioxide in the blood. Hypocapnia usually results from deep or rapid breathing, known as hyperventilation.

The Chvostek sign is a clinical sign that someone may have a low blood calcium level. The Chvostek sign is the abnormal twitching of muscles that are activated (innervated) by the facial nerve. When the facial nerve is tapped in front of the ear, the facial muscles on the same side of the face will contract sporadically. The muscles that control the nose, lips and eyebrows are often the ones that will spasm.

<span class="mw-page-title-main">Respiratory alkalosis</span> Medical condition

Respiratory alkalosis is a medical condition in which increased respiration elevates the blood pH beyond the normal range (7.35–7.45) with a concurrent reduction in arterial levels of carbon dioxide. This condition is one of the four primary disturbance of acid–base homeostasis.

The choking game or blackout challenge is the act of intentionally cutting off oxygen to the brain with the goal of inducing temporary loss of consciousness and euphoria.

<span class="mw-page-title-main">Central neurogenic hyperventilation</span> Abnormal pattern of breathing

Central neurogenic hyperventilation (CNH) is an abnormal pattern of breathing characterized by deep and rapid breaths at a rate of at least 25 breaths per minute. Increasing irregularity of this respiratory rate generally is a sign that the patient will enter into coma. CNH is unrelated to other forms of hyperventilation, like Kussmaul's respirations. CNH is the human body's response to reduced carbon dioxide levels in the blood. This reduction in carbon dioxide is caused by contraction of cranial arteries from damage caused by lesions in the brain stem. However, the mechanism by which CNH arises as a result from these lesions is still very poorly understood. Current research has yet to provide an effective means of treatment for the rare number of patients who are diagnosed with this condition.

<span class="mw-page-title-main">Metabolic alkalosis</span> Medical condition

Metabolic alkalosis is a metabolic condition in which the pH of tissue is elevated beyond the normal range (7.35–7.45). This is the result of decreased hydrogen ion concentration, leading to increased bicarbonate, or alternatively a direct result of increased bicarbonate concentrations. The condition typically cannot last long if the kidneys are functioning properly.

Freediving blackout, breath-hold blackout or apnea blackout is a class of hypoxic blackout, a loss of consciousness caused by cerebral hypoxia towards the end of a breath-hold dive, when the swimmer does not necessarily experience an urgent need to breathe and has no other obvious medical condition that might have caused it. It can be provoked by hyperventilating just before a dive, or as a consequence of the pressure reduction on ascent, or a combination of these. Victims are often established practitioners of breath-hold diving, are fit, strong swimmers and have not experienced problems before. Blackout may also be referred to as a syncope or fainting.

<span class="mw-page-title-main">Tetany</span> Medical condition, exhibiting involuntary contraction of muscles

Tetany or tetanic seizure is a medical sign consisting of the involuntary contraction of muscles, which may be caused by disorders that increase the action potential frequency of muscle cells or the nerves that innervate them.

<span class="mw-page-title-main">Breathing</span> Process of moving air into and out of the lungs

Breathing is the process of moving air into and from the lungs to facilitate gas exchange with the internal environment, mostly to flush out carbon dioxide and bring in oxygen.

<span class="mw-page-title-main">Salicylate poisoning</span> Medical condition

Salicylate poisoning, also known as aspirin poisoning, is the acute or chronic poisoning with a salicylate such as aspirin. The classic symptoms are ringing in the ears, nausea, abdominal pain, and a fast breathing rate. Early on, these may be subtle, while larger doses may result in fever. Complications can include swelling of the brain or lungs, seizures, low blood sugar, or cardiac arrest.

References

  1. ↑ Seelig, MS; Berger, AR; Spielholz, N (August 1975). "Latent Tetany And Anxiety, Marginal Magnesium Deficit, And Normocalcemia" (PDF). Dis Nerv Syst. 36 (8): 461–5. PMID   1164868. S2CID   6696448. Archived from the original (PDF) on 2019-09-12.
  2. ↑ "Review and Hypothesis: Might Patients with the Chronic Fatigue Syndrome Have Latent Tetany of Magnesium Deficiency".
  3. 1 2 "Spasmophilia in the Cardiological Outpatient Department: A Retrospective Study of 228 Sub-saharan Africans over 5 Years". ResearchGate. Retrieved 2019-09-14.
  4. 1 2 Toruńska, Katarzyna (May 2003). "[Tetany as a difficult diagnostic problem in the neurological outpatient department]". Neurologia I Neurochirurgia Polska. 37 (3): 653–664. ISSN   0028-3843. PMID   14593759.
  5. 1 2 Bongi, Susanna Maddali; Del Rosso, Angela; Lisa, Diana; Orlandi, Martina; De Scisciolo, Giuseppe (September 2015). "Ischemia-hyperpnea test is useful to detect patients with fibromyalgia syndrome". European Journal of Rheumatology. 2 (3): 89–95. doi:10.5152/eurjrheum.2015.0094. ISSN   2147-9720. PMC   5047258 . PMID   27708937.
  6. 1 2 "eMedicine - Hyperventilation Syndrome: Article by Edward Newton, MD" . Retrieved 2007-12-20.
  7. ↑ Shu, BC; Chang, YY; Lee, FY; Tzeng, DS; Lin, HY; Lung, FW (2007-10-31). "Parental attachment, premorbid personality, and mental health in young males with hyperventilation syndrome". Psychiatry Research. 153 (2): 163–70. doi:10.1016/j.psychres.2006.05.006. PMID   17659783. S2CID   3931401.
  8. ↑ "Hyperventilation" . Retrieved 2007-12-20.
  9. 1 2 "Neurology - Hyperventilation Syndrome | Brad McKechnie, DC, DACAN" . Retrieved 2007-12-20.
  10. ↑ Natelson, Benjamin H. (1998). Facing and fighting fatigue: a practical approach. New Haven, Conn: Yale University Press. pp.  40. ISBN   978-0-300-07401-7.
  11. ↑ Mangin, David; Bequignon, Emilie; Zerah-Lancner, Francoise; Isabey, Daniel; Louis, Bruno; Adnot, Serge; Papon, Jean-François; Coste, André; Boyer, Laurent (September 2017). "Investigating hyperventilation syndrome in patients suffering from empty nose syndrome". The Laryngoscope. 127 (9): 1983–1988. doi:10.1002/lary.26599. ISSN   1531-4995. PMID   28407251. S2CID   25389674.
  12. ↑ "FFAAIR | Syndrome du Nez Vide (SNV)". www.ffaair.org (in French). Retrieved 2019-09-10.
  13. ↑ "Nijmegen questionnaire". Health Navigator: New Zealand. Retrieved 28 February 2023.
  14. ↑ van Dixhoorn J, Duivenvoorden HJ (1985). "Efficacy of Nijmegen Questionnaire in recognition of the hyperventilation syndrome". J Psychosom Res. 29 (2): 199–206. doi:10.1016/0022-3999(85)90042-x. PMID   4009520.
  15. ↑ Jones, M; Harvey, A; Marston, L; O'Connell, NE (May 31, 2013). "Breathing exercises for dysfunctional breathing/hyperventilation syndrome in adults (review)" (PDF). The Cochrane Database of Systematic Reviews. 5 (5): CD009041. doi:10.1002/14651858.cd009041.pub2. PMID   23728685.
  16. ↑ Bergeron, J. David; Le Baudour, Chris (2009). "Chapter 9: Caring for Medical Emergencies". First Responder (8 ed.). New Jersey: Pearson Prentice Hall. p. 262. ISBN   978-0-13-614059-7. Do not use a paper bag in an attempt to treat hyperventilation. These patients can often be cared for with low-flow oxygen and lots of reassurance
  17. ↑ "Hyperventilation Syndrome Medication". Medscape. Retrieved 31 December 2013.
  18. ↑ Winter, A (1951). "A Rapid Emergency Treatment for Hyperventilation Syndrome". J Am Med Assoc. 147 (10): 990. doi:10.1001/jama.1951.03670270080028.
  19. ↑ Anahad O'Connor (2008-05-13). "The Claim: If You're Hyperventilating, Breathe Into a Paper Bag". New York Times . Retrieved 2014-02-09.
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