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Hyperventilation

Hyperventilation is deep and rapid breathing. It may be caused due to panic attacks, anxiety, or physical or emotional stress. It is also known as over-breathing and may leave you feeling breathless. It is more common in women than men and people aged 15 to 55 years. We breathe in oxygen, followed by breathing out carbon dioxide. During hyperventilation, we tend to breathe excessively. That is, we over-breathe, and this leaves us breathless. This increases the removal of carbon dioxide from the blood, so the carbon dioxide pressure inside the blood decreases, causing a condition called respiratory alkalosis, where the blood becomes more alkaline. Alkalosis constricts the blood vessels that supply blood to the brain, resulting in symptoms like tingling sensation and light-headedness. Severe hyperventilation may also result in loss of consciousness.

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Types

There are two types of hyperventilation:


  • Acute (sudden) hyperventilation: It is easily recognised and commonly diagnosed in emergency rooms. It is triggered by stress, anxiety, or emotionally upset.

  • Chronic (recurring) hyperventilation: In this condition, the patient’s PCO2 levels are low. It can be an issue for people with asthma, lung cancer, or emphysema.

Symptoms

During hyperventilation, you may not be aware that you are hyperventilating. It can last for about 20-30 minutes. The symptoms you may be aware of are:


  • Light-headedness, dizziness, or weakness

  • Breathlessness

  • Chest pain and palpitations

  • Muscle spasm in hands and feet

  • Belching or bloating

  • Numbness and tingling in the arms or near the mouth

  • Dry mouth

  • Problems sleeping

  • Confusion, anxiousness, nervous or tense

  • Repeated sighing or yawning


Some symptoms you may not realise are related to hyperventilation syndrome. Less frequent symptoms include:

  • Twitching

  • Headache

  • Sweating

  • Gas, bloating, or burping

  • Blurred vision or tunnel vision

  • Fainting

Causes And Risk Factors

Causes


The causes of hyperventilation can be divided into:

  • Emotional causes[2,5]

  • Anxiety or panic attacks

  • Stress

  • Nervousness or tension

  • Medical causes:[2,5]

  • Infection

  • Drugs like aspirin overdose

  • Pregnancy

  • Bleeding

  • Ketoacidosis and similar conditions

  • Certain lung and heart problems

  • Stimulant medicines


Risk Factors


Some clinical conditions increase the risk of getting hyperventilation. These include:

  • Anxiety or panic disorder: Anxiety and panic disorder is probably the most common cause of hyperventilation. This type of hyperventilation is called acute or sudden hyperventilation. The two almost form a vicious cycle; in a sense, anxiety can lead to hyperventilation, and this rapid breathing can make you panic.

  • Heart failure and heart attack: Heart failure, a chronic condition in which your heart can no longer pump out oxygen-rich blood, can cause you to hyperventilate. But this type of hyperventilation is called chronic hyperventilation.

  • Lung disease[2,4]

  • Pneumonia[2,4]

  • Ketoacidosis[2,4]

Prevention

Specific methods can be tried to prevent hyperventilation episodes:


  • Breathing exercise

  • Medicine or therapy to manage anxiety or panic attacks

  • Learn relaxation methods like meditation or progressive muscle relaxation

  • Loosen your clothes if you feel restricted and your breathing feels shallow

  • Learn belly-breathing techniques when you are not hyperventilating so that you can use them when needed.

  • Eat healthy food and avoid caffeinated drinks.

  • Regular exercise

Diagnosis

Diagnosis for hyperventilation can be made in the following ways:

Test to exclude other diagnoses:


  • Pulse Oximetry: In hyperventilation, pulse oximetry shows oxygen saturation at or close to 100%[2,6]

  • Chest X-ray: In hyperventilation, chest X-rays are normal

  • ECG: Hyperventilation causes ST-segment depression, T wave inversions, and prolonged QT intervals. It is done to detect cardiac ischemia.

  • CT Angiography, D-dimer, Ventilation, or Perfusion Scanning: This test will be done to rule out pulmonary embolism


Arterial blood gas(ABG) measurements when metabolic acidosis is suspected to cause hyperventilation.

Other Methods:



  • Nijmegen Questionnaire (NQ): Questions related to physiological and psychological factors will be asked for a clinical diagnosis of hyperventilation.

  • The Hyperventilation Provocation test: It requires the patient to breathe as deeply and rapidly as possible for 2 or 3 minutes. If it mimics the symptoms experienced in daily life, hyperventilation can be confirmed.

  • Cardiopulmonary exercise testing: This testing is done when patients don’t experience symptoms at rest but during movement.

Treatment

The treatment for hyperventilation is focused on getting your breathing and carbon dioxide levels back in control. If you are at the hospital following things will be done:


  1. A healthcare practitioner will check the oxygen levels in your blood via a pulse oximeter

  2. A healthcare practitioner will then talk to you and help you stay calm

  3. A different breathing exercise may be recommended, like:



  • Breathing through pursed lips like you are whistling, or you can also cover one nostril and breathe through the other nostril.

  • You can slow your breathing to once every 5 seconds or until symptoms go away.

  • You can try the belly-breathing method. Place a hand on your belly while the other one is on your chest. Take a deep breath as if you are filling your belly, and let your belly push your hand out. Next, Exhale slowly, pushing the air out of your belly with your hands. Repeat the steps 5 to 10 times.

  • If required, you will be asked to breathe into a tube.

  • You may also be asked to take medicine to help you relax. The repeated episodes of uncontrolled ventilation are called hyperventilation syndrome, which can be treated using anxiolytic medicines.


The long-term treatment options also depend on the cause of your hyperventilation. Clinical conditions like anxiety or panic disorder, heart failure and heart attack, Asthma, chronic obstructive pulmonary disease, pulmonary embolism, pneumonia, and ketoacidosis due to which hyperventilation is caused need to be treated.

Home care:


If your hyperventilation is due to anxiety, panic, or stress, there are a few steps you can take at home. To prevent future attacks, you, your family, and your friends can learn these methods.

When you start hyperventilating, the aim is to raise the level of carbon dioxide in your blood. This will get rid of many of your symptoms. These methods include:

  • To help relax your breathing, get reassurance from a family member or friend. It is necessary to stay relaxed and use a soft, relaxed tone. Sentences like "you do not have a heart attack,” "you are doing fine," and "you are not going to die" are very helpful.

  • Learn and practice breathing exercises every day, so that they can be used at the time of a hyperventilation episode.

Lifestyle Management

Do not dismiss the patient’s symptoms. Acknowledge they have real symptoms which require explanation. It is essential to let them know that the associated symptoms of tingling and light-headedness are harmless. Some measures you can take to you stop over-breathing are:


  • Learn relaxation techniques like meditation or progressive muscle relaxation

  • Practice breathing techniques that help you breathe from your diaphragm and abdomen and not from your chest wall.

  • Exercise regularly

  • Visit a mental health professional to help learn about and treat your anxiety or panic

Prognosis And Complications

Prognosis


People with hyperventilation usually farewell. They typically improve swiftly with an explanation. In one follow-up study of 173 patients, it was found that people with a cardiovascular manifestation of hyperventilation were not subjected to any other disease. Some people are also likely to relapse due to stress.

Complications


A possible complication of hyperventilation is hypocapnia, also known as hypocarbia. It is caused by a decrease in alveolar and blood carbon dioxide (CO2) levels below the normal range of 35 mm Hg. It results in fainting and seizures. Other possible complications will depend on the cause of hyperventilation.

Alternative Treatments


  • One alternative treatment being studied, with not much evidence to support its use, is acupuncture therapy. It is documented that acupuncture affects emotional factors because it influences centres within the brain. Therefore, it may help in hyperventilation by reducing the anxiety part of the condition.

  • Another common alternative when breathing exercises don’t reduce your symptoms is breathing through a paper bag. Take 6 to 12 easy breaths with a paper bag (not a plastic bag) held over your mouth and nose. Then remove the bag and breathe normally. Next, try the belly breathing exercise mentioned above. Alternate between these techniques until your hyperventilation stops.


References. 

  1. Hyperventilation. John Hopkins. Available at: https://www.hopkinsmedicine.org/health/conditions-and-diseases/hyperventilation

  2. Hyperventilation. MedlinePlus. Available at: https://medlineplus.gov/ency/article/003071.htm

  3. T F Waites. Arch Intern Med. 1978;138(11):1700-1.

  4. Hyperventilation. UOFM. Available at: https://www.uofmhealth.org/health-library/hypvn#tp2736 

  5. Understanding Hyperventilation Syndrome. Saint Luke’s. Available at: https://www.saintlukeskc.org/health-library/understanding-hyperventilation-syndrome

  6. Hyperventilation Syndrome: MSD Manual. Available at: https://www.msdmanuals.com/en-in/professional/pulmonary-disorders/symptoms-of-pulmonary-disorders/hyperventilation-syndrome



  1. L  S  Vidotto, et al. J Bras Pneumol 2019;45(1):e20170347

  2. Andrew Robson. Breathe (Sheff) 2017;13(1):45-50.

  3. Hyperventilation Syndrome. Oxford Medicine Online. Available at: https://oxfordmedicine.com/view/10.1093/med/9780198703860.001.0001/med-9780198703860-chapter-29#med-9780198703860-chapter-29-div1-163

  4. Hypocarbia. NCBI. Available at: https://www.ncbi.nlm.nih.gov/books/NBK493167/

  5. Gibson, D., et al. The Journal of Alternative and Complementary Medicine. 2007;13(1):39-46.

  6. Winter, A. Journal of the American Medical  Association. 1951;147(10):990.

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