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• W3048019172 abstract "Hyperventilation syndrome is seldom considered as a diagnostic probability, but nevertheless, it is surprisingly common. By most estimates, this abnormality occurs as the primary or major contributing diagnosis in as many as 10% of all general medical patients1Jones M Harvey A Marton L O'Connell NE Breathing exercises for dysfunctional breathing/hyperventilation syndrome in adults.Cochrane Database Syst Rev. 2013; 5CD009041PubMed Google Scholar,2Magarian GJ Hyperventilation syndromes: infrequently recognized common expressions of anxiety and stress.Medicine. 1982; 61: 219-236Crossref PubMed Scopus (167) Google Scholar and up to 25% of all patients complaining primarily of “dizziness” or “fainting.”3Magarian GJ Middaugb DA Linz DH Hyperventilation syndrome: a diagnosis begging for recognition.West J Med. 1983; 138: 733-736PubMed Google Scholar My experience as a consultant over many years agrees with these estimates. Moreover, several years ago, together with a physician associate, I reviewed the outpatient records of a cohort of applicants referred to us by the US Social Security Administration for determination of long-term disability and found—surprisingly—that hyperventilation played a major role in disability in approximately 15% of such subjects, despite the fact that this diagnosis was rarely considered by the managing physicians. Failure to recognize this problem leads not only to much suffering but also to large and unnecessary financial costs to an already overburdened medical system. This point is best illustrated by the following hypothetical example synthesized from personal experience: A 42-year-old woman presents with 5-year history of recurrent “dizziness” (described more specifically as “lightheadedness”) often leading to reduced consciousness and sometimes culminating in fainting. Associated with these episodes are sensations of numbness and tingling in the arms and legs, especially over the left side of the body, chest pain, dryness of the mouth, alternating hot and cold bodily sensations, muscle spasms, and profound general weakness felt more prominently on her left side. She is uncertain about her breathing during the spells, but notes the frequent sensation of being unable to get a “deep breath” or air “cutting off” midway in her chest. Although these episodes could occur at any time, they would typically occur in the presence of large crowds, in warm church services, and with spells of anxiety. Unable to establish a diagnosis, her primary physician referred her to a neurologist, who, after a normal neurological examination and several tests that included a magnetic resonance imaging (MRI) of the brain, electroencephalogram (EEG), and Doppler study of the carotid arteries, told her that there was no neurological explanation for her symptoms. Because her symptoms included chest pain, she was then referred to a cardiologist, who, after a normal physical examination, proceeded with additional tests that included an electrocardiogram (ECG), ambulatory electrocardiograph (Holter) monitor, echocardiogram, and treadmill stress test, all of which disclosed normal findings. In the presence of anxiety and lacking objective physical abnormalities, she was referred to a psychiatrist, who concluded that her spells were a manifestation of “panic attacks,” which, according to the criteria listed in the current psychiatric handbook,4American Psychiatric AssociationDiagnostic and Statistical Manual of Mental Disorders.5th ed. American Psychiatric Association, Washington DC2013Crossref Google Scholar include, among others, the following features: “Trembling or shaking, sensations of shortness of breath or being smothered, feeling of choking, chest pain or discomfort, feeling dizzy, unsteady, lightheaded, or faint, chills or hot flashes, and paresthesias (numbness or tingling sensations), chills or hot flashes, and palpitations, and/or accelerated heart rate.” Although these manifestations are listed as inherent to the panic disorder itself, they also comprise the typical features of hyperventilation syndrome. But because the psychiatric handbook provided no reason to consider hyperventilation as a cause of any of these symptoms, the psychiatrist concluded that they were all solely as a result of the panic disorder. Reassuring her that physical maladies were absent, he then prescribed psychotropic drugs directed toward the control of anxiety. Despite these measures, the patient continued to have the spells, although partially diminished in frequency. How emotional stress can induce an excessive respiratory response is likely rooted in the evolutionary “flight-or-fight” reaction, wherein, in anticipation of imminent need for increased exertion combined with increased adrenergic drive, rapid respiration results. If increased exertion is not required, however, excessive and inappropriate breathing (hyperventilation) produces hypocapnia, respiratory alkalosis, and a complex array of physiologic changes5Gardner WN The pathophysiology of hyperventilation disorders.Chest. 1996; 109: 516-534Abstract Full Text Full Text PDF PubMed Scopus (219) Google Scholar that include widespread vasoconstriction (including cerebral) with increased neurogenic excitability, and they are likely responsible for most of the signs and symptoms as noted in the hypothetical example provided. These changes may even produce bronchoconstriction that may actually result in audible wheezing, augmenting the sensation of dyspnea as well as simulating or intensifying preexisting asthma.6Ferguson A Addington-Caensler E Dyspnea and bronchospasm from inappropriate post exercise hyperventilation.Ann Intern Med. 1969; 71: 1063-1072Crossref PubMed Scopus (31) Google Scholar Thus, because hyperventilation can complicate asthma, the clinician should consider both asthma and hyperventilation when encountering features of both conditions. Although frequently manifested in the form of acute attacks, hyperventilation may occur in a more chronic and insidious form.5Gardner WN The pathophysiology of hyperventilation disorders.Chest. 1996; 109: 516-534Abstract Full Text Full Text PDF PubMed Scopus (219) Google Scholar Such patients may present with unimpressive symptoms that may include atypical chest pain, fatigue, mild dyspnea, or exercise intolerance. Air hunger is common, hinting the possible presence of hyperventilation, and some have even suggested that this may be an important causative factor in chronic fatigue syndrome7Rosen SD King JC Wilkinson JB et al.Is chronic fatigue syndrome synonymous with effort syndrome.J R Soc Med. 1990; 83: 761-764Crossref PubMed Scopus (37) Google Scholar; however, this assumption requires further investigation. Patients in this latter category may be especially difficult to manage, possibly requiring such combined measures as breathing training, antidepressants, and cognitive behavioral therapy. The primary physician, observing the patient's demeanor during history taking, may have noticed cues revealed by her occasional sighs or deep breaths together with other possible overt manifestations of anxiety. If her complaints also include any features, alone or in combination, listed in the case description noted previously, this diagnosis should be considered. Acknowledging this possibility, the clinician then should instruct the patient to breathe as deeply and as rapidly as possible for at least 2 or 3 minutes, or until some discomfort appears that includes at least numbness and tingling or a sensation of dizziness.3Magarian GJ Middaugb DA Linz DH Hyperventilation syndrome: a diagnosis begging for recognition.West J Med. 1983; 138: 733-736PubMed Google Scholar,8Lum JR Hyperventilation syndromes in medicine and psychiatry: a review.J R Soc Med. 1987; 80: 229-231Crossref PubMed Google Scholar,9Han JN Steggen K Scepers R et al.Subjective symptoms and breathing pattern at rest and following hyperventilation in anxiety and somatoform disorders.J Psychosom Res. 1998; 45: 519-532Crossref PubMed Scopus (34) Google Scholar If the patient responds affirmatively when asked if these sensations are similar or identical to any of those accompanying the spells, then the diagnosis is confirmed or strongly suspected. Further confirmation can be accomplished by explanation of the effects of hyperventilation, together with how to control and suppress its symptoms by first triggering it by rapid breathing and then terminating it with breath-holding, which are maneuvers that should be practiced at home. Relieving symptoms through rebreathing into a paper bag has been suggested2Magarian GJ Hyperventilation syndromes: infrequently recognized common expressions of anxiety and stress.Medicine. 1982; 61: 219-236Crossref PubMed Scopus (167) Google Scholar,3Magarian GJ Middaugb DA Linz DH Hyperventilation syndrome: a diagnosis begging for recognition.West J Med. 1983; 138: 733-736PubMed Google Scholar but, in my opinion, is usually not required. The diagnosis is further confirmed if and when subsequent attacks are eliminated by these simple measures. I have noticed, however, that, in cases in which symptoms have been present for a long time, acceptance and control may be difficult, possibly owing to a deeply ingrained pattern of behavior or, in some cases, possibly to secondary gain from an attentive family or friends. Also, for uncertain reasons, the usual chest pain occurring during the attacks may not be reproduced promptly by the rapid breathing maneuver. A cardiac origin of such pain can usually be excluded by careful history taking and, when necessary, appropriate testing. In such cases, breath control or simple reassurance may be all that is required to minimize or eliminate pain and reduce superimposed anxiety. The diagnosis of panic disorder offers a special therapeutic opportunity: The fear and anxiety that initiate the panic response are often compounded by the unpleasant subjective complaints caused by the breathing disorder itself. This, in turn, further increases the fear and rapidity of ventilation, thus creating, in effect, a vicious cycle. By demonstrating the role played by the aggravating hyperventilation, the clinician can interrupt this feedback cycle sufficiently to ameliorate, or even eliminate, the panic response itself. To accomplish this objective, however, the clinician must suspect the likely superimposition of the breathing disorder on the panic state. First, it must be considered. Various commonly coexisting somatic complaints lacking objective confirmation10Tavel ME Somatic symptom disorders without known physical causes: one disease with many names?.Am J Med. 2015; 128: 1054-1058Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar,11Tavel ME Hyperventilation syndrome-hiding behind pseudonyms.Chest. 1990; 97: 1285-1288Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar may divert attention from the underlying breathing disturbance. The rapid breathing may be erroneously considered as “shortness of breath” in response to cardiac or pulmonary abnormalities. When dizziness and altered consciousness are combined with bodily sensations of numbness, paresthesias, and weakness, especially when they seem to involve predominantly one side of the body,12Tavel ME Hyperventilation syndrome and unilateral somatic symptoms.JAMA. 1964; 187: 301Crossref PubMed Scopus (9) Google Scholar neurological evaluation may be sought to consider focal disorders such as transient ischemic attacks (TIAs). Because the diagnosis of hyperventilation syndrome is not subject to the usual laboratory or imaging means, a simple office procedure of forced breathing, as described, runs counter to convention and has been challenged by some5Gardner WN The pathophysiology of hyperventilation disorders.Chest. 1996; 109: 516-534Abstract Full Text Full Text PDF PubMed Scopus (219) Google Scholar that require complex pulmonary studies that include end-tidal or arterial partial pressure of carbon dioxide (PCO2) levels. But the simple breathing maneuver provides the simplest and most direct way to determine whether hyperventilation is producing some or all of the various symptoms.3Magarian GJ Middaugb DA Linz DH Hyperventilation syndrome: a diagnosis begging for recognition.West J Med. 1983; 138: 733-736PubMed Google Scholar,8Lum JR Hyperventilation syndromes in medicine and psychiatry: a review.J R Soc Med. 1987; 80: 229-231Crossref PubMed Google Scholar,13Hornsveld HK Garssen B Dop MJ et al.Double-blind placebo-controlled study of the hyperventilation provocation test and the validity of the hyperventilation syndrome.Lancet. 1996; 348: 154-158Abstract Full Text Full Text PDF PubMed Scopus (118) Google Scholar A wide variety of patients manifest features that strongly suggest the presence—or contributory role—of hyperventilation, but this diagnosis is seldom considered. Thus, provocative testing is seldom, if ever, performed, and accurate diagnosis is never established. Physicians managing large general medical populations would be well advised to consider this diagnosis far more frequently. Various specialty groups would also benefit from such awareness. The results could be gratifying to both patients and clinicians alike!" @default.
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• W3048019172 title "Hyperventilation Syndrome: Why Is It Regularly Overlooked?" @default.
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