What is hyperventilation

Hyperventilation is rapid and deep breathing. Hyperventilation is also called overbreathing, and it may leave you feeling breathless.

You breathe in oxygen and breathe out carbon dioxide. Excessive breathing creates a low level of carbon dioxide in your blood. This causes many of the symptoms of hyperventilation. Respiratory alkalosis is a condition marked by a low level of carbon dioxide (CO2) in the blood due to hyperventilation.

You may hyperventilate from an emotional cause such as during a panic attack. Or, it can be due to a medical problem, such as bleeding or infection.

Your health care provider will determine the cause of your hyperventilation. Rapid breathing may be a medical emergency and you need to get treated, unless you have had this before and your doctor has told you that you can treat it on your own.

If you frequently overbreathe, you may have a medical problem called hyperventilation syndrome.

When you’re overbreathing, you might not be aware you’re breathing fast and deep. But you’ll likely be aware of the other symptoms, including:

• Feeling lightheaded, dizzy, weak, or not able to think straight
• Feeling as if you can’t catch your breath
• Chest pain or fast and pounding heartbeat
• Belching or bloating
• Dry mouth
• Muscle spasms in the hands and feet
• Numbness and tingling in the arms or around the mouth
• Problems sleeping

Treatment is aimed at the condition that causes hyperventilation. Breathing into a paper bag — or using a mask that causes you to re-breathe carbon dioxide — sometimes helps reduce symptoms when anxiety is the main cause of hyperventilation.

Can you die from hyperventilation?

That depends on what is causing your hyperventilation. If your hyperventilation is caused by stress, panic or anxiety, the short answer is no. Seizures may occur if hyperventilation is extremely severe ¹. This is very rare. On the other hand, if your hyperventilation is caused by bleeding, heart problem, lung disease, diabetic ketoacidosis, infection, sepsis or drugs overdose, then the answer is yes, you can die from hyperventilation.

Hyperventilation causes

Emotional causes include:

• Anxiety and nervousness
• Panic attack
• Situations where there is a psychological advantage in having a sudden, dramatic illness (for example, somatization disorder)
• Stress

Medical causes include:

• Bleeding
• Heart problem such as heart failure or heart attack
• Drugs (such as an aspirin overdose)
• Infection such as pneumonia or sepsis
• Ketoacidosis and similar medical conditions
• Lung disease such as asthma, chronic obstructive pulmonary disease (COPD), or pulmonary embolism
• Pregnancy
• Severe pain
• Stimulant

Hyperventilation symptoms

When you’re hyperventilate, you might not be aware you’re breathing fast and deep. But you’ll likely be aware of the other symptoms, including:

• Feeling lightheaded, dizzy, weak, or not able to think straight
• Feeling as if you can’t catch your breath
• Chest pain or fast and pounding heartbeat
• Belching or bloating
• Dry mouth
• Muscle spasms in the hands and feet
• Numbness and tingling in the arms or around the mouth
• Problems sleeping or sleep disturbances
• Blurred vision
• Weakness
• Fatigue

Psychiatric

• Anxiety, depression, phobias, feeling far away, sensations of unreality

Neurologic

• Paresthesias in extremities or periorally, lightheadedness, dizziness, disorientation, impaired thinking, seizures, syncope, headaches

Cardiologic

• Palpitations (fast heart beat), chest pain

Respiratory

Dyspnea (shortness of breath or air hunger) often without provocation characterized as being unable to take a satisfying deep inspiration, exaggerated thoracic breathing, sighing, yawning

Gastrointestinal

• Dry mouth, bloating, belching, flatulence

Muscular

• Cramping, spasm, musculoskeletal chest wall pain (chest wall syndrome)

Hyperventilation test

Your doctor will perform a physical exam and ask about your symptoms.

Your breathing will also be checked. If you are not breathing quickly at the time, the provider may try to cause hyperventilation by telling you to breathe in a certain way. The provider will then watch how you breathe and check which muscles you’re using to breathe.

Tests that may be ordered include:

• Arterial blood gas, which measures oxygen and carbon dioxide levels in your blood
• Chest CT scan
• ECG to check your heart
• Ventilation/perfusion scan of your lungs to measure breathing and lung circulation
• X-rays of your chest

Hyperventilation treatment

Your doctor will examine you for other causes of your hyperventilation.

If your doctor has said your hyperventilation is due to anxiety, stress, or panic, there are steps you can take at home. You, your friends, and family can learn techniques to stop it from happening and prevent future attacks.

If you start hyperventilating, the goal is to raise the carbon dioxide level in your blood. This will end most of your symptoms. Ways to do this include:

• Get reassurance from a friend or family member to help relax your breathing. Words like “you are doing fine,” “you are not having a heart attack,” and “you are not going to die” are very helpful. It’s very important that the person stays calm and uses a soft, relaxed tone.
• To help get rid of carbon dioxide, learn to do pursed lip breathing. This is done by puckering your lips as if you’re blowing out a candle, then breathing out slowly through your lips.

Over the long term, measures to help you stop hyperventilation include:

• If you have been diagnosed with anxiety or panic, see a mental health professional to help you understand and treat your condition.
• Learn breathing exercises that help you relax and breathe from your diaphragm and abdomen, rather than from your chest wall.
• Practice relaxation techniques, such as progressive muscle relaxation or meditation.
• Exercise regularly.

If these methods alone don’t prevent hyperventilation, your doctor may recommend medicine.

What is Hyperventilation syndrome

Hyperventilation syndrome is defined as breathing in excess of that required to maintain normal blood PaO2 and PaCO2 ². Hyperventilation syndrome may occur in relatively young patients under a stressful condition ³. Hyperventilation syndrome is usually considered to be benign; however, hyperventilation and subsequent respiratory alkalosis may provoke severe complications such as myocardial infarction and death ⁴. The symptoms of hyperventilation syndrome are dyspnea (shortness of breath or air hunger), carpo-pedal muscle spasm related to tetany, numbness of the extremities, tachycardia, palpitation, dizziness, headache, paresthesis, syncope and unconsciousness etc ⁵. Hyperventilation syndrome tends to be presented in aged between 15 and 55, occurs predominantly in women and sometimes have a history of psychosis ⁵.

In the face of acute hyperventilation syndrome, the clinician should exclude neurological or non-neurological organic cause including lesions in the pons or midbrain tegmentum, liver disease, cardiac disease and epileptic seizures ⁶. The neurologic manifestation of hyperventilation syndrome, such as “disorientation and twitching”, can be clinically misdiagnosed as epileptic seizures. Occasionally, complex partial seizure (arising particularly from insular cortex) may involve hyperventilation as part of aura, although this is usually accompanied by automatism and other obvious signs of seizure ⁶.

Hyperventilation is a well-established procedure for seizure provocation during performance of EEG, and the American EEG society ⁷, International League Against Epilepsy ⁸ and National Institute for Health and Clinical Excellence ⁹ all recommend that hyperventilation need to be performed as part of a standard EEG. It have been well known that many forms of epileptic seizures can be provoked by voluntary hyperventilation, especially effective in generalized epilepsies ¹. A large-scaled study reported that 3-Hz generalized spike and waves were provoked by hyperventilation in 88% of 234 patients with childhood absence epilepsy ¹⁰. On the other hand, it is not clear whether hyperventilation can activate the partial seizures. In recent published cases of seizures, the incidence of partial seizures during hyperventilation was more variable; with a range from none in 159 patients ¹¹ up to 24.7% of 97 patients ¹².

Hyperventilation syndrome causes

Although hyperventilation may have organic or physiologic causes, the hyperventilation syndrome is usually associated with emotional triggers and thoracic breathing tendency ¹³. Many people who are anxiety-laden, stressed or depressed have hyperventilatory breathing patterns and complain of their inability to obtain satisfying deep breaths. Anxiety, anger and other emotions produce increases in both rate and depth of respirations probably mediated by a hyperadrenergic state ¹³. Once hyperventilation is initiated, persisting stresses of everyday living or the stresses of new bothersome symptoms from hyperventilation create the potential for a self-perpetuating cycle of chronic hyperventilation.

Persons who hyperventilate more commonly exhibit obsessional behavior, excessive body consciousness, phobias, feelings of inadequacy and maladjustments in many stages of life. Lum ¹⁴ believes that an exaggerated tendency to breathe using chestwall musculature is an important factor allowing for the development and once developed, the persistence of the hyperventilation syndrome.

Hyperventilation syndrome signs and symptoms

Common signs and symptoms of acute hyperventilation syndrome include ⁵:

• Feeling lightheaded, dizzy, weak, or not able to think straight
• Feeling as if you can’t catch your breath
• Chest pain or fast and pounding heartbeat
• Belching or bloating
• Dry mouth
• Muscle spasms in the hands and feet
• Numbness and tingling in the arms or around the mouth
• Problems sleeping or sleep disturbances
• Blurred vision
• Weakness
• Fatigue

Psychiatric

• Anxiety, depression, phobias, feeling far away, sensations of unreality
• Deja-vu or hallucination, have been rarely reported ¹⁵.

Neurologic

• Paresthesias in extremities or periorally, lightheadedness, dizziness, disorientation, impaired thinking, seizures, syncope, headaches
• Acute hyperventilation syndrome not only can be clinically misdiagnosed as epileptic seizures, but also complex partial seizures may involve hyperventilation as a part of aura ¹⁶.

Cardiologic

• Palpitations (fast heart beat), chest pain

Respiratory

Dyspnea (shortness of breath or air hunger) often without provocation characterized as being unable to take a satisfying deep inspiration, exaggerated thoracic breathing, sighing, yawning

Gastrointestinal

• Dry mouth, bloating, belching, flatulence

Muscular

• Cramping, spasm, musculoskeletal chest wall pain (chest wall syndrome)

The hyperventilation syndrome may be associated with a myriad of symptoms, affecting both men and women equally. The most frequent complaints for which medical attention is sought are lightheadedness or dizziness, dyspnea and chest pain. Substantial weakness, exercise intolerance, fatigue and peripheral or perioral numbness and tingling, occurring in isolation or in concert with other hyperventilatory symptoms, are almost always present. Many patients have multiple other complaints. When symptoms are taken in isolation, the syndrome is often not considered. However, when taken together, the entire symptom complex often makes the diagnosis rather obvious.

The dizziness of hyperventilation may be described as lightheadedness or an unsteady, giddy feeling, similar to drunkenness or vertigo. In one review of 104 patients who presented to a specialty clinic for the evaluation of dizziness, 23 percent had hyperventilation as the sole or prominent contributing factor. There may also be some degree of disorientation and mental impairment ¹³.

Breathlessness is a common complaint and is usually described as the inability to inhale a satisfyingly deep breath or the feeling of difficult or uncomfortable breathing. It may be manifested by periodic, predominantly thoracic deep breaths, sighing and yawning. Sighing dyspnea is not a manifestation of cardiac failure. Although the hyperventilation syndrome rarely is associated with an obvious increase in respiratory rate, astute observers usually will note an increase in thoracic
respiratory efforts. Paradoxically, whereas many people take deep breaths in an effort to relax, they may be provoking the very state they wish to avoid. The dyspnea of hyperventilation syndrome may arise from fatigued respiratory muscles, overworked from chronic, excessive respiratory efforts. Since this type of dyspnea rarely occurs in the absence of other related symptoms, it is important that other manifestations of the hyperventilation syndrome be sought in all cases of otherwise unexplained dyspnea.

Gastrointestinal manifestations include dry mouth, bloating, belching and flatulence, related to aerophagia associated with overbreathing. Depression with attendant anorexia and weight loss may mimic systemic disease.

Cardiovascular symptoms of the syndrome are primarily palpitations and chest pain, which may mimic angina. Continuous ambulatory electrocardiographic monitoring of hyperventilators has shown frequent sinus tachycardia and supraventricular arrhythmias, even during sleep. Hyperventilatory symptoms without
apparent provocation may occur during these times.

The chest pain of hyperventilation is variably described. It may be sharp and stabbing, thought to be related to pressure on the diaphragm from gastric distention or diaphragmatic hypertonicity related to a generalized hypertonic muscular contractile state. Other types of chest pain have features that may strongly suggest angina including location and radiation patterns. The pain may be described as dull, gnawing, burning or constricting and localized to the precordial or retrosternal area but is often rather diffuse and of greater duration than is typical of angina pectoris. It is not predictably associated with events that usually provoke angina, frequently occurring at rest or after exertion, and is not reliably relieved by nitroglycerin. Occasionally, “pseudoischemic” electrocardiographic patterns may be seen in patients with chest pain from hyperventilation. It currently remains uncertain whether hyperventilation-induced coronary vasospasm and myocardial ischemia contribute to the chest pain associated with the hyperventilation syndrome. Unfortunately, a diagnosis of noncardiac chest pain, while initially gratifying, usually does not result in a significant reduction in outpatient clinic or emergency room visits as symptoms often persist. Therefore, in evaluating chest pain, the historical data base should include questions directed toward the possibility of hyperventilation lest the etiologic basis of the chest pain be dismissed as noncardiac, yet unrecognized as hyperventilatory.

Other symptoms of hyperventilation are usually present but rarely offered voluntarily. Apart from other disorders the patient may have, the physical examination is often normal. Patients often do not appear overtly anxious though they are frequently depressed. Obvious hyperventilation is usually lacking although occasional deep breaths, sighing or yawning and palpable chest wall tenderness may be noted. The diagnosis of chest wall syndrome requires exclusion of the hyperventilation syndrome which may be its basis.

It is critical to recognize that the presence of hyperventilation syndrome does not exclude the presence of an organic disease. In fact, reaction to the symptoms of an organic disease may be a prime factor provoking hyperventilation.

Chronic hyperventilation syndrome treatment

As many patients with hyperventilation syndrome have had symptoms for months or years and have seen other physicians without appreciating the cause of their symptoms, it is important that the patient be confronted with the cause-and-effect relationship between hyperventilation and their symptoms. A hyperventilatory trial is crucial for therapeutic success. This can be accomplished by having the patient breathe deeply at a rate of 30 to 40 times per minute. Most patients with the hyperventilation syndrome will recognize at least some of their symptoms within several minutes and often in seconds. This recognition and subsequent explanation of hyperventilation greatly enhances the potential for improvement. An explanation and reassurance without the patient actually experiencing the cause-and-effect relationship of overbreathing at the time is often without therapeutic benefit.

After provocation of symptoms during a hyperventilatory trial, breathing into a lunch bag-sized brown paper bag will result in resolution of those symptoms that are directly related to hypocapnea. Dyspnea and chest pain, however, may persist in that they are not caused by hypocapnea, but more likely by the excessive use of thoracic musculature.

Because many patients have experienced substantial adverse effects on their employment and social interactions it is beneficial for a spouse or a friend to be present during a hyperventilation trial. Family and friends may be highly skeptical that something as simple as overbreathing can be having such devastating effects on the patient and indirectly upon them as well. Convincing both the patient and others provides support for the patient as he or she attempts to regain control.

Although some believe bag rebreathing is of little value, some experts have found it to be useful, allowing patients an escape from symptoms. Initially, encourage patients to attempt bag rebreathing, relax and get away from the situation that may have triggered the response. As a result, patients appreciate a newfound control. This greatly reduces the anxiety and stress that fuel the hyperventilation cycle.

Long-term control may be achieved by relaxation therapy and retraining patients to become diaphragmatic rather than thoracic breathers. Referral to behavior modification experts may be of value in particularly difficult patients with long-standing symptoms. In anxious and depressed persons with chronic  hyperventilation syndrome have rarely seen substantial benefit from the use of anxiolytic or antidepressant medications when the hyperventilatory component was unrecognized or being inadequately addressed. In conjunction with therapeutic measures directed toward the hyperventilatory tendency these drugs may be of additional benefit though experts often find them unnecessary.

Anxiety is the main cause of hyperventilation syndrome. Thus, benzodiazepines including midazolam or diazepam are used as the first choice drug for the treatment of hyperventilation syndrome ². Tomioka et al ¹⁷ have previously reported three cases with hyperventilation syndrome in dentistry that were improved or prevented by the administration of a beta-adrenergic blocker, because hyperventilation syndrome reflects the enhancement of sympathoadrenal tone ¹⁸.

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