Introduction

Does the patient frequently feel short of air, in need of fresh air or feel a weight on the chest? Does the heart sometimes beat too fast or too fast, even at rest? Does he or she suffer from dry mouth? Does he or she feel strange sensations in the fingers, such as tingling, or tension in the muscles?

He may be hyperventilating…

Hyperventilation [2] affects 6 to 10% of the population. It affects both sexes, but more often women than men. It can occur in children, but is more common in people aged 15-55.

Hyperventilation syndrome is also known as tetany attacks or spasmophilia. Tetany is a syndrome of neuromuscular hyperexcitability resulting in muscular contractions most often in the extremities of the limbs (hands, feet) and more rarely in the face, sometimes accompanied by cramps, paresthesia (tingling) and tremors. Spasmophilia refers to attacks that combine muscular tetany and breathing difficulties (including hyperventilation).

What is hyperventilation?

Definition

According to Lewis and Howell, « Hyperventilation syndrome is a syndrome characterized by a variety of somatic symptoms induced by physiologically inappropriate hyperventilation and reproducible, in whole or in part, by voluntary hyperventilation » (Lewis, Howell, 1986).

Hyperventilation is characterized by an increase in breathing frequency and/or an increase in the amplitude of breathing movements.

Under the influence of stress or anxiety [3], breathing changes (faster rhythm and/or larger breathing movements). It exceeds the metabolic oxygen demand  and produces an excessive release of carbon dioxide. The subsequent decrease in carbon dioxide causes an alkalosis [4] (pH > 7.45) which in turn leads to a series of physiological changes including hypophosphatemia [5] and hypocalcemia [6] responsible for tetany attacks.

Hypocapnia [7] (PaCO₂ < 4.7mmol) may appear transiently during hyperventilation episodes or become chronic. Simple respiratory efforts, sighs or yawns, are sufficient to maintain it.

The symptoms

Hyperventilation manifests itself in many and varied symptoms:

• a feeling of running out of air (rarely related to exercise)
• chest tightness
• dry mouth
• heat or cold stroke
• a wetness of the hands
• heart palpitations (sometimes with significant arrhythmia)
• tingling, pins and needles or sleepy sensations in the extremities (feet, hands)
• ankylosis of the arms (numbness, stiffness)
• muscle cramps
• chest pain (sometimes mimicking angina [8]) or abdominal pain
• headaches
• a feeling of weakness and fatigue
• difficulties in concentrating
• dizziness, lightheadedness
• a feeling of losing consciousness (sometimes leading to syncope)
• irritability
• a depressive state
• anxiety, panic attacks, phobias
• insomnia, waking up at night (sometimes with a feeling of suffocation and/or profuse sweating)

These symptoms, themselves anxiety-provoking, can lead to anxiety and panic attacks. In some cases, their number and/or intensity are such that individuals feel as if they are going mad or fear they will die of a heart attack.

The diversity of symptoms leads hyperventilating individuals to consult different specialists such as pulmonologists, cardiologists and gastroenterologists, often on numerous occasions, before the diagnosis of hyperventilation is made.

Forms acute, sub-acute and chronic

Symptoms may occur in the form of attacks, but frequently become chronic.

The acute form

The acute form is uncommon.

The attacks are dramatic. Patients present with severe dyspnoea [9] sometimes accompanied by a feeling of suffocation, agitation, feelings of terror and panic, chest pain, paresthesias [10] peripheral (fingers) and perioral, rigidity of fingers or arms, syncope, etc.

The picture may suggest a life-threatening emergency (myocardial infarction, intoxication, epilepsy, diabetes), leading the family to call the emergency services. Although annoying, these hyperventilation attacks are considered benign.

The subacute form

The subacute form is much more common than the acute form.

Despite the disappearance of the initial cause of stress, in the absence of diagnosis and appropriate treatment, hyperventilation may continue, although less loudly. Usually, the sensation of suffocation changes to a feeling of running out of air and panic to anxiety. The discomfort, dyspnea, tingling, cramps, tachycardia, etc. become a source of worry. Patients worry about their symptoms and their health to the point that many of them are convinced that they have a serious illness. They enter a vicious circle in which their symptoms sustain their state of anxiety by becoming a worry and stress factor themselves.

The chronic form

The chronic form is the most frequent. This final stage of hyperventilation syndrome results from the perpetuation of the vicious circle of hyperventilation/stress/anxiety/anxiety. When the disorder has been present for several years, it is not uncommon for patients to have forgotten the original stressful event.

Chronic hyperventilation syndrome is difficult to diagnose because of the wide variety of possible clinical presentations. Generally, patients do not present spectacular symptoms. Their complaints are minor, imprecise and non-specific, such as fatigue or even exhaustion, unrelated to the effort made (similar to chronic fatigue syndrome). Dyspnea is not constant. It is expressed by a feeling of lack of air or by a sensation of respiratory blockage. It is accompanied by yawning, sighing and/or a slight shortness of breath when speaking, perceptible to an informed witness but rarely noticed by the subject himself. Chest pain, persistent irritative cough, heart palpitations and arrhythmia, headache and paresthesia are among the most commonly reported symptoms. Typically, patients complain of anxiety disorders (anxiety, panic disorder, phobias), depression and/or sleep disorders (insomnia, nightmares).

Screening for hyperventilation: the Nijmegen questionnaire

This questionnaire consists of 16 items scored 0 for « never occurs », 1 for « occurs rarely », 2 for « occurs sometimes » and 3 for « occurs often ».  A score of 23 or higher is indicative of a significant hyperventilation syndrome. Lower values may indicate mild hyperventilation.

• 1 Feeling of nervous tension
• 2 Inability to breathe deeply
• 3 Accelerated or slowed breathing
• 4 Short breaths
• 5 Palpitations
• 6 Coldness of the extremities
• 7 Dizziness
• 8 Anxiety
• 9 Tight chest
• 10 Chest pain
• 11 Visual blur
• 12 Tingling of the fingers
• 13 Ankylosis of arms and fingers
• 14 Feeling of confusion
• 15 Abdominal bloating
• 16 Perioral tingling

How to combat hyperventilation ?

Below we suggest four breathing methods that help people to recover their well-being: rebreathing [11] , straw breathing, apnea and relaxation based on abdominal breathing.

In the event of an acute attack, during the first episode, it is preferable to call on a doctor who can establish a differential diagnosis with a serious pathology. He or she may also administer a tranquilliser or sedative if deemed necessary. In the case of a chronic syndrome, it is essential to treat the mood or anxiety disorders that cause the hyperventilation.

Rebreathing

This technique should only be used in the event of an acute crisis. It involves breathing through the mouth into a paper or plastic bag, closed around the lips and nose. Hyperventilation is a breathing disorder characterized by a decrease in carbon dioxide. By breathing into a bag, the patient re-breathes in the carbon dioxide he or she has just exhaled and thus gradually restores his or her CO₂ level. It is not advisable to continue rebreathing for more than a few minutes, ten at the most. The bag should be removed as soon as the signs of hyperventilation disappear.

Rebreathing should be used with caution and only when hyperventilation is caused by stress or anxiety. Indeed, it can be dangerous if performed by or on a person with asthma whose symptoms are mistaken for hyperventilation. Similarly, a heart attack can be mistaken for hyperventilation. In both cases, the reduction in oxygen supply and increase in carbon dioxide can be fatal.

Straw breathing

Breathing through a straw works and is safe.

The patient should breathe in through the nose and out slowly through the mouth through an 8-to-10-centimetre straw. It is advisable not to tighten the lips on the straw and to breathe normally, without trying to deepen the breath. If the exercise is too difficult, the patient can use a shorter straw. If it is too easy, a longer straw can be used and/or the patient can blow into a glass of water.

Apnea

The technique for correcting hypocapnia is to slow down ventilation to artificially recover a normal capnia. In practice, the patient must inhale calmly, without deepening his breathing (which would increase the oxygen supply already too high in relation to the metabolic demand), then hold an apnea for 5 to 10 seconds, 3 times consecutively, every 20 minutes[12] , or even more if necessary. He should then exhale in a relaxed manner, without forcing (a deep exhalation would release a significant amount of CO₂  and counteract the effects of the apnea). Breathing in and out should be as normal as possible. At no time should the subject experience a sensation of suffocation that would cause him/her to take a deleterious breath. If 5 seconds provokes a respiratory thirst, he will adapt the duration of the apneas to his capacities and will limit them, for example, to 3 seconds.

Breathing-based relaxation

In hyperventilation syndrome, thoracic breathing is favoured over diaphragmatic breathing. It therefore seems logical that respiratory correction should involve re-educating abdominal breathing.

Here is an example of a relaxation session based on abdominal breathing:

« Sit comfortably [13]. Your legs are uncrossed. Your feet are flat on the floor. Place one hand on your stomach and the other on your chest. If you wish, you can close your eyes. If you prefer to keep them open, look at an object of your choice. Take a deep breath. Breathe in slowly through your nose, silently. As you breathe in, mentally count slowly to five. You feel the air entering you… You inhale very slowly, quietly, deeply… You feel your chest opening. You feel your chest opening up. Bend your torso, pull your shoulders back, straighten your head. Gradually inflate the lower ribs, the rib cage and the abdomen… Hold your breath for a few seconds… Now exhale slowly through your mouth. Let the air out of your body peacefully, calmly, at your own pace. Slowly count to five as you exhale… Your body relaxes. Your head and shoulders return to a natural position. Slowly empty your chest and belly. Breathe out quietly, letting a stream of air out of your mouth as if you were blowing through a straw. Notice how naturally your body relaxes. Continue to exhale for a few seconds. Finish this exhalation by emptying the belly by contracting the abdominal muscles. Take another deep breath in, now breathing through the belly. Breathe in gently through the nose. Pay attention to your hands. It is the belly that should rise, not your chest. Feel what is happening inside you. The air goes down into your belly. It inflates your belly. Your belly lifts. It pushes forward. You hold the air for a few seconds… You exhale slowly through your slightly ajar mouth. You empty the air completely by contracting your belly. Take another slow belly breath, through your nose, being attentive to what is happening in your body… You inflate your belly… You exhale slowly through your mouth. You feel calm… You feel good… You open your eyes slowly and come back here.

The inhalations and exhalations are deep but slow, which reduces the amount of oxygen taken in and carbon dioxide released.

Articles in the series

Josse E. (2020). Relaxation. https://www.resilience-psy.com/la-relaxation/

Josse E. (2020). Some techniques of self-hypnosis focused on external phenomena (for adults). http://www.resilience-psy.com/spip.php?article428

Josse E. (2020). Stress and anxiety hyperventilation syndrome. Cause, symptoms, screening and solutions.

Bibliography

Lewis R.A., Howell J.B. (1986). Definition of the hyperventilation syndrome. Bull Eur Physiopathol Respir 1986;22:201-5.

Prosper M. (2008). Hyperventilation syndrome. Rev Med Suisse 2008; volume 4. 2500-2505

van Dixhoorn J., Duivenvoorden H.J. (1985). Efficacy of Nijmegen questionnaire in recognition of the hyperventilation syndrome. J Psychosom Res 1985;29:199-206.

Evelyne Josse, 2020

Lecturer at the University of Lorraine (Metz). Psychologist, psychotherapist (EMDR, hypnosis, brief therapy), psychotraumatologist

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[1] Evelyne Josse specializes in psychotherapy of psychological trauma and grief. She teaches these topics at universities in Belgium and France (DU) and trains hypnotherapists in the treatment of traumatized and bereaved patients.

[2] Some authors prefer to speak of dysfunctional breathing rather than hyperventilation.

[3] Hyperventilation may be the physiological response to hypoxia, lung disease, central nervous system damage, metabolic acidosis, sepsis, some brain tumors, hyperthyroidism, altitude, fever, pain, etc. When faced with a hyperventilation syndrome, a differential diagnosis should be made in order to rule out a serious pathology.

[4] Alkalosis is an increase in blood pH.

[5] Hypophosphataemia is a decrease in plasma phosphates.

[6] Hypocalcaemia is a decrease in the level of calcium in the blood.

[7] A decrease in the concentration of carbon dioxide in the blood is called hypocapnia.

[8] Angina (constriction of the chest) or angina pectoris is the heart symptom of coronary heart disease.

[9] Respiratory discomfort

[10] Tingling, tingling, numbness.

[11] Term used in the Anglo-Saxon literature.

[12] The 20-minute period is given as a guide. In any case, the exercise should be carried out very frequently and regularly until the symptoms have completely disappeared.

[13] This type of relaxation can also be done lying on the back.