Chest
Volume 109, Issue 2, February 1996, Pages 516-534
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The Pathophysiology of Hyperventilation Disorders

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PHYSIOLOGY

Hyperventilation is an abnormality of respiratory control and is defined as breathing in excess of metabolic requirements, ie, CO2 production. In subjects with normal lungs, PaCO2 is very close to alveolar PCO2 (PACO2), which in turn can be approximated by end-tidal PCO2 (PETCO2). Alveolar ventilation ( V˙A), CO2 production ( V˙co2), and PACO2 are linked through an equation with the general form of V˙co2α=V˙A*PACO2/ (barometric pressure-H2O vapor pressure), the graphic

SYMPTOMS

Hyperventilation is unlikely to be a problem to a patient unless it results in symptoms, and the way in which these symptoms are induced may hold the key to understanding why hyperventilation becomes a major problem for some patients. Painful tingling in the hands and feet, numbness and sweating of the hands, and cerebral symptoms following voluntary hyperventilation were first described by Haldane and Poulton.67 The first cases of spontaneous hyperventilation with dizziness and tingling

SIGNS

Signs are often unhelpful in detection of hyperventilation. While increase in chest wall movement and rate may be obvious in acute hyperventilation, in chronic hyperventilation this may not be so and resting PETCO2 can be halved with only about a 10% increase in minute ventilation as shown in Figure 1 for patients with chronic hyperventilation.31 Patients with hyperventilation often sigh repeatedly (see below), but even in acute hyperventilation as discussed above, dramatic sighing or panting

Measurement of PCO2

The gold standard for diagnosis of hyperventilation and respiratory alkalosis is measurement of arterial PCO2 and blood gas parameters. However, arterial puncture is invasive, may itself induce anxiety and hyperventilation, and will fail to diagnose patients with variable or transient hyperventilation. Alternative measures are less satisfactory.

End-Tidal PCO2: PETCO2127, 128 can be measured by capnograph or mass spectrometer from a small sample extracted continuously from a manifold through

ETIOLOGY

Factors that can induce hyperventilation will be discussed individually, although such a division is artificial and a number of factors often combine to induce symptomatic hypocapnia. These factors are shown in Figure 3 and can be classified as psychogenic, organic, and physiologic. It is useful to distinguish those that can initiate hyperventilation from those that sustain it.

HYPERVENTILATION-CLINICAL PRESENTATIONS

The clinical finding of a low arterial or PETCO2 will provide a diagnosis of hyperventilation, but this may not be associated with symptoms of hypocapnia, or such symptoms may be of minor importance compared with the symptoms of the disorder causing the hyperventilation. In these cases, a diagnosis of hyperventilation is of little clinical relevance. In other situations, the symptoms of hyperventilation are pivotal to the patient's clinical presentation. In our view, it is not clinically useful

CLINICAL MANAGEMENT

A positive clinical strategy with a stepwise approach to assessment is required. It is helpful to categorize patients according to the groupings described above, and simplistic labeling of patients as having hyperventilation syndrome should be avoided. These patients are very time consuming, and a detailed initial history and assessment with multiple follow-ups are usually required. In our experience, joint management by a chest physician and a liaison psychiatrist in a chest clinic offers the

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REFERENCES (221)

  • HornsveldH et al.

    Symptom reporting during voluntary hyperventilation and mental load: implications for diagnosing hyperventilation syndrome

    J Psychosom Res

    (1990)
  • RaffertyGF et al.

    Relation of hypocapnic symptoms to rate of fall of end-tidal PCO2 in normal subjects

    Respir Med

    (1992)
  • LewisT et al.

    Breathlessness in soldiers suffering from irritable heart

    BMJ

    (1916)
  • SoleyMH et al.

    The etiology of effort syndrome

    Am J Med Sci

    (1938)
  • GuttmannE et al.

    Hyperventilation and the effort syndrome

    BMJ

    (1940)
  • WoodP

    Da Costa's syndrome

    BMJ

    (1941)
  • WhitePD

    The soldier's irritable heart

    JAMA

    (1942)
  • KerrWJ et al.

    Physical phenomomena associated with anxiety states: the hyperventilation syndrome

    Cal West Med

    (1938)
  • LewisBI

    Chronic hyperventilation syndrome

    JAMA

    (1954)
  • AmesF

    The hyperventilation syndrome

    J Ment Sci

    (1955)
  • LewisBI

    Hyperventilation syndrome: a clinical and physiological evaluation

    Cal Med

    (1959)
  • HardonkHJ et al.

    Hyperventilation syndrome

  • MagarianGJ

    Hyperventilation syndromes: infrequently recognized common expressions of anxiety and stress

    Medicine

    (1982)
  • BrashearRE

    Hyperventilation syndrome

    Lung

    (1983)
  • LumLC

    Hyperventilation syndromes in medicine and psychiatry: a review

    J Soc Med

    (1987)
  • GardnerWN et al.

    Invited review: hyperventilation in clinical practice

    Br J Hosp Med

    (1989)
  • FriedR

    The psychology and physiology of breathing in behavioural medicine, clinical psychology, and psychiatry

    (1993)
  • LewisRA et al.

    Definition of the hyperventilation syndrome

    Bull Eur Physiopathol Respir

    (1986)
  • GardnerWN

    Hyperventilation disorders

    J R Soc Med

    (1990)
  • LewisBI

    The hyperventilation syndrome

    Ann Intern Med

    (1953)
  • BassC et al.

    Respiratory and psychiatric abnormalities in chronic symptomatic hyperventilation

    BMJ

    (1985)
  • LumLC

    The syndrome of habitual chronic hyperventilation

    Rec Adv Psychosom Med

    (1976)
  • StoopA et al.

    Hyperventilation syndrome: measurement of objective symptoms and subjective complaints

    Respiration

    (1986)
  • FolgeringH et al.

    Some anomalies in the control of PACO2 in patients with hyperventilation syndrome

    Bull Eur Physiopathol Respir

    (1978)
  • DentR et al.

    Does the hyperventilation syndrome exist [abstract]

    Thorax

    (1983)
  • CunninghamDJC et al.

    Integration of respiratory responses to changes in alveolar partial pressures of CO2 and O2 and in arterial pH

  • HowellJBL

    Behavioural breathlessness

    Thorax

    (1990)
  • LoeschckeHH

    Homoiostase des arteriellen CO2-drucks und anpassung der lungenventilation an den Stoffwechsel als leistungen eines regelsystems

    Klin Wochenschr

    (1960)
  • SaltzmanHA et al.

    Correlation of clinical and physiologic manifestations of sustained hyperventilation

    N Engl J Med

    (1963)
  • FahriLE

    Gas stores of the body

  • LepperEH et al.

    Variations in the pH and bicarbonate of the plasma and of the alveolar CO2 during forced breathing

    Biochem J

    (1927)
  • BrassfieldCR et al.

    A correlation of the pH of arterial blood and urine as affected by changes in pulmonary ventilation

    Am J Physiol

    (1941)
  • BrownEBJ

    Physiological effects of hyperventilation

    Physiol Rev

    (1953)
  • ArbusGS et al.

    Characterization and clinical application of the ‘significance band’ for acute respiratory alkalosis

    N Engl J Med

    (1969)
  • SiesjoBK et al.

    Invited review: a new theory for the regulation of the extracellular pH in the brain

    Scand J Clin Lab Invest

    (1969)
  • KrapfR et al.

    Chronic respiratory alkalosis: the effect of sustained hyperventilation on renal regulation of acid-base equilibrium

    N Engl J Med

    (1991)
  • GennariFJ et al.

    The nature of the renal adaptation to chronic hypocapnia

    J Clin Invest

    (1972)
  • SeveringhausJW et al.

    Respiratory control at high altitude suggesting active transport regulation of CSF pH

    J Appl Physiol

    (1963)
  • ForwandSA et al.

    Effect of acetazolamide on acute mountain sickness

    N Engl J Med

    (1968)
  • HoustonCS et al.

    Respiratory and circulatory changes during acclimatization to high altitude

    Am J Physiol

    (1947)
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