CLINICAL FEATURES

Hyperventilation:
a practical guide

Whats new ?
There is no consensus about the denition of the term
hyperventilation syndrome and its use should be
abandoned

William N Gardner

Management of hyperventilation involves treatment of

underlying psychiatric and organic disorders combined
with reassurance and explanation; breathing retraining
is seldom indicated and can be harmful

Definitions
The term hyperventilation is incorrectly applied by most physicians to a range of vague and imprecise clinical presentations. It
is often used in cases of breathlessness when no clear respiratory
disorder has been diagnosed, when the patient repeatedly reports
complaints that do not fit any precise diagnostic category, and when
there are abnormalities of respiratory pattern. Almost invariably, it
is used to imply that there is an ill-defined underlying psychiatric
cause for the symptoms. This is not necessarily correct.
The precise physiological definition of hyperventilation is
breathing in excess of metabolic requirements. It invariably implies
arterial hypocapnia (reduced arterial partial pressure of carbon
dioxide, PaCO2), which can be documented by arterial or end-tidal
measurements. Hyperventilation is a clinical finding and not a disease. It implies increased respiratory drive, which can have many
causes and is thus no different from other abnormal biochemical
measures for which the cause must be sought. The term hyperventilation syndrome was first used to describe patients with a
combination of organic and psychiatric symptoms, but has since
been used in so many different contexts that it has no universally
agreed meaning. In the authors opinion, it should not be used.

Respiratory disorders can stimulate breathing via vagal and

chest wall afferents. Mild asthma can reduce PaCO2 to one-half of
the resting level, as can chronic obstructive pulmonary disease,
fibrosing alveolitis, pulmonary hypertension, pulmonary embolism
and heart failure. Mild asthma may present only with attacks of
hyperventilation and tetany. It is not excluded by normal lung
function tests, but a childhood history of chestiness, a strong
family history, associated hay fever and low early-morning peak
flow are suggestive. Chest radiography may be normal in fibrosing
alveolitis and diagnosis may require high-resolution CT. Pulmonary
embolism, pulmonary hypertension and mild heart failure can be
difficult to diagnose when mild, and may be missed if the patient
is labelled with hyperventilation syndrome.
Pain is a potent cause of hyperventilation.
Pregnancy and the menstrual cycle resting PaCO2 is reduced in
pregnancy and during the second half of the menstrual cycle. This
probably contributes to the fact that hyperventilation is diagnosed
more often in women than in men.

Clinical features and diagnosis

Aetiology

Hypocapnia without symptoms has no immediate clinical relevance. Hypocapnia causes symptoms by two mechanisms.
Vasoconstriction of small blood vessels, particularly in the
brain and periphery, leads to various vague complaints such as
light-headedness and, in extreme cases, unilateral paralysis and
loss of consciousness.
Increased neuronal excitability causes paraesthesiae and, rarely,
tetany of the extremities.
Symptom questionnaires (e.g. the Nijmegen) contain many
non-specific symptoms and should not be used in isolation for
diagno-sis without the additional demonstration of hypocapnia.
Breathlessness is often quoted as a clinical feature of hyperventilation. The struggle to breathe can sometimes result in hypocapnia, but this is seldom sufficient to cause symptoms. Hypocapnia per se is not a cause of breathlessness. When a patient
presents with a primary complaint of breathlessness, this is the
condition for which a cause should be sought. Many patients complain of air hunger or a feeling that they cannot take a satisfying
breath. In the authors opinion, this is a separate syndrome that
often causes mild panic, which in turn can lead to symptomatic
hyperventilation. Air hunger is poorly described and difficult to
manage, but often responds to inhaled corticosteroids and/or
antidepressants.

The causes of hyperventilation are usually multifactorial and

complex. Often, several conditions that alone would not cause
significant hyperventilation combine to reduce PaCO2 to the level
at which symptoms occur (about 2.7 kPa), particularly in patients
with a constitutionally low resting PaCO2.
Psychiatric disorders can cause hyperventilation, but clinicians
should not automatically suggest a psychiatric cause this is unfair
to the patient, induces secondary anxiety, and hinders the search
for the true cause of the complaint. Diagnoses such as depression,
anxiety and panic disorder can usually be excluded by the general
physician by simple questioning, but more complex psychiatric
or psychological problems should be referred to a psychiatrist.
Even when present, psychiatric conditions may be secondary to
an underlying complaint (or the physicians attitude to the complaint) and may have no primary aetiological importance.

William N Gardner is Reader in Respiratory Medicine and Consultant

Chest Physician in the Department of Respiratory Medicine and Allergy at
Guys, Kings and St Thomas School of Medicine, London, UK.

MEDICINE

2003 The Medicine Publishing Company Ltd

INVESTIGATIONS

Misattribution of the symptoms of hypocapnia to a lifethreatening condition such as stroke or heart attack is a major
source of morbidity and presentation to casualty departments.
Admission to a coronary unit and failure to recognize the true
basis of the attack can lead to a vicious circle of increasing anxiety, further hyperventilation and invalidism. This vicious circle
is compounded by the tendency of patients to breathe deeply
when faced with unexplained symptoms, and by the tendency
of physicians to immediately label such patients with an anxiety state, particularly after repeated presentations. As a result, fit
young adults with only trivial disease may come to be regarded
as chronic thick-folder syndromes, and may become a lifetime
drain on medical resources.

Imaging in chest disease

Fergus V Gleeson

Imaging in chest disease may be performed:

to investigate symptoms (e.g. high temperature, cough)
to confirm or exclude suspected diagnoses (e.g. pulmonary
embolic disease, cancer)
in the further investigation of known diseases (e.g. diffuse lung
disease)
to monitor disease status (e.g. consolidation in pneumonia,
pleural effusion in empyema, mediastinal lymphadenopathy
in lung cancer).
A combination of different imaging modalities may be used to aid
diagnosis and follow-up.
Chest radiography remains the mainstay of imaging in the diagnosis and management of chest disease; 50% of all radiographs
taken are of the chest. It must be remembered that exposure of
patients to any form of ionizing radiation now requires justification under the new European Union Ionising Radiation (Medical
Exposure) Regulations, 2000. Adequate clinical details must be
written on the request card, and all radiology departments require
written protocols to allow examinations to be performed legally.

Management
Management of these patients requires a positive approach, clear
thinking and the application of good medical practice. It can be
undertaken by any physician, but a joint approach by a physician
and a psychiatrist is ideal.
The first stage is to take a careful history that disentangles
secondary factors from the primary initiating factors. The circumstances surrounding the first attack should be elucidated and
pointers to conditions such as mild asthma (particularly childhood
chestiness, hay fever and family history) should be noted. The
reaction of the doctor to whom the patient first presented, and
the patients beliefs about his or her symptoms, should be sought.
Elucidation of the initiating and sustaining factors is important
both for treatment and to educate patients about the basis of their
symptoms.
A full range of blood tests, chest radiography and lung function tests should be performed. Misattribution of the symptoms
to serious disease is often prevented only by further, specialized
investigations such as CT of the lung or brain, coronary angiography and ventilationperfusion scans. Such tests may reveal
unexpected disease. Any underlying organic condition should be
treated.
Patients should be reassured that hyperventilation, though
alarming, is seldom life-threatening. They should be instructed
not to take large breaths and to try to forget about their breathing. Relaxation training can be helpful. Breathing exercises are
justifiable only in rare cases involving mild panic, and there is no
scientific basis for attempts to alter the balance between diaphragm
and chest wall movements. Such training can often do more harm
than good, by focusing attention on breathing and causing undue
introspection.

Techniques in chest radiography

Projections: the two standard views are the erect postero-anterior
(PA) and lateral projections. Additional views such as apical,
oblique rib and decubitus are used less commonly than in the

Whats new ?
Picture archiving and communication systems are a
recent technological development enabling easy digital
lm storage and transmission
Multi-slice CT provides excellent contrast enhancement
and has revolutionized diagnosis of pulmonary embolic
disease
High-resolution CT has had a major impact on diagnosis
of diffuse lung disease

FURTHER READING
Folgering H. The hyperventilation syndrome. In: Altose M D,
Kawakami Y, eds. Control of breathing in health and disease.
New York: Dekker, 1999: 63360.
Gardner W N. Review: The pathophysiology of hyperventilation
disorders. Chest 1996; 109: 51634.

MEDICINE

Fergus V Gleeson is Consultant Radiologist at the Churchill Hospital,

Oxford, UK. He qualied from the Royal London Hospital, London, and
trained in radiology in Cambridge, London and Los Angeles, USA. His
special interest is thoracic radiology and his research interest is pleural
disease.

2003 The Medicine Publishing Company Ltd