Journal of the Royal Society of Medicine Volume 80 April 1987 229

Hyperventilation syndromes in medicine and psychiatry: a review

L C Lum FRCP FRACP Formerly Consultant Chest Physician, Papworth Hospital, Cambridge

Keywords: hyperventilation syndromes, chest pain, phobic disorders

In 1940 Lewis' described DaCosta's syndrome (a prototype of hyperventilation syndromes. Nixon

frequent presentation of hyperventilation) as 'one and Freeman and their associates have produced a
of the commonest afflictions of sedentary town valuable series of papers on the relationship between
dwellers'. In this issue of the JRSM(p. 216), the paper hyperventilation, chest pain, and ischaemia, empha-
'Role of the nurse counsellor in managing patients sizing the importance of breathing control in treat-
with the hyperventilation syndrome' prompts a ment 16"7, and also observed that the ventilatory
review of recent advances in this field. response of hyperventilators to emotional stimuli
The 1980s have seen a remarkable upsurge of was three times as great as controls"8.
interest in the role of hyperventilation in functional
illness, anxiety disorder, panic and phobic states2-4. Diagnosis
In a previous review5 the author traced the changing Symptomatology alone, however suggestive, is insuf-
concepts over the last 50 years, from the early realiz- ficient for diagnosis. Patients may fail to identify
ation6 that overbreathing was the physiological their (often bizarre) symptoms with descriptions in
mechanism whereby anxiety produces somatic dis- questionnaires. Sensations produced by direct hypo-
turbance, to the later view7 that anxiety disorders carbic stimulation of cortical neurones do not have a
arose from the persistence of symptoms due to counterpart in everyday experience. Often symptoms
unrecognized hyperventilation. Yet, even in 1982, a (e.g. paraesthesiae) which are denied on direct
Lancet editorial8 commented on how rarely this questioning, are recognized when produced during
diagnosis was even considered. Snaith9, reviewing voluntary overbreathing. The latter test is essential.
panic disorder, failed to mention it. Reproduction, on voluntary overbreathing, of
In England, with few exceptions, hyperventilation sufficient symptoms for the patient to identify with
was generally ignored'0, but the Third International spontaneous symptoms, has always been the touch-
Workshop on Respiratory Psychopathology held in stone of diagnosis. Recommended rates of enforced
Bordeaux in 1983 exposed English clinicians to the breathing have varied from 18-20 per minute6"19 to
work of those who, particularly in Germany, the 60-70 per minute20. Beumer and Hardonk20 advocate
Netherlands and France, had been active in the field a standardized procedure of three minutes breathing
for more than a decade. The resulting 1984 symposium at 60 respirations per minute, and require that the
at Southampton attempted a consensus definition end-tidal Pco2 measured at three minutes post-
of symptomatology and diagnostic criteria". This hyperventilation should remain below 66% of the
was flawed by a widespread unfamiliarity with the resting value.
subject, and a general lack of appreciation that This last procedure, useful as a standard in research
overbreathing can occur during apparently normal units, is unnecessary in clinical practice. For a work-
respiration. ing clinical diagnosis, the literature and personal
Overbreathing, in chronic hyperventilation, is experience suggest that the rate is immaterial, pro-
rarely grossly visible2. When a 'normal' respiration vided that deep breathing at a rate comfortable for
rate (e.g. 16-17) is coupled with a modest but the patient is sustained for about three minutes. A
imperceptible increase oftidal volume (e.g. to 750 ml/ single deep breath lowers the Pco2 by 7-16 mmHg and
minute), substantial overbreathing occurs. More- maximal lowering occurs in 60 seconds6; 7-8 deep
over, once it is established, an occasional, imper- breaths at a normal rate can lower the Pco2 by
ceptible deep breath will keep the Pco2 low'2"3. about 50%21. Prolonged, meticulous auscultation
From the earliest clinical accounts'4, disordered of the chest, with deep breaths through the mouth,
breathing (rapid, thoracic respirations with marked effectively but unobtrusively lowers the Pco2 to
changes in rate and rhythm, and frequent sighing) symptomatic levels. Deep breathing can be continued
has been noted as the hallmark of hyperventilation. if necessary for a further period while the pulse and
On the other hand, respiratory alkalosis alone can- heart rate are monitored.
not fully explain the symptomatology2. However, in Symptoms of cerebral vasoconstriction and
1963's and in an unpublished lecture delivered in hypoxia (i.e. dizziness, unsteadiness, blurred vision)
1976, Wyke emphasized the all-pervasive effects of commonly start within 20-30 seconds, especially if
changes in arterial carbon dioxide on nervous system the standing position is adopted. Paraesthesiae
function. This led to the concept that symptoms arise, are often slower, reflecting a different mechanism.
not so much from chronic hypocarbia, but from rapid Chest pains are produced in only 50% following the 0141-0768/87/
changes in arterial carbon dioxide (fluctuating hypo- customary three minutes overbreathing22. Although 040229-03/$02.00/0
carbia) produced by the unstable breathing pattern. persistence to 20 minutes almost invariably produces i 1987
This now provides a sound neurophysiological basis them, the possibility of dysrhythmias23 or even The Royal
for the great majority of clinical findings. ischaemia" is a potent deterrent. Society of
DaCosta's syndrome has figured prominently as a It is an everyday observation that antecedent Medicine
230 Journal of the Royal Society of Medicine Volume 80 April 1987

anxiety clearly predisposes to symptom production, In the overall picture, however, true ischaemic
e.g. in panic attacks. Allen and Agus'9 reproduced pain should rarely confuse. The most usual cause is
hallucinations by a preliminary slow hyperventi- spasm and strain in the muscles and joints of the
lation for 10 minutes, followed by more vigorous precordium6. Firm digital pressure usually identifies
overbreathing. exquisitely tender spots. While in acute coronary dis-
Bass and Gardner24 have taken the extreme view ease it is prudent to err on the side of overdiagnosis,
that the diagnosis of hyperventilation requires the there is good reason not to do so with chronic chest
Paco2 on repeated measurements to be below an pain syndromes. Here the risk of sudden death is
arbitrary value of 30 mmHg. This, however, ignores low, not easily prevented, and erroneous diagnosis
the fact that hyperventilation is commonly episodic, can readily evoke disabling neurotic illness, more
rather than continuous2, and overlooks the funda- grievous than the disease34. Associated muscle pains,
mental role of carbon dioxide in acid base particularly in the pectorals, shoulder girdle and
homoeostasis. The Henderson-Hesselbalch equation: neck, are very common, invariably exhibiting tender
trigger spots.
pH = pK + log [HCO3-J
[C02] Air hunger: Breathlessness per se is not common30,
shows that any fall in Pco2 from the resting or steady but air hunger - a need to take a deep, satisfying
state value produces an immediate rise in pH (i.e. breath, accompanied by a feeling of difficulty in
respiratory alkalosis), and its sequelae. Their analogy inflating the lungs - is both common and highly
with diabetes is ill-chosen: experienced clinicians will suggestive. It is due to the characteristic over-
know that hypoglycaemic symptoms can occur at inflation of the chest.
normal blood sugar levels, following a fall from In the normal breathing range (35-45% of the vital
higher values. As in episodic hypocarbia, it is the capacity), inspiration is aided by recoil ofthe rib cage
metabolic change that matters. Theirs, however, is towards its position of rest (45% VC). Inflation of the
very much a minority viewpoint, based on a small chest above this volume is opposed by the elastic
recorded experience. It would exclude 75-80% of forces in the rib cage35. It demands extra effort,
clinical cases23. Any physician will of course be which is interpreted as inspiratory difficulty, evoking
mindful of thyrotoxicosis and asthma, but the pro- a desire for even larger breaths. This is readily
liferation of investigations, in the relentless pursuit appreciated by trying to breathe with the upper
of remote possibilities, is to be deplored. One views chest, while holding the thorax semi-inflated.
with alarm their recommendation that the diagnosis
also requires histamine challenge to exclude bron- Dizziness or unsteadiness: These are among the
chial hyperreactivity, given that this would apply to commonest symptoms. Of 104 patients investigated
6-10% of the outpatient population7'25 - 27. Bass et at a dizziness clinic, hyperventilation accounted
al.28, in a series of 46 patients with chest pain but for 24%, while vascular disease (the usual suspect)
normal coronary arteries, reported a persisting accounted for only 4%36. Disturbed mentation, poor
morbidity in 63% at one year, while only 7% lost their memory and depersonalization are very frequent.
pain. By contrast 76% of similar cases, who had their
breathing treated, were asymptomatic at one year and Symptoms related to sympathetic dominance: These
remained completely symptom-free at 6-11 years29. include tachycardia, dysrhythmias, dry throat,
The whole weight of the literature, however, is in swallowing difficulty, tremors, emotional sweating,
agreement with Magarian2: 'the diagnosis does not and bloating.
require arterial blood gas determinations, but rather
the constellation ofsymptoms with their provocation Panic disorder and phobic states
by a controlled trial of hyperventilation.' These are common psychic manifestations37, but
Allen and Agus 9 have shown that all the components
Mechanisms of symptom production of 'schizophrenic reaction, acute undifferentiated
Chestpains: These are reported by general physicians type' (DSM III), including hallucinations, can be pro-
in about 40-50% of cases, though not necessarily as duced by hyperventilation. The author has recorded
the presenting symptom26'30; cardiologists report hallucinations in 21 patients.
more27. The author finds an overall incidence of 45% Ley4 identified the symptoms of 'panic disorder'
in GP referrals, but it is a prime complaint in less than and 'generalized anxiety disorder' with those of
half of these. A sharp lancinating pain, lasting from hyperventilation, and stated that 'the panic attack
seconds to a few minutes, is attributed to a forceful consists of a synergistic interaction between hyper-
hyperadrenergic heartbeat striking the sensitized ventilation and fear'. Similarly with agoraphobics,
precordium. Dull aching (left precordial or sub- the symptoms of hypocapnoeaprecede the experience
sternal and persisting for hours or days) arises in the offear. Garssen et al.3 found that 60% of agoraphobes
intercostal muscles31 and in the strained muscles and hyperventilated, and 60% of hyperventilators were
ligaments in the anterior chest, due to excessive agoraphobic. Gorman et al.38 studying lactate-
upper thoracic movement32. induced panic attacks, demonstrated a precipitous
True myocardial pain may occur. Coronary spasm drop in Pco2 at the point ofpanic. This occurred only
has in recent years been increasingly implicated, in those who panicked. Salkovskis et al.39 recorded
and is compounded by decreased oxygen yield to the substantial falls in Paco2 during panic attacks in a
tissues due to a leftward shift in the oxyhaemoglobin patient undergoing renal dialysis.
dissociation curve. 'Catecholamine myopathy' has Among 701 cases of chronic hyperventilation
also been described"7. Hyperventilation pain may recently studied, panic attacks and phobic avoidance
colour the picture in 57% of cases of true coronary were the principal complaints in 344 (49%) (Lum, in
artery disease, and is the sole cause in 60% of cases preparation). Bonn et al.40 found that breathing re-
with normal arteries33. education in agoraphobics, when combined with
 Journal of the Royal Society of Medicine Volume 80 April 1987 231

standard behavioural techniques, was so clearly in patients considered to have the hyperventilation
superior to the latter alone that they did not feel it syndrome. JR Soc Med 1986;79:76-83
ethically justifiable to withhold this treatment from 19 Allen TE, Agus B. (1968) Hyperventilation leading to
patients solely for academic research. hallucinations. Am JPsychiatry 1968;125:632-7
20 Beumer HJ, Hardonk HM. Hyperventilation syndrome.
Handbook of Clinical Neurology 1979;38:309-60
Allergies 21 Lum LC. Physiological considerations in the treatment
The incidence of allergic manifestations in hyper- of hyperventilation syndromes. Journal of Drug
ventilators is high4" and is related to the known Research 1983;8:1867-72
22 Evans DWE, Lum LC. Hyperventilation: an important
increase in histamine production provoked by hyper- cause of pseudo-angina. Lancet 1977;ii:155-7
ventilation", presumably due to destabilization 23 Lum LC. The syndrome of chronic habitual hyperventi-
of mast cells. Most asthmatics breathe like hyper- lation. In: Hill 0, ed. Modern trends in psychosomatic
ventilators and have a resting Pco2 in the lower medicine- 111. London: Butterworths, 1976
ranges of normal (personal observations). 24 Bass C, Gardner WN. Respiratory and psychiatric
Hyperventilators frequently have irritable bowel abnormalities in chronic symptomatic hyperventi-
symptoms. Headaches, even migraine, are common. lation. Br Med J 1985;290:1387-90
Many exhibit definite food intolerance. Similarly, 25 McKell TE, Sullivan AJ. The hyperventilation syn-
many subjects of food allergy develop symptoms of drome as gastroenterology. Gastroenterology 1947;9:6
hyperventilation43. The aetiological relationship is 26 Singer EP. The hyperventilation syndrome in clinical
at present obscure. medicine. NY State J Med 1958;58:1494-1500
27 Yu PN, Yim BJ, Standfield CA. Hyperventilation
In summary, it is clear that hyperventilation can syndrome; changes in electrocardiogram etc. during
mimic many organic diseases, and it frequently com- voluntary hyperventilation. Arch Intern Med 1959;
plicates them. It now must be recognized as a major 103:902
factor in many neuroses, particularly panic disorder 28 Bass C, Wade C, Hand D, Jackson G. Patients with
and phobic states. It is high time that it should angina with normal and near normal coronary arteries:
be awarded the attention merited by 'one of the clinical and psychosocial state 12 months after angio-
commonest afflictions of sedentary town dwellers'. graphy. Br Med J 1983;287:1505-8
29 Evans DWE, Lum LC. Hyperventilation as a cause of
chest pain mimicking angina. Practical Cardiology
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