- Richard M Schwartzstein, MD
Richard M Schwartzstein, MD
- Professor of Medicine
- Harvard Medical School
- Jeremy Richards, MD, MA
Jeremy Richards, MD, MA
- Assistant Professor of Medicine
- Medical University of South Carolina
- Jonathan A Edlow, MD, FACEP
Jonathan A Edlow, MD, FACEP
- Professor of Medicine and Emergency Medicine
- Harvard Medical School
- Section Editors
- Mark D Aronson, MD
Mark D Aronson, MD
- Editor-in-Chief — Primary Care (Adult); Hospital Medicine
- Section Editor — General Medicine
- Professor of Medicine
- Harvard Medical School
- Robert S Hockberger, MD, FACEP
Robert S Hockberger, MD, FACEP
- Section Editor — Adult Signs and Symptoms
- Emeritus Professor of Medicine
- David Geffen School of Medicine at UCLA
The hyperventilation syndrome describes a condition in which an inappropriate increase in minute ventilation beyond metabolic needs (ie, a respiratory alkalosis) is associated with a wide range of symptoms without a clear organic precipitant. As with other medical "syndromes," there is controversy about the etiology, diagnosis, and treatment of this condition.
This topic will discuss the pathophysiology, clinical presentation, diagnosis, and treatment of patients presenting with hyperventilation syndrome. Detailed discussions of associated disorders are presented separately. (See "Panic disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis" and "Pharmacotherapy for panic disorder with or without agoraphobia in adults" and "Psychotherapy for panic disorder with or without agoraphobia in adults" and "Generalized anxiety disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis" and "Acute stress disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis" and "Evaluation of the adult with dyspnea in the emergency department".)
Hyperventilation — Alveolar hyperventilation is present when the arterial tension of carbon dioxide (PaCO2) decreases below the normal range <36 mmHg (<4.8 kPa).
Hyperpnea — Increase in the depth and rate of respiration leading to an increase in the minute volume of ventilation, which is the product of tidal volume per breath multiplied by respiratory rate, and consistent with an increase in metabolism as reflected by CO2 production. Thus, the PaCO2 is normal in a patient with hyperpnea (an example of hyperpnea is the increase in ventilation that occurs during moderate exercise).
Tachypnea — Increased respiratory rate >20 breaths per minute. The PaCO2 cannot be predicted by tachypnea alone since PaCO2 reflects the relationship between CO2 production and alveolar ventilation (PaCO2 = VCO2/VA).To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Lewis RA, Howell JB. Definition of the hyperventilation syndrome. Bull Eur Physiopathol Respir 1986; 22:201.
- Hornsveld HK, Garssen B, Dop MJ, et al. Double-blind placebo-controlled study of the hyperventilation provocation test and the validity of the hyperventilation syndrome. Lancet 1996; 348:154.
- Gardner WN. The pathophysiology of hyperventilation disorders. Chest 1996; 109:516.
- Bass C. Hyperventilation syndrome: a chimera? J Psychosom Res 1997; 42:421.
- Howell JB. Behavioural breathlessness. Thorax 1990; 45:287.
- Cowley DS, Roy-Byrne PP. Hyperventilation and panic disorder. Am J Med 1987; 83:929.
- Rapee R. Differential response to hyperventilation in panic disorder and generalized anxiety disorder. J Abnorm Psychol 1986; 95:24.
- Brashear RE. Hyperventilation syndrome. Lung 1983; 161:257.
- Pfortmueller CA, Pauchard-Neuwerth SE, Leichtle AB, et al. Primary Hyperventilation in the Emergency Department: A First Overview. PLoS One 2015; 10:e0129562.
- Jack S, Rossiter HB, Pearson MG, et al. Ventilatory responses to inhaled carbon dioxide, hypoxia, and exercise in idiopathic hyperventilation. Am J Respir Crit Care Med 2004; 170:118.
- Ritz T, Meuret AE, Bhaskara L, Petersen S. Respiratory muscle tension as symptom generator in individuals with high anxiety sensitivity. Psychosom Med 2013; 75:187.
- Boulding R, Stacey R, Niven R, Fowler SJ. Dysfunctional breathing: a review of the literature and proposal for classification. Eur Respir Rev 2016; 25:287.
- AMES F. The hyperventilation syndrome. J Ment Sci 1955; 101:466.
- Nardi AE, Freire RC, Zin WA. Panic disorder and control of breathing. Respir Physiol Neurobiol 2009; 167:133.
- Raichle ME, Plum F. Hyperventilation and cerebral blood flow. Stroke 1972; 3:566.
- Han JN, Stegen K, Simkens K, et al. Unsteadiness of breathing in patients with hyperventilation syndrome and anxiety disorders. Eur Respir J 1997; 10:167.
- Hauge A, Thoresen M, Walløe L. Changes in cerebral blood flow during hyperventilation and CO2-breathing measured transcutaneously in humans by a bidirectional, pulsed, ultrasound Doppler blood velocitymeter. Acta Physiol Scand 1980; 110:167.
- Yates BJ, Miller AD. Physiological evidence that the vestibular system participates in autonomic and respiratory control. J Vestib Res 1998; 8:17.
- Goebel JA. The ten-minute examination of the dizzy patient. Semin Neurol 2001; 21:391.
- Gandevia SC, Killian K, McKenzie DK, et al. Respiratory sensations, cardiovascular control, kinaesthesia and transcranial stimulation during paralysis in humans. J Physiol 1993; 470:85.
- Schwartzstein RM, Manning HL, Weiss JW, Weinberger SE. Dyspnea: a sensory experience. Lung 1990; 168:185.
- Saisch SG, Wessely S, Gardner WN. Patients with acute hyperventilation presenting to an inner-city emergency department. Chest 1996; 110:952.
- Demeter SL, Cordasco EM. Hyperventilation syndrome and asthma. Am J Med 1986; 81:989.
- Martínez-Moragón E, Perpiñá M, Belloch A, de Diego A. [Prevalence of hyperventilation syndrome in patients treated for asthma in a pulmonology clinic]. Arch Bronconeumol 2005; 41:267.
- Prys-Picard CO, Kellett F, Niven RM. Disproportionate breathlessness associated with deep sighing breathing in a patient presenting with difficult-to-treat asthma. Chest 2006; 130:1723.
- Kerr WJ, Gliebe PA, Dalton JW. Physical Phenomena Associated with Anxiety States: The Hyperventilation Syndrome. Cal West Med 1938; 48:12.
- Howell JB. The hyperventilation syndrome: a syndrome under threat? Thorax 1997; 52 Suppl 3:S30.
- Tobin MJ, Chadha TS, Jenouri G, et al. Breathing patterns. 2. Diseased subjects. Chest 1983; 84:286.
- Thompson SA, Duncan JS, Smith SJ. Partial seizures presenting as panic attacks. BMJ 2000; 321:1002.
- Hornsveld H, Garssen B, van Spiegel P. Voluntary hyperventilation: the influence of duration and depth on the development of symptoms. Biol Psychol 1995; 40:299.
- Callaham M. Hypoxic hazards of traditional paper bag rebreathing in hyperventilating patients. Ann Emerg Med 1989; 18:622.
- Moy ML, Woodrow Weiss J, Sparrow D, et al. Quality of dyspnea in bronchoconstriction differs from external resistive loads. Am J Respir Crit Care Med 2000; 162:451.
- Chevalier B, Schwartzstein R. The role of the methacholine inhalation challenge: Avoiding a misdiagnosis of asthma. J Respir Dis 2001; 22:153.
- Meuret AE, Ritz T. Hyperventilation in panic disorder and asthma: empirical evidence and clinical strategies. Int J Psychophysiol 2010; 78:68.
- Goossens L, Leibold N, Peeters R, et al. Brainstem response to hypercapnia: a symptom provocation study into the pathophysiology of panic disorder. J Psychopharmacol 2014; 28:449.
- Vickers K. Hypersensitivity to hypercapnia: definition/(s). Psychiatry Res 2012; 197:7.
- Hornsveld H, Garssen B. The low specificity of the Hyperventilation Provocation Test. J Psychosom Res 1996; 41:435.
- Lindsay S, Saqi S, Bass C. The test-retest reliability of the hyperventilation provocation test. J Psychosom Res 1991; 35:155.
- Kinnula VL, Sovijärvi AR. Elevated ventilatory equivalents during exercise in patients with hyperventilation syndrome. Respiration 1993; 60:273.
- Simon PM, Schwartzstein RM, Weiss JW, et al. Distinguishable types of dyspnea in patients with shortness of breath. Am Rev Respir Dis 1990; 142:1009.
- van Dixhoorn J, Duivenvoorden HJ. Efficacy of Nijmegen Questionnaire in recognition of the hyperventilation syndrome. J Psychosom Res 1985; 29:199.
- van Dixhoorn J, Folgering H. The Nijmegen Questionnaire and dysfunctional breathing. ERJ Open Res 2015; 1.
- Munemoto T, Masuda A, Nagai N, et al. Prolonged post-hyperventilation apnea in two young adults with hyperventilation syndrome. Biopsychosoc Med 2013; 7:9.
- MacDonald KF, Bowers JT, Flynn RE. Posthyperventilation apnea associated with severe hypoxemia. Chest 1976; 70:554.
- DeGuire S, Gevirtz R, Kawahara Y, Maguire W. Hyperventilation syndrome and the assessment of treatment for functional cardiac symptoms. Am J Cardiol 1992; 70:673.
- DeGuire S, Gevirtz R, Hawkinson D, Dixon K. Breathing retraining: a three-year follow-up study of treatment for hyperventilation syndrome and associated functional cardiac symptoms. Biofeedback Self Regul 1996; 21:191.
- Jones M, Harvey A, Marston L, O'Connell NE. Breathing exercises for dysfunctional breathing/hyperventilation syndrome in adults. Cochrane Database Syst Rev 2013; :CD009041.
- Van De Ven LL, Mouthaan BJ, Hoes MJ. Treatment of the hyperventilation syndrome with bisoprolol: a placebo-controlled clinical trial. J Psychosom Res 1995; 39:1007.
- Folgering H, Rutten H, Roumen Y. Beta-blockade in the hyperventilation syndrome. A retrospective assessment of symptoms and complaints. Respiration 1983; 44:19.
- Kraft AR, Hoogduin CA. The hyperventilation syndrome. A pilot study on the effectiveness of treatment. Br J Psychiatry 1984; 145:538.
- Hyperventilation syndrome
- PREVALENCE AND EPIDEMIOLOGY
- CLINICAL PRESENTATION
- Somatic symptoms
- Psychological symptoms
- Physical examination
- DIFFERENTIAL DIAGNOSIS
- Initial evaluation
- - Bedside assessment
- - Point-of-care testing
- - Caution about breathing into paper bag
- Further evaluation
- Follow-up testing
- Evaluation of recurrent episodes
- Specialist referral
- Ancillary diagnostic testing
- Acute management
- Treatment to prevent recurrent episodes
- SUMMARY AND RECOMMENDATIONS