Hyperventilation

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Dyspnea Microchapters

Overview

Pathophysiology

Causes

Differentiating Hyperventilation from other Diseases

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vindhya BellamKonda, M.B.B.S [2], Iqra Qamar M.D.[3]

Overview

Hyperventilation is the state of rapid breathing which results in the reduction in carbon dioxide levels (below normal) thereby leading to hypocapnia.[1] During rapid breathing, the body loses more carbon dioxide (CO2) than it can produce resulting in net reduction of CO2 levels. This state of rapid/faster breathing is most commonly seen in stress and anxiety and termed as hyperventilation syndrome. Kussmaul breathing is also a type of hyperventilation and done to reduce the acidity of body as seen in metabolic acidosis. Hyperventilation may also be voluntarily manifested following episodes of rapid deep breathing. The symptoms of hyperventilation are variable. Some patients are completely asymptomatic while others may present with minimal symptoms such as headache and numbness or tingling in the hands, feet, and lips. More severe symptoms include dizziness, lightheadedness, and fainting. Some patient also report having chest pain and slurred speech particularly when accompanied by the Valsalva maneuver. Voluntary deep breathing and induction of hyperventilation is a common practice among young individuals to attain focus and adrenaline rush. Other similar terms that are completely different from hyperventilation include hyperpnea and tachypnea.

Hyperpnea is commonly seen with exercise or any major physical activity as well as in response to hypoxic states. In these conditions the energy demand of the body either goes up or is not adequately met. To meet this energy deficit, the body increases the depth and rate of breathing which is known as hyperpnea. Other common examples of hyperpneic state include sepsis, anemia, and individuals living at high altitudes. Tachypnea is derived from a Greek word which means "rapid breathing". Tachypnea means rapid and shallow breathing and is also seen with exercise as a compensatory mechanism to increase the oxygen content of the body.

Pathophysiology

Physiology of breathing

The basic physiology of normal breathing is as follows:

  • The CNS regulates the depth and frequency of each breath to maintain normal levels of carbon dioxide (CO2) and oxygen (O2) in the blood and tissues.
  • The CNS measures the amount of CO2 in the body to regulate the breathing process.
  • As the CO2 and O2 gas exchange mechanism is simultaneous and continuous, any condition resulting in increased high carbon dioxide concentration primarily signals a low oxygen concentration.
  • In addition, metabolism in the body uses O2 and results in the production of CO2 as a byproduct.

Hyperventilation

Under physiologic conditions, the volume of alveolar gas is in equilibrium with the arterial gas. [2]

  • With each breath approximately 10% of the alveolar gas is replaced with atmospheric air.
  • The rate and depth of breathing determines the level of CO2 in the body.
  • A rapid and deep breath will lead to a better alveolar - atmospheric gas exchange leading to low CO2 levels.
  • It is to be noted that atmospheric air has 21% O2 content as compared to just 0.03% of CO2 content.
  • This results in low CO2 content (hypocapnia) with each rapid and deep breath.

Mechanism of Alkalosis

The mechanism of the development of alkalosis following hyperventilation is as follows:[3]

  • Majority of the CO2 in human body is stored as carbonic acid and is a major factor in determining the pH of the body.
  • Loss of CO2 results in blood becoming more alkaline and increase in blood pH.
  • In the normal individual, the resultant alkalosis would automatically be countered by reduced breathing except when the neural control is altered or disturbed.

Response of brain vasculature to hyperventilation and hypoventilation

The response of vessels in the brain to hyperventilation and hypoventilation is as follows:[4][5][6]

  • Conditions causing high CO2 levels (hypercapnia) results in the body assuming that the O2 levels are low.
  • As a result, to increase the O2 supply the blood vessels in the brain dilate.

Causes

Following are the various causes of hyperventilation.

Life-Threatening Causes

Common Causes

Causes by Organ System

Cardiovascular Cheyne-stokes respirations, congestive cardiac failure, pulmonary embolism, stroke
Chemical/Poisoning Ammonium chloride, camphor , glycol ether , inhalation of irritants, methanol, salicylate poisoning
Dental No underlying causes
Dermatologic No underlying causes
Drug Side Effect Aminophylline, aspirin, coffee abuse, pralidoxime, tiagabine
Ear Nose Throat No underlying causes
Endocrine Diabetic ketoacidosis, renal disease
Environmental Acute stress disorder
Gastroenterologic Abdominal surgery, acute liver failure, acute porphyria, end stage liver failure, hepatic cirrhosis, intestinal fistula, pyloric stenosis
Genetic Acute porphyria, arginosuccinic aciduria, carbamoylphosphate synthetase 1 deficiency disease, carbonic anhydrase va deficiency, hereditary fructose-1,6-bisphosphatase deficiency, Pitt-hopkins syndrome
Hematologic Acute porphyria
Iatrogenic No underlying causes
Infectious Disease CNS infection, fever
Musculoskeletal/Orthopedic Hip cancer
Neurologic Altitude sickness, acute brain trauma, central neurogenic hyperventilation, cerebrovascular accident, CNS infection, Cree leukoencephalopathy, damaged respiratory pathways, epilepsy, epileptic encephalopathy, early infantile, 2; head injury, intracranial space-occupying lesion, meningoencephalitis, pain, Pitt-Hopkins syndrome, raised intracranial pressure, stroke, vasovagal attacks
Nutritional/Metabolic Diabetic ketoacidosis, hereditary fructose-1,6-bisphosphatase deficiency, heat stroke, lactic acidosis
Obstetric/Gynecologic No underlying causes
Oncologic Bronchial neoplasm, rib tumor
Ophthalmologic No underlying causes
Overdose/Toxicity Biguanide intolerance
Psychiatric Acute stress disorder, adult panic-anxiety syndrome, agoraphobia, anxiety, Briquet's syndrome, combat stress reaction, Cree leukoencephalopathy,crying or severe distress, Da Costa syndrome, depression, distress, excitement, fear, functional disorders, grief, hypochondriasis, hysteria, malingering, pain, panic attack, phobia, primary habit disorder, Rett's syndrome, schizophrenia, stress, strong emotions
Pulmonary Acute altitude sickness, apneustic respirations, asthma, ataxic respiration, biot's respiration, central neurogenic hyperventilation, Cheyne-stokes respirations, damaged respiratory pathways, diffuse pulmonary fibrosis, emphysema , hyperventilation syndrome, inhalation of irritants, lung damage, metabolic acidosis, persistent hypoxemia, pleural effusion, pneumonia, pneumothorax, pulmonary embolism, pulmonary oedema
Renal/Electrolyte Acid-base imbalance, metabolic acidosis, phaeochromocytoma, renal disease
Rheumatology/Immunology/Allergy Asthma, pseudoallergic reactions
Sexual No underlying causes
Trauma Brain trauma, head injury, lung damage, raised intracranial pressure, sponatneous pneumothorax, stroke, surgical relocation of ureters in ileum or colon
Urologic Surgical relocation of ureters in ileum or colon
Miscellaneous Abdominal surgery, adulation, childbirth, fever

Causes in Alphabetical Order

Differentiating Hyperventilation from other Diseases

Various diseases that can cause hyperventilation may include diseases of respiratory, cardiovascular, endocrine, central nervous system, and musculoskeletal system. Pregnancy, sepsis, and hepatic failure are other conditions that may also result in hyperventilation. Given below is a differential diagnosis of diseases presenting with hyperventilation.

Abbreviations: ABG (arterial blood gas); ACE (angiotensin converting enzyme); βhCG (beta human chorionic gonadotropin); BMP (basic metabolic panel); BNP (brain natriuretic peptide); CBC (complete blood count); COPD (chronic obstructive pulmonary disease); CSF (cerebrospinal fluid); CXR (chest X-ray); CT (computed tomography); DLCO (diffusing capacity of the lung for carbon monoxide); DOE (dyspnea on exercise); ECG (electrocardiogram); FEF (forced expiratory flow rate); FEV1 (forced expiratory volume); FT4 (free T4); FVC (forced vital capacity); HRCT (high resolution computed tomography); JVD (jugular vein distention); LFTs (liver function tests); MCV (mean corpuscular volume); MEN (multiple endocrine neoplasia); MRI (magnetic resonance imaging); P2 (pulmonic heart sound); Plt (platelet); PT (prothrombin time); RBC (red blood cell); RV (residual volume); SIADH (syndrome of inappropriate antidiuretic hormone); S3 ( third heart sound); S4 (fourth heart sound); T3 ((Triiodothyronine); TLC (total lung capacity); TSH (thyroid stimulating hormone); VC (vital capacity); VMA(vanillylmandelic acid); Vt (tidal volume); WBC (white blood cell);

Organ system Diseases Clinical manifestations Diagnosis Other features
Symptoms Physical exam
Chest pain Dyspnea Fever Palpitations Cyanosis Tachypnea JVD Peripheral edema Auscultation ABGs Lab findings Imaging PFT Gold standard
Pulmonary system Pneumothorax[7] + + +/- + +/- + - - +/- Hypoxemia - X- ray -

CT-scan -

  • bullae
Pulmonary embolism[8] +/- + +/- + +/- + +/- - Respiratory alkalosis
  • Normal
Pneumonia[9] +/- + + + +/- + - - +/- Hypoxemia
  • Normal
Exacerbation of asthma/COPD[10] +/- + +/- + + + - - +/- Hypoxemia
Interstitial lung disease[11][12] +/- + +/- + + + +/- - +/- Hypoxemia _
  • CXR- Reticular infiltrates
  • Honey combing
Intrapulmonary shunt[13] +/- + - - + +/- - - +/- Hypoxemia
Upper airway obstruction[14] - + - -/+ -/+ + -/+ - +/- Hypoxemia -
High altitude sickness[15][16][17] - + +/- + +/- + - + Respiratory alkalosis
  • EKG- Right sided heart strain
  • Test in a hypobaric chamber with and without supplemental O2-breathing
Cardiovascular system Acute coronary syndrome[18] + + - +/- +/- +/- +/- +/- - -
Heart failure[19] +/- + - +/- + +/- + + Respiratory alkalosis CXR shows
Dysrhythmias[18] +/- + - + - +/- - - Normal
  • Normal
  • Normal
Shock[20][21] +/- +/- +/- +/- +/- +/- +/- +/- Combined acid-base disorders are frequently encountered in different stages
Metabolic/Systemic disorders Diabetic ketoacidosis[22] - + +/- - - - - - Metabolic acidosis
  • Normal
  • Normal
Hypocalcemia[23][24] - + - + - +/- - - Respiratory alkalosis
  • Normal
  • Serum Ionized calcium
Hypoglycemia[25][26] - +/- - +/- - - - - Normal
  • Normal
  • 72-hour supervised fasting test
Endocrine system Hyperthyroidism[27][28] +/- + - +/- - +/- - - Variable
  • Normal
Pheochromocytoma[29][30] - + +/- + - +/- - -
  • Asymmetric chest expansion
 Normal
  • Normal
CNS Central nervous system tumor[31][32] - +/- - - - +/- - -
  • Normal
 Variable based on tumor location
  • Normal
Anxiety/panic attacks[33] +/- + - +/- - - - -
  • Normal
 Normal
  • Normal
  • Normal
  • Normal
Others Pregnancy[34] +/- + - - - - - +/-
  • Normal
 Respiratory alkalosis
  • Normal
Hepatic failure[35][36] - +/- +/- +/- +/- + + + +/- Respiratory alkalosis
  • Normal
Sepsis[37] - + +/- +/- - - - -
  • Normal
 Variable based on the sepsis phase
  • Normal
  • Normal

References

  1. ↑ Kenneth Baillie and Alistair Simpson. [ttp://www.altitude.org/calculators/oxygencalculator/oxygencalculator.htm "Hyperventilation calculator"]. Apex (Altitude Physiology EXpeditions). Retrieved 2006-08-10. - Online interactive oxygen delivery calculator that mimicks hyperventilation
  2. ↑ Barrett, Kim (2012). "Chapter 34. Introduction to Pulmonary Structure and Mechanics". Ganong's review of medical physiology. New York London: McGraw-Hill Medical McGraw-Hill distributor. ISBN 978-0071780032.
  3. ↑ Engelking, Larry R. (2015). "Respiratory Alkalosis": 590–595. doi:10.1016/B978-0-12-391909-0.50091-8.
  4. ↑ Stocchetti N, Maas AI, Chieregato A, van der Plas AA (2005). "Hyperventilation in head injury: a review". Chest. 127 (5): 1812–27. doi:10.1378/chest.127.5.1812. PMID 15888864.
  5. ↑ Ainslie PN, Ashmead JC, Ide K, Morgan BJ, Poulin MJ (2005). "Differential responses to CO2 and sympathetic stimulation in the cerebral and femoral circulations in humans". J Physiol. 566 (Pt 2): 613–24. doi:10.1113/jphysiol.2005.087320. PMC 1464750. PMID 15890697.
  6. ↑ Battisti-Charbonney A, Fisher J, Duffin J (2011). "The cerebrovascular response to carbon dioxide in humans". J Physiol. 589 (Pt 12): 3039–48. doi:10.1113/jphysiol.2011.206052. PMC 3139085. PMID 21521758.
  7. ↑ Currie GP, Alluri R, Christie GL, Legge JS (2007). "Pneumothorax: an update". Postgrad Med J. 83 (981): 461–5. doi:10.1136/pgmj.2007.056978. PMC 2600088. PMID 17621614.
  8. ↑ Bĕlohlávek J, Dytrych V, Linhart A (2013). "Pulmonary embolism, part I: Epidemiology, risk factors and risk stratification, pathophysiology, clinical presentation, diagnosis and nonthrombotic pulmonary embolism". Exp Clin Cardiol. 18 (2): 129–38. PMC 3718593. PMID 23940438.
  9. ↑ Simonetti AF, Viasus D, Garcia-Vidal C, Carratalà J (2014). "Management of community-acquired pneumonia in older adults". Ther Adv Infect Dis. 2 (1): 3–16. doi:10.1177/2049936113518041. PMC 4072047. PMID 25165554.
  10. ↑ Qureshi H, Sharafkhaneh A, Hanania NA (2014). "Chronic obstructive pulmonary disease exacerbations: latest evidence and clinical implications". Ther Adv Chronic Dis. 5 (5): 212–27. doi:10.1177/2040622314532862. PMC 4131503. PMID 25177479.
  11. ↑ Bohadana A, Izbicki G, Kraman SS (2014). "Fundamentals of lung auscultation". N Engl J Med. 370 (8): 744–51. doi:10.1056/NEJMra1302901. PMID 24552321.
  12. ↑ Spicknall KE, Zirwas MJ, English JC (2005). "Clubbing: an update on diagnosis, differential diagnosis, pathophysiology, and clinical relevance". J Am Acad Dermatol. 52 (6): 1020–8. doi:10.1016/j.jaad.2005.01.006. PMID 15928621.
  13. ↑ Vodoz JF, Cottin V, Glérant JC, Derumeaux G, Khouatra C, Blanchet AS; et al. (2009). "Right-to-left shunt with hypoxemia in pulmonary hypertension". BMC Cardiovasc Disord. 9: 15. doi:10.1186/1471-2261-9-15. PMC 2671488. PMID 19335916.
  14. ↑ Darras KE, Roston AT, Yewchuk LK (2015). "Imaging Acute Airway Obstruction in Infants and Children". Radiographics. 35 (7): 2064–79. doi:10.1148/rg.2015150096. PMID 26495798.
  15. ↑ Basnyat B, Murdoch DR (2003). "High-altitude illness". Lancet. 361 (9373): 1967–74. doi:10.1016/S0140-6736(03)13591-X. PMID 12801752.
  16. ↑ Schoene RB (2008). "Illnesses at high altitude". Chest. 134 (2): 402–416. doi:10.1378/chest.07-0561. PMID 18682459.
  17. ↑ Stream JO, Grissom CK (2008). "Update on high-altitude pulmonary edema: pathogenesis, prevention, and treatment". Wilderness Environ Med. 19 (4): 293–303. doi:10.1580/07-WEME-REV-173.1. PMID 19099331.
  18. ↑ 18.0 18.1 Bruyninckx R, Aertgeerts B, Bruyninckx P, Buntinx F (2008). "Signs and symptoms in diagnosing acute myocardial infarction and acute coronary syndrome: a diagnostic meta-analysis". Br J Gen Pract. 58 (547): 105–11. doi:10.3399/bjgp08X277014. PMC 2233977. PMID 18307844.
  19. ↑ Gaggin, Hanna K.; Januzzi, James L. (2013). "Biomarkers and diagnostics in heart failure". Biochimica et Biophysica Acta (BBA) - Molecular Basis of Disease. 1832 (12): 2442–2450. doi:10.1016/j.bbadis.2012.12.014. ISSN 0925-4439.
  20. ↑ Churpek MM, Zadravecz FJ, Winslow C, Howell MD, Edelson DP (2015). "Incidence and Prognostic Value of the Systemic Inflammatory Response Syndrome and Organ Dysfunctions in Ward Patients". Am J Respir Crit Care Med. 192 (8): 958–64. doi:10.1164/rccm.201502-0275OC. PMC 4642209. PMID 26158402.
  21. ↑ Kelly AM, Kyle E, McAlpine R (2002). "Venous pCO(2) and pH can be used to screen for significant hypercarbia in emergency patients with acute respiratory disease". J Emerg Med. 22 (1): 15–9. PMID 11809551.
  22. ↑ Westerberg DP (2013). "Diabetic ketoacidosis: evaluation and treatment". Am Fam Physician. 87 (5): 337–46. PMID 23547550.
  23. ↑ Tohme JF, Bilezikian JP (1993). "Hypocalcemic emergencies". Endocrinol Metab Clin North Am. 22 (2): 363–75. PMID 8325292.
  24. ↑ Cooper MS, Gittoes NJ (2008). "Diagnosis and management of hypocalcaemia". BMJ. 336 (7656): 1298–302. doi:10.1136/bmj.39582.589433.BE. PMC 2413335. PMID 18535072.
  25. ↑ Hepburn DA, Deary IJ, Frier BM, Patrick AW, Quinn JD, Fisher BM (1991). "Symptoms of acute insulin-induced hypoglycemia in humans with and without IDDM. Factor-analysis approach". Diabetes Care. 14 (11): 949–57. PMID 1797507.
  26. ↑ Towler DA, Havlin CE, Craft S, Cryer P (1993). "Mechanism of awareness of hypoglycemia. Perception of neurogenic (predominantly cholinergic) rather than neuroglycopenic symptoms". Diabetes. 42 (12): 1791–8. PMID 8243825.
  27. ↑ Iglesias P, Acosta M, Sánchez R, Fernández-Reyes MJ, Mon C, Díez JJ (2005). "Ambulatory blood pressure monitoring in patients with hyperthyroidism before and after control of thyroid function". Clin Endocrinol (Oxf). 63 (1): 66–72. doi:10.1111/j.1365-2265.2005.02301.x. PMID 15963064.
  28. ↑ Forfar JC, Muir AL, Sawers SA, Toft AD (1982). "Abnormal left ventricular function in hyperthyroidism: evidence for a possible reversible cardiomyopathy". N Engl J Med. 307 (19): 1165–70. doi:10.1056/NEJM198211043071901. PMID 7121544.
  29. ↑ Neumann HP, Pawlu C, Peczkowska M, Bausch B, McWhinney SR, Muresan M; et al. (2004). "Distinct clinical features of paraganglioma syndromes associated with SDHB and SDHD gene mutations". JAMA. 292 (8): 943–51. doi:10.1001/jama.292.8.943. PMID 15328326.
  30. ↑ Bravo EL (1991). "Pheochromocytoma: new concepts and future trends". Kidney Int. 40 (3): 544–56. PMID 1787652.
  31. ↑ Forsyth PA, Posner JB (1993). "Headaches in patients with brain tumors: a study of 111 patients". Neurology. 43 (9): 1678–83. PMID 8414011.
  32. ↑ Valentinis L, Tuniz F, Valent F, Mucchiut M, Little D, Skrap M; et al. (2010). "Headache attributed to intracranial tumours: a prospective cohort study". Cephalalgia. 30 (4): 389–98. doi:10.1111/j.1468-2982.2009.01970.x. PMID 19673912.
  33. ↑ Taylor CB (2006). "Panic disorder". BMJ. 332 (7547): 951–5. doi:10.1136/bmj.332.7547.951. PMC 1444835. PMID 16627512.
  34. ↑ Lee SY, Chien DK, Huang CH, Shih SC, Lee WC, Chang WH (2017). "Dyspnea in pregnancy". Taiwan J Obstet Gynecol. 56 (4): 432–436. doi:10.1016/j.tjog.2017.04.035. PMID 28805596.
  35. ↑ Lee WM (1993). "Acute liver failure". N Engl J Med. 329 (25): 1862–72. doi:10.1056/NEJM199312163292508. PMID 8305063.
  36. ↑ Gill RQ, Sterling RK (2001). "Acute liver failure". J Clin Gastroenterol. 33 (3): 191–8. PMID 11500606.
  37. ↑ Askim Å, Mehl A, Paulsen J, DeWan AT, Vestrheim DF, Åsvold BO; et al. (2016). "Epidemiology and outcome of sepsis in adult patients with Streptococcus pneumoniae infection in a Norwegian county 1993-2011: an observational study". BMC Infect Dis. 16: 223. doi:10.1186/s12879-016-1553-8. PMC 4877975. PMID 27216810.

See also

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