Emergency Management of Hyperventilation

Introduction

Hyperventilation (over-breathing) is when a person breathes deeper and faster than normal. Breathing is an act that a person performs without conscious thinking. But in certain situations, such as a panic attack or metabolic acidosis (too much acid in the body), a person's breathing pattern can change and become more rapid and deep. As a result, the gas exchange (oxygen-carbon dioxide exchange) in the lungs gets affected. The person exhales more carbon dioxide, leading to a drop in the carbon dioxide levels in the blood. Hyperventilation is more common in women (especially during pregnancy) and can occur between the first and sixth decade of life. It is usually associated with stress, anxiety, or nervousness. Frequent hyperventilation episodes could be due to hyperventilation syndrome.

What Are the Common Causes of Hyperventilation?

Many situations can cause hyperventilation, including the following:

• Stress.
• Panic attack.
• Anxiety or anxiety disorders.
• Too much exercise.
• Respiratory problems such as asthma.
• Underlying lung diseases.
• Head injury.
• Shock.
• Certain medications and drugs.
• High altitude.
• Metabolic acidosis or diabetic ketoacidosis (conditions in which the acid levels in the body are high).
• Bleeding.
• Heart conditions such as heart attack or failure.
• Infections (sepsis or pneumonia).
• Pregnancy.

What Are the Common Symptoms Seen in Hyperventilation?

The symptoms seen commonly in hyperventilating patients include:

• The patients feel they cannot get enough air (cannot catch their breath).
• Shortness of breath.
• Not able to think straight.
• Lightheadedness.
• Feeling weak and dizzy.
• Pounding heart with a rapid heartbeat.
• Chest pain, tightness, or discomfort.
• Dry mouth.
• Trouble sleeping.
• Spasm of muscles of the hands and feet.
• Bloating.
• Numbness (in the arms, feet, or around the mouth).
• Frequent yawning (and sighs).

How to Manage Hyperventilation at Home?

If the hyperventilation is due to stress, anxiety, or panic attacks, a few steps can be taken at home. The aim of controlled breathing is to increase the carbon dioxide levels in the blood, which would help relieve the symptoms. Focusing on controlled breaths can help the hyperventilating patients to begin breathing normally again. The following methods can help a hyperventilating patient:

• The caregiver must gently reassure the patient, using a calm, soft, and relaxed voice.
• The patients must purse their lips (as though blowing out a candle) and breathe in slowly through their noses. They must then breathe out slowly through the lips (that are pursed).
• Keeping their mouth closed, the patients must press on one nostril (closed with their finger) and breathe slowly through the open nostril. This has to be repeated several times. The patients must ensure that they are breathing through their noses and not through their mouths.

When Should a Hyperventilating Person See a Doctor?

The patients must visit a doctor in the following scenarios:

• Any person who experiences hyperventilation for the first time must visit a doctor or rush to the emergency room for evaluation.
• If the patient has hyperventilated before, but cannot get their breathing under control with home care within a few minutes.
• If the patient is trying to change their breathing patterns, but it is not working, and the patient's condition is worsening, or they have difficulty breathing.
• Patients who have:
• Chest pain, tightness, or discomfort that worsens with deep breaths.
• Fast heartbeat.
• Fever.
• Unconsciousness (fainting).

What Are the Tests to Diagnose Hyperventilation?

The diagnosis of hyperventilation is clinical, based on the patient's symptoms and history. However, several diagnostic tests are performed to exclude other medical conditions:

1. Arterial Blood Gas Test: The oxygen and carbon dioxide levels in the blood are measured using the arterial blood gas test.
2. Testing the End-Expiratory Air: This is used to measure the carbon dioxide levels (less painful and less invasive).
3. Electrocardiogram (ECG): This test excludes heart-related problems such as arrhythmia and coronary heart disease. ECG also reveals a heart rhythm abnormality (prolonged QT interval) due to decreased blood calcium levels in an acute attack.
4. D-Dimer Test: This test helps to rule out pulmonary embolism (clots in the lungs) as the cause of the patient’s symptoms.
5. Chest X-Ray: This imaging test is essential to rule out lung-related issues such as pulmonary embolism or pneumothorax.
6. Toxicology Screening: A series of tests are done to detect the presence of certain drugs, poisons, and other toxic agents in the patient.
7. Electroencephalogram (EEG): This is used to distinguish acute hyperventilation syndrome from epileptic seizures.
8. Ventilation or Perfusion Scan of the Lungs: These scans help to measure breathing and lung circulation.

How Is Hyperventilation Treated?

Managing Hyperventilation Without Medications: If the patient's hyperventilation is due to anxiety, it can produce symptoms that lead to serious physical illnesses that further worsen the patient's hyperventilation (which leads to a vicious cycle). Identifying the nature of hyperventilation (and its underlying cause) is essential. It is crucial for such patients to seek help from a mental health professional. The following can help hyperventilating patients with a psychological cause such as anxiety:

• Rebreathing into a paper bag can help (by increasing the carbon dioxide levels). However, it should be used with caution and only when the underlying cause is determined and any underlying physical disease (such as heart or lung problems or ketoacidosis) is ruled out.
• Breathing exercises and relaxation techniques can help to manage hyperventilation syndrome and dysfunctional breathing.
• If the patient has asthma along with the breathing issue, physiotherapy interventions such as breathing retraining exercises can help to improve the patient's quality of life.
• Regular exercise and a healthy lifestyle.

If these methods alone do not prevent hyperventilation, medications are used to resolve the symptoms.

Management With Medications: Behavior therapy is the most useful treatment method. However, medications help in severe conditions. These include:

• Benzodiazepines - These are used in severe conditions (only occasionally, as they can cause dependence and sedation).
• Tricyclic Antidepressants - Medications for the management of depression.
• Propranolol - These are used if the patient does not have asthma or lung conditions.
• Selective Serotonin Reuptake Inhibitors (SSRIs) - Medications used for the treatment of major depressive episodes and anxiety disorders.

Treatment of the Underlying Conditions and Diseases: The underlying medical conditions and diseases, such as panic disorders, agoraphobia, obsessive-compulsive disorders, and hyperventilation syndrome, are treated to relieve the symptoms of hyperventilation.

Conclusion

Hyperventilation is when the patient experiences dysfunctional breathing with rapid and deep breaths. The most common cause of hyperventilation is panic attacks or anxiety. Hyperventilation with minimum discomfort can be managed with controlled breathing and relaxation techniques at home when caused by anxiety or stress. However, it is essential to rush to the emergency department immediately for evaluation and treatment in case of acute attacks.