Subject Characteristics

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Hyperventilation syndrome BYAHMAD YOUNES
PROFESSOR OF THORACIC MEDICINE Mansoura faculty
of medicine
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Hyperventilation syndrome

• Hyperventilation syndrome (HVS) represents a
  relatively common emergency department (ED)
  presentation that is readily recognized by most
  clinicians.
• The underlying patho-physiology has not been
  clearly elucidated.
• HVS is a condition in which minute ventilation
  exceeds metabolic demands, resulting in
  hemodynamic and chemical changes that produce
  characteristic dysphoric symptoms.
• Inducing a drop in PaCO2 through voluntary
  hyperventilation reproduces these symptoms.
• Many patients with HVS do not manifest low PaCO2
  during attacks.

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Hyperventilation syndrome

• A better term for this syndrome might be
  behavioral breathlessness or psychogenic dyspnea,
  with hyperventilation seen as a consequence
  rather than a cause of the condition.
• Some patients may be physiologically at risk for
  the development of psychogenic dyspnea.
• Symptoms of HVS and panic disorder overlap
  considerably, though the 2 conditions remain
  distinct.
• Approximately 50 of patients with panic disorder
  and 60 of patients with agoraphobia manifest
  hyperventilation as a symptom, whereas only 25
  of patients with HVS manifest panic disorder.

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The Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, classifies the anxiety
disorders into the following categories

• Anxiety due to a general medical condition
• Substance-induced anxiety disorder
• Generalized anxiety disorder
• Panic disorder
• Acute stress disorder
• Posttraumatic stress disorder (PTSD)
• Adjustment disorder with anxious features
• Obsessive-compulsive disorder (OCD)
• Social phobia
• Specific phobia and agoraphobia

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Hyperpnea or hyperventilation

• Hyperpnea or hyperpnoea is increased depth of
  breathing when required to meet metabolic demand
  of body tissues, such as during or following
  exercise, or when the body lacks oxygen
  (hypoxia), for instance in high altitude or as a
  result of anemia.
• Tachypnea differs from hyperpnea in that
  tachypnea is rapid shallow breaths, while
  hyperpnea is deep breaths.
• In hyperpnoea, the increased breathing rate is
  desirable as it meets the metabolic needs of the
  body.
• In hyperventilation, the rate of ventilation is
  inappropriate for the body's needs (except in
  respiratory acidosis, when CO2 needs to be
  breathed off). The resulting decrease in CO2
  concentration results in the typical symptoms of
  light-headedness, tingling in peripheries, visual
  disturbances etc. In hyperpnoea, there are
  generally no such symptoms .

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Panic Disorder 

• Panic disorder is characterized by the
  spontaneous and unexpected occurrence of panic
  attacks, the frequency of which can vary from
  several attacks per day to only a few attacks per
  year.
• Panic attacks can occur in other anxiety
  disorders but occur without discernible
  predictable precipitant in panic disorder
• To make the diagnosis of panic disorder, panic
  attacks cannot directly or physiologically result
  from substance use, medical conditions, or
  another psychiatric disorders

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Panic attacks are a period of intense fear in
which 4 of 13 defined symptoms develop abruptly
and peak rapidly less than 10 minutes from
symptom onset.

• Palpitations
• Sweating
• Trembling or shaking
• Sense of shortness of breath or smothering
• Feeling of choking
• Chest pain or discomfort
• Nausea or abdominal distress
• Feeling dizzy, unsteady, light-headed, or faint
• Derealization or depersonalization (feeling
  detached from oneself)
• Fear of losing control or going crazy
• Fear of dying
• Numbness or tingling sensations
• Chills or hot flashes

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Collectively, phobic disorders (social phobia,
specific phobia, and agoraphobia) are the most
common forms of psychiatric illness, surpassing
the rates of mood disorders and substance abuse

• Agoraphobia is defined as anxiety toward places
  or situations in which escape may be difficult or
  embarrassing
• Most cases of agoraphobia develop as a
  complication of panic disorders.
• A person previously experiences a panic attack in
  a specific situation or environment and this
  triggers a vicious circle.
• They begin to worry so much about having a panic
  attack again that they feel the symptoms of panic
  attack returning when they are in a similar
  situation or environment. This then causes the
  person to avoid that particular situation or
  environment.

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Conversion disorder, factitious disorder,
and malingering

• Conversion disorder, factitious disorder,
  and malingering have one major characteristic in
  common they represent conditions that are not
  real.  
• Properly diagnosing your patient with one of
  these psychiatric ailments will allow you to
  create appropriate plans of care for your
  patients .

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1. Conversion Disorder is a psychiatric
condition that results in a neurological complaint
or symptom, without any underlying neurological
cause.  

• Patients may experience seizures (i.e.
  pseudo-seizures), weakness, non-responsiveness,
  numbness, and even vision loss.  
• The symptoms are not intentional, yet upon
  further investigation no biological explanation
  for the symptoms can be found.
• The name conversion disorder formerly known as
  "hysteria", comes from Sigmund Freud who stated
  that stress can cause a psychiatric ailment to
  convert to a medical problem.  
• It is thought that symptoms arise in response to
  stressful situations affecting a patient's mental
  health.

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2. Factitious Disorder (Munchausen Syndrome )

• Factitious Disorder (a Somatoform Disorder) is a
  condition where patients intentionally fake
  disease, or intentionally cause disease in order
  to play the patient role.
• The main distinction between this and conversion
  disorder is the intentional nature of factitious
  disorder.
• Often referred to a factitious disorder is
  characterized by patients frequently feigning
  illness to obtain attention, sympathy, or other
  emotional feedback.
• They achieve this goal through exaggerating
  symptoms, deliberately faking symptoms, or even
  intentionally creating real symptoms.

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Münchausen syndrome by proxy

• Münchausen syndrome by proxy (MSbP or MBP) is a
  term that is used to describe a behavior pattern
  in which a caregiver deliberately exaggerates,
  fabricates, and/or induces physical,
  psychological, behavioral, and/or mental health
  problems in those who are in their care.
• With deception at its core, this behavior is an
  elusive, potentially lethal, and frequently
  misunderstood form of child abuse or medical
  neglect that has been difficult to define, detect
  and confirm.

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3. Malingering

• Malingering is the intentional faking or creating
  of illness in order to obtain secondary gain
  (e.g. workers compensation, disability payments,
  avoiding work or jail time, pain medication,
  etc.).
• Malingering is NOT a psychiatric illness this is
  the first major distinction from the other two
  disorders.
• Malingering is an intentional abuse of the
  medical system to obtain personal benefit.
• Malingerers abuse the system to obtain secondary
  gain while patients with factitious disorder
  attempt only to obtain emotional, or primary
  gain.  In simpler terms, the end goal of a
  malingerer usually involves monetary value, while
  the goals of patients with factitious disorder
  have no such value

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QUICK REVIEW

• Conversion Disorder Unintentional, due to
  emotional stressors, no gain to the patient
• Factitious Disorder (Munchausen) Intentional,
  primary or emotional gain
• Malingering Intentional, secondary and often
  monetary gain.

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Pathophysiology of HVS

• Acute HVS accounts for only 1 of cases but is
  more easily diagnosed.
• Chronic HVS can present with a myriad of
  respiratory, cardiac, neurologic, or
  gastrointestinal (GI) symptoms without any
  clinically apparent over-breathing by the
  patient.
• Because of the subtlety of hyperventilation, many
  patients with chronic HVS are admitted and
  undergo extensive and expensive testing in an
  attempt to discover organic causes of their
  complaints.
• Certain stressors provoke an exaggerated
  respiratory response, including emotional
  distress, sodium lactate, caffeine,
  isoproterenol, cholecystokinin, and Co2 .

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Pathophysiology

• Patients with HVS were shown to be more likely to
  have had overprotective parents when they were
  children. A sudden stressful situation later in
  life can then incite the first episode of HVS.
• Infusion of lactate provokes symptoms of panic in
  80 of patients with panic disorder but in only
  10 of controls. Approximately one half of the
  lactate responders develop acute hyperventilation
  as part of the panic reaction.
• Lactate levels are higher and remain elevated
  longer in patients with panic disorder than in
  controls, suggesting that abnormal metabolism of
  lactate is involved in the pathogenesis,

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Pathophysiology

• Patients with HVS tend to breathe by using the
  upper thorax rather than the diaphragm, and this
  results in chronic over-inflation of the lungs.
• When stress induces a need to take a deep breath,
  the deep breathing is perceived as dyspnea.
• The sensation of dyspnea creates anxiety, which
  encourages more deep breathing, and a vicious
  circle is created.

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Pathophysiology

• Patients with panic disorder have a lower
  threshold for the fight-or-flight response.
• In susceptible patients, even minor stresses can
  trigger the syndrome, which then tends to
  manifest with primarily psychiatric complaints
  (eg, fear of death, impending doom, or
  claustrophobia).
• It is believed that HVS patients tend to focus on
  somatic complaints related to the physiologic
  changes produced by hyperventilation.
• Initiating stimuli and abnormal stress responses
  may be identical but are expressed differently in
  each group.

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Etiology

• The cause of HVS is unknown, but some persons who
  are affected appear to have an abnormal
  respiratory response to stress, sodium, lactate,
  and other chemical and emotional triggers, which
  results in excess minute ventilation and
  hypocarbia.
• In most patients, the mechanics of breathing are
  disordered in a characteristic way. When
  stressed, these patients rely on thoracic
  breathing rather than diaphragmatic breathing,
  resulting in a hyper-expanded chest and high
  residual lung volume.
• Because of the high residual volume, they are
  then unable to take a normal tidal volume with
  the next breath and consequently experience
  dyspnea.

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Etiology

• Proprioceptors in the lung and chest wall signal
  the brain with a suffocation alarm that
  triggers release of excitatory neurotransmitters
  that are responsible for many of the symptoms
  such as palpitations, tremor, anxiety, and
  diaphoresis.
• The incidence of HVS is higher in first-degree
  relatives than in the general population, but no
  clear genetic factors have been identified.

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Epidemiology

• As many as 10 of patients in a general internal
  medicine practice are reported to have HVS as
  their primary diagnosis.
• The peak incidence is between the ages of 15 and
  55 years, but cases have been reported in all age
  groups except infants.
• HVS has a strong female preponderance the
  female-to-male ratio may be as high as 71.

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Prognosis

• Patients with chronic HVS experience multiple
  exacerbations throughout their lives.
• Children who experience acute HVS often continue
  this pattern into adulthood.
• Many patients have associated disorders (eg,
  agoraphobia) that may dominate the clinical
  picture.
• Patients who are treated with breathing
  retraining, stress reduction therapy, and various
  medications (eg, benzodiazepines or selective
  serotonin reuptake inhibitors SSRIs) experience
  significant reductions in the frequency and the
  severity of exacerbations.
• Death attributable to HVS is extremely rare.

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Prognosis

• A leftward shift in the oxyhemoglobin
  dissociation curve and vasospasm related to low
  PaCO2 could cause myocardial ischemia in patients
  with coronary artery disease (CAD) and
  hyperventilation syndrome.
• Certain patients are disabled psychologically by
  their symptoms, and many patients carry false
  diagnoses.
• Patients with HVS often undergo unnecessary
  testing and suffer from the complications of
  these interventions (eg, angiography,
  thrombolytics, or nasal reconstruction).
• Withholding such therapy may be difficult in a
  patient with crushing chest pain and dyspnea. the
  chronicity of the condition often causes
  different physicians to repeat these unnecessary
  investigations.

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Patient Education

• Patients should receive
• 1- Clear explanation of the underlying
  patho-physiology and
• 2- should be instructed in the technique of
  deflation of the upper chest followed by
  controlled diaphragmatic breathing.

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Complications

• The complications encountered in patients with
  this syndrome are related mainly to the invasive
  procedures and investigations (eg, angiography)
  that are used in the workup of HVS .
• Complications may also occur as a result of
  symptoms produced indirectly by hyperventilation
  (eg, injuries sustained in a fall during a
  syncopale episode attributable to
  hyperventilation).

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Screening for OSA prior to surgery

• Pulse oximetry as a single metric of sleep apnea
  lacks the sensitivity and specificity of PSG and
  multi-channel home sleep testing.
• If the goal is only to cipher out those with an
  AHI of 15 or 20 or more, pulse oximetry can be
  considered.
• Centers for Medicare and Medicaid Services, 2009
  reported that the final decision supporting
  equally effective testing utilizing PSG and home
  sleep tests, as measured by outcomes and patient
  compliance.
• While patients with mild OSA may not require
  preoperative PAP therapy, patients with moderate
  and severe OSA who have been on PAP therapy
  should continue treatment in the preoperative
  period .
• Patients who have been noncompliant with
  instructions for CPAP use prior to surgery and
  are in need of CPAP post-surgery, pose the
  highest risk of potential complications.

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Acute hyperventilation

• Patients often present dramatically, with
  agitation, hyperpnea and tachypnea, dyspnea,
  wheezing, chest pain , dizziness, palpitations,
  tetanic cramps (eg, carpopedal spasm),
  paresthesias, generalized weakness, and Syncope.
  The patient often complains of a sense of
  suffocation.
• An emotionally stressful precipitating event can
  often be identified.
• Wheezing may be heard because of broncho-spasm
  from hypo-carbia.

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Carpopedal spasm occurs when acute hypocarbia
causes reduced ionized calcium and phosphate
levels, resulting in involuntary contraction of
the feet or (more commonly) the hands .
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Cardiac symptoms

• The chest pain associated with HVS usually has
  atypical features, but on occasion, it may
  closely resemble typical angina.
• It tends to last hours rather than minutes, and
  is often relieved rather than provoked by
  exercise. It is usually unrelieved by
  nitroglycerin.
• The diagnosis of HVS should be considered in
  young patients without cardiac risk factors who
  present with chest pain, particularly if the pain
  is associated with paresthesias and carpo-pedal
  spasm.
• ECG abnormalities may include prolonged QT
  interval, ST depression or elevation, and T-wave
  inversion.

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Cardiac symptoms

• In patients with subcritical coronary artery
  stenosis, the vasospasm induced by hypocarbia may
  be sufficient to provoke myocardial injury.
• The incidence of HVS is high among patients with
  mitral valve prolapse (MVP), and the chest pain
  associated with MVP may be due to
  hyperventilation.
• Prinzmetal angina (ie, coronary artery vasospasm)
  is triggered by HVS, but the chest pain
  associated with this syndrome normally would be
  expected to respond to nitrates or calcium
  channel blockers.

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Central nervous system symptoms

• Central nervous system (CNS) symptoms occur
  because hypocapnia causes reduced cerebral blood
  flow (CBF).CBF decreases by 2 for every 1 mm Hg
  decrease in PaCO2.
• Symptoms of dizziness, weakness, confusion, and
  agitation are common . Patients may experience
  visual hallucinations, syncope or seizure .
• Paresthesias occur more commonly in the upper
  extremity and are usually bilateral. Perioral
  numbness is very common.
• Gastrointestinal symptoms
• (eg, bloating, belching, flatus, or epigastric
  pressure) may result from aerophagia.

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Metabolic changes

• Acute metabolic changes result from intracellular
  shifts and increased protein binding of various
  electrolytes during respiratory alkalosis.
• Acute secondary hypocalcemia can result in
  carpopedal spasm, muscle twitching, a prolonged
  QT interval, and positive Chvostek and Trousseau
  signs.
• Hypokalemia tends to be less pronounced than
  hypocalcemia but can produce generalized
  weakness.
• Acute secondary hypophosphatemia is common and
  may contribute to paresthesias and generalized
  weakness.

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Chvosteks sign is twitching of facial muscles in
response to tapping over the area of the facial
nerve Trousseaus sign is carpopedal spasm that
results from ischemia, such as that induced by
pressure applied to the upper arm from an
inflated sphygmomanometer cuff .
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Chvosteks sign is neither sensitive nor
specific for hypocalcemia, since it is absent in
about one third of patients with hypocalcemia and
is present in approximately 10 of persons with
normal calcium levels.

• Trousseaus sign is more sensitive and specific
  it is present in 94 of patients with
  hypo-calcemia and in only 1 of persons with
  normal calcium levels.

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Chronic hyperventilation

• The diagnosis of chronic HVS is much more
  difficult than that of acute HVS because
  hyperventilation is usually not clinically
  apparent. Often, these patients have already
  undergone extensive medical investigations and
  have been assigned several misleading diagnoses.
• Two thirds of patients with chronic HVS have a
  persistently slightly low PaCO2 with compensatory
  renal excretion of bicarbonate, resulting in a
  near-normal pH level.
• These patients tend to have more prominent CNS
  symptoms than patients who maintain normal PaCO2
  during attacks.
• Usually present with dyspnea and chest pain.
• Frequent sighing respirations (2-3 breaths/min)
  and frequent yawning are noted.

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Chronic hyperventilation

• The respiratory alkalosis can be maintained with
  occasional deep sighing respirations, which are
  observed often in patients with chronic HVS.
• When faced with an additional stress that
  provokes hyperventilation, the physiologic
  acid-base reserve is less, and these patients
  become symptomatic more readily than patients
  without HVS.
• Dry mouth occurs with mouth breathing and
  anxiety.
• Many of these patients suffer from
  obsessive-compulsive disorders, experience sexual
  and marital difficulties, and have poor
  adaptations to stress.
• Chronic HVS may have symptoms that mimic those of
  virtually any serious organic disorder, but they
  usually have atypical features of these diseases.
  

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Differential Diagnoses

• Asthma
• Atrial Fibrillation
• Myocardial Infarction
• Diabetic Ketoacidosis
• Metabolic Acidosis
• Nasopharyngeal Stenosis
• Pneumothorax, Pneumomediastinum
• Pulmonary Embolism
• Respiratory Distress Syndrome, Adult
• Carbon monoxide poisoning
• Panic Disorders

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Approach Considerations

• Upon a first attack of acute HVS, the diagnosis
  depends on recognizing the typical constellation
  of signs and symptoms and ruling out the serious
  conditions that can cause the presenting
  symptoms.
• Acute coronary syndrome (ACS) and pulmonary
  embolism (PE) are the 2 most common serious
  entities that may present similarly to HVS.
• Clinical assessment is sufficient to rule these
  out. More specific testing is sometimes
  warranted.
• A standard workup for atypical chest pain,
  including pulse oximetry, chest radiography, and
  ECG, may still be warranted depending on the
  clinical picture.

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Approach Considerations

• Patients with a history of HVS who have undergone
  an appropriate workup at some earlier time may
  not need any further laboratory evaluation in the
  setting of a recurrence. Recognition of the
  typical constellation of dyspnea, agitation,
  dizziness, atypical chest pain, tachypnea and
  hyperpnea, paresthesias, and carpopedal spasm in
  a young, otherwise healthy patient with an
  adequate prior evaluation is sufficient to make
  the diagnosis.
• A low pulse oximetry reading in a patient who is
  hyperventilating should never be attributed to
  HVS. The patient should always be evaluated for
  other causes of hyperventilation.

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Approach Considerations

• A normal pulse oximetry reading is not helpful,
  because a severe defect in gas exchange can
  easily be masked by hyperventilation.
• A fraction of patients with chronic PE will have
  compensated chronic hyperventilation that may
  mimic primary chronic hyperventilation.
• ABG is indicated if any doubt exists as to the
  patients underlying respiratory status it may
  be helpful when HVS-induced acidosis is
  suspected, or when shunting or impaired pulmonary
  gas exchange is considered.

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Approach Considerations

• ABG sampling confirms a compensated respiratory
  alkalosis in a majority of cases. The pH is
  typically near normal, with a low PaCO2 and a low
  bicarbonate level.
• ABG sampling is also useful in ruling out
  toxicity from carbon monoxide poisoning, which
  may present similarly to HVS.
• Toxicology screening is indicated.
• If acute PE is being considered, ELISA D-dimer
  assay may be helpful.

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Pulse CO-oximeters

• Pulse Co-oximetry measures absorption at several
  wavelengths to distinguish the percentage of
  oxygenated Hemoglobin compared to the total
  amount of hemoglobin (Hb), including
  carboxyhemoglobin (carboxy-Hb), Methemoglobin
  (met-Hb), oxyhemoglobin (oxy-Hb), and reduced Hb.
• When a patient presents with carbon monoxide
  poisoning (CO), the pulse CO-oximeter will detect
  the levels of each hemoglobin and will report the
  oxyhemoglobin saturation as markedly reduced ,

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Pulse CO-oximeters

• Traditionally, this measurement is made from
  arterial blood processed in a blood gas analyzer
  with a CO-oximeter.
• More recently, pulse CO-oximeters have made it
  possible to estimate carboxyhemoglobin with
  non-invasive technology similar to a Pulse
  oximeter.
• In contrast, the use of a standard pulse oximeter
  is not effective in the diagnosis of CO poisoning
  as patients suffering from carbon monoxide
  poisoning may have a normal oxygen saturation
  reading on a pulse oximeter .

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Approach Considerations

• Imaging studies are not indicated when the
  diagnosis of HVS is clear.
• Because PE can present with findings identical to
  those of HVS, a first-ever episode of acute HVS
  may warrant V/Q scanning or CT pulmonary
  angiography to rule out perfusion defects.
• Chest radiography is indicated for patients who
  are at high risk for cardiac or pulmonary
  pathology.

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Approach Considerations

• ECG changes are common and may include the
  following
• 1- ST depression or elevation
• 2- Prolonged QT interval
• 3- T-wave inversion
• 4- Sinus tachycardia
• Rebreathing into a paper bag is not recommended
  in the field. Deaths have occurred in patients
  with acute myocardial infarction (MI),
  pneumothorax, and pulmonary embolism (PE) who
  were initially misdiagnosed with HVS and treated
  with paper bag rebreathing.

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Rebreathing into a paper bag 1- Have the
hyperventilating person breathe slowly into a
paper bag that's held closely around his or her
mouth and nose. 2- The person should breathe
like this for five to seven minutes. 3-Talk to
the individual the entire time. Try to distract
him or her and make the person feel comfortable
and safe. 4- If symptoms fail to improve or the
person loses consciousness, take him or her to
the emergency room.
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Approach Considerations

• Patients should be referred to a consultant
  psychiatrist, psychologist with expertise in
  managing HVS.
• Some physiotherapists and respiratory therapists
  have extensive experience in retraining patients
  in proper breathing techniques and should be
  consulted.

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Breathing Techniques

• Rebreathing into a paper bag is no longer a
  recommended technique, because significant
  hypoxia and death have been reported.
• Paper bag rebreathing is often unsuccessful in
  reversing the symptoms of HVS, because patients
  have difficulty complying with the technique.
  Moreover, carbon dioxide itself may be a chemical
  trigger for anxiety in these patients.
• Simple reassurance and an explanation of how
  hyperventilation produces the patients symptoms
  are usually sufficient to terminate the episode.
• Provoking the symptoms by having the patient
  voluntarily hyperventilate for 3-4 minutes often
  convinces the patient of the diagnosis.

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Breathing Techniques

• Most patients with HVS tend to breathe with the
  upper thorax and have hyper-inflated lungs
  throughout the respiratory cycle. Because
  residual lung volume is high, they are unable to
  achieve full tidal volume and experience dyspnea.
• Physically compressing the upper thorax and
  having patients exhale maximally decreases
  hyperinflation of the lungs.
• Instructing patients to breathe abdominally,
  using the diaphragm more than the chest wall,
  often leads to improvement in subjective dyspnea
  and eventually corrects many of the associated
  symptoms.

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What is calm breathing?

• Calm breathing (sometimes called diaphragmatic
  breathing) is a technique that helps you slow
  down your breathing when feeling stressed or
  anxious.
• Newborn babies naturally breathe this way, and
  singers, wind instrument players, and yoga
  practitioners use this type of breathing.
• Diaphragmatic breathing slows the respiratory
  rate, gives patients a distracting maneuver to
  perform when attacks occur, and provides patients
  with a sense of self-control during episodes of
  hyperventilation.
• This technique has been shown to be very
  effective in a high proportion of patients with
  HVS.

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Why is calm breathing important?

• Our breathing changes when we are feeling
  anxious. We tend to take short , quick, shallow
  breaths, or even hyperventilate this is called
  overbreathing.
• It is a good idea to learn techniques for
  managing overbreathing, because this type of
  breathing can actually make you feel even more
  anxious (e.g., due to a racing heart, dizziness,
  or headaches)!
• Calm breathing is a great portable tool that
  you can use whenever you are feeling anxious.
  However, it does require some practice.

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How to Do It?

• Calm breathing involves taking smooth, slow, and
  regular breaths.
• Sitting upright is usually better than lying down
  or slouching, because it can increase the
  capacity of your lungs to fill with air.
• It is best to 'take the weight' off your
  shoulders by supporting your arms on the
  side-arms of a chair, or on your lap.

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How to Do It ?

• 1. Take a slow breath in through the nose,
  breathing into your lower belly (for about 4
  seconds)
• 2. Hold your breath for 1 or 2 seconds
• 3. Exhale slowly through the mouth (for about 4
  seconds)
• 4. Wait a few seconds before taking another
  breath
• About 6-8 breathing cycles per minute is often
  helpful to decrease anxiety, but find your own
  comfortable breathing rhythm.
• These cycles regulate the amount of oxygen you
  take in so that you do not experience the
  fainting, tingling, and giddy sensations that are
  sometimes associated with overbreathing.

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Helpful Hints

• Make sure that you arent hyperventitating it is
  important to pause for a few seconds after each
  breath.
• Try to breathe from your diaphragm or abdomen.
• Your shoulders and chest area should be fairly
  relaxed and still. If this is challenging at
  first, it can be helpful to first try this
  exercise by lying down on the floor with one hand
  on your heart, the other hand on your abdomen.
  Watch the hand on your abdomen rise as you fill
  your lungs with air, expanding your chest. (The
  hand over your heart should barely move, if at
  all.)

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Pharmacologic Therapy

• Several medications, including benzodiazepines
  and selective serotonin reuptake inhibitors
  (SSRIs), have been employed to reduce the
  frequency and severity of episodes of
  hyperventilation.
• These agents require prolonged use and are best
  managed by a consultant on an ongoing outpatient
  basis rather than through sporadic prescriptions
  after an ED visit.
• Use of benzodiazepines for stress relief and for
  resetting the trigger for hyperventilation is
  effective, but again, patients may require
  prolonged treatment.

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Pharmacologic Therapy

• Benzodiazepines are useful in the treatment of
  hyperventilation resulting from anxiety and panic
  attacks.
• By binding to specific receptor sites, these
  agents appear to potentiate the effects of
  gamma-aminobutyric acid (GABA) and to facilitate
  inhibitory GABA neurotransmission and the actions
  of other inhibitory transmitters.
• Alprazolam (xanax) is indicated for treatment of
  anxiety and management of panic attacks.
• Lorazepam (ativan) is a sedative-hypnotic of the
  benzodiazepine class that has a short time to
  onset of effect and a relatively long half-life.

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Pharmacologic Therapy

• Diazepam (valium) depresses all levels of the CNS
  (eg, limbic and reticular formation), possibly by
  increasing the activity of GABA. It is considered
  second-line therapy for seizures.
• Paroxetine (paxil) is the alternative drug of
  choice for HVS. It is a potent selective
  inhibitor of neuronal reuptake of serotonin and
  has a weak effect on neuronal reuptake of
  norepinephrine and dopamine.

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