treatment of the hyperventilation syndrome
Post on 19-May-2022
10 Views
Preview:
TRANSCRIPT
Henry Ford Hospital Medical Journal
Volume 22 | Number 4 Article 4
12-1974
Treatment of the Hyperventilation SyndromeHans von Brauchitsch
Follow this and additional works at: https://scholarlycommons.henryford.com/hfhmedjournalPart of the Life Sciences Commons, Medical Specialties Commons, and the Public Health
Commons
This Article is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in HenryFord Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons.
Recommended Citationvon Brauchitsch, Hans (1974) "Treatment of the Hyperventilation Syndrome," Henry Ford Hospital Medical Journal : Vol. 22 : No. 4 ,203-210.Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol22/iss4/4
Henry Ford Hosp. Med. Journal
Vol . 22, No. 4, 1974
Treatment of the Hyperventilation Syndrome
Hans von Brauchitsch, M D *
A review oi the literature on the hyperventilation syndrome reveals a variety of treatment approaches and a virtual absence of controlled studies of this common problem. Attempts to treat the condition by changing the respiratory pattern through mechanical means can be traced back to the first century A.D. The "paper bag method" of treatment has many psychological drawbacks and is often unsuccessful. Several avenues of drug treatment have been explored: acidifiers, minor tranquilizers, antidepressants, and stimulants. Reports of success with insight-oriented intensive psychotherapy are scarce. Some forms of group psychotherapy have been tried with success. The model of the "medical friendship" may be most appropriate, and abreaction as well as verbal ventilation may prevent respiratory hyperventilation at least temporarily. Research is badly needed, utilizing the physiological changes occurring in the hyperventilation syndrome.
'Formerly, Department of Psychiatry, Henry Ford Hospital
Address requests for reprints to Dr. von Brauchitsch at the University of Oklahoma, Health Sciences Center, P.O. Box 26901, Oklahoma City, OK 73190.
I HE American Handbook of Psychiatry discusses the hyperventi lat ion syndrome under the heading of " C o m m o n l y Neglected Psychosomatic Syndromes".' Considering the fact that this disorder may be more prevalent than schizophrenia, that subjectively it is profoundly unpleasant, and that mil l ions of dollars are spent yearly for emergency care and treatment, one wonders why most textbooks lend it a few f leeting sentences, at best.
It has been established that approximately 5% of all patients ^een in gast r oen te ro l ogy , ' over 10% of those seen in internal medic ine ' and up to one third of all patients in general practice" suffer f rom hypervent i lat ion. The syndrome is frequent ly encountered by the pediatrician^ and is of great concern to the o b s t e t r i c i a n . " O f all medical specialities, the psychiatrist's office appears to be the only one in which hyperventi lators are seen rarely, if at all.
Since patients wi th hyperventi lat ion syndromes are almost always first seen by non-psychiatric physicians, one questions why are they so rarely referred to psychiatrists? It may well be that the seemingly gross organic pathology of the syndrome leads the primary physician to rule out all possible concomitant organic factors. Or the opposite may be t rue: the sharp discrepancy between the alleged harmlessness of the condi t ion and its dramatic symptomatology may
203
von Brauchitsch
produce a shrug-of-the-shoulder, " just-another-hypervent i lator" att i tude f rom the emergency room physician. The att i tude of bel i t t l ing the seriousness of the syndrome is the least just i f ied. Hyperventi lat ion attacks may not threaten physical survival, but the hyperventi lat ion syndrome in its chronic form can become an exceedingly disabling and intractable condi t ion. In my experience, very few hyperventi lators are ever cured, and a large percentage become literally cr ippled to the point of social useless-ness. For this reason, a review of the unfo r tuna te ly meager the rapeu t i c armamentarium available to the physician may help to stimulate efforts to f ind more reliable remedies.
Nosology and Classification
It is reasonable to question whether the hyperventi lat ion syndrome is a disease entity or one of the ubiquitous physiological concomitants of anxiety. I have chosen to treat the condi t ion for practical reasons as i f it were a nosological entity. But I am wi l l ing to concede that, even in the context of this paper, the term could delineate a target symptom rather than a disease. The fact that the hyperventi lat ion syndrome produces measurable organic changes of b lood gases, pH of b lood and ur ine, elect rocardiogram, electroencephalogram, etc wou ld place it theoretically into the category of psychosomatic diseases. One source of confusion regarding defini t ion of the syndrome, however, is that it tends to be grouped w i th purely psychological disturbances, especially wi th the so-called "actual neuroses". The list of condit ions identical w i th or closely related to the hyperventi lat ion syndrome appears endless.
It is possible to distinguish between acute and chronic hyperventilation syndrome. Transitions occur and the presence of one form does not preclude the emergence of the other. The acute
hyperventi lat ion syndrome is frequently associated wi th acute, overwhelming anxiety and therefore also called anxiety state, anxiety neurosis, hysterical attack, or hyperventi lat ion tetany. The anxiety label is popular among psychiatrists, but not entirely correct, since not all hyperventi lat ion attacks are accompanied by overt anxiety, and because not all anxiety states produce noticeable hyperventi lat ion . It is certainly not related to hysteria in the form of neurosis, al though it may occur more frequently in patients diagnosed as hysterical characters."-'' The chron ic hype rven t i l a t i on synd rome tends to produce a mult i tude of physical symptoms often wi thout pronounced emotional concomitants. Many physical complaints refer to the heart rather than to respiration and account for hyperventi lat ion syndrome being labelled as Da Costa's syndrome, neurocirculatory asthenia, ef fort syndrome, soldier's heart, irritable heart, vasomotor instability, vasomotor neurosis, cardiac neurosis, etc. '"
In many cases, the chronic fatigue (chronic hyperventi lat ion f rom vigorous physical exercise') forms a picture identical w i th that of neurasthenia, effort syndrome, or chronic exhaustion state. The condi t ion may simulate the symptoms of funct ional hypoglycemia" ; the typical dry tongue caused by mouth-breathing has been described under the name of xerostomia. Finally, it may be associated w i th chronic aerophagia, producing a mult i tude of " func t iona l " gastrointestinal s y m p t o m s . C o m m o n to all forms is the pathognomic "s ighi n g " , open-mouthed respiratory pattern which uses intercostal respiratory muscles.
Treatment
A. Increase of Blood Dioxide Content
Since the hyperventi lat ion syndrome is characterized by carbon dioxide deplet ion and paradoxical st imulation of
204
Treatment of the Hyperventilation Syndrome
the medullary respiratory centers, it appears logical to treat the condi t ion by manipulat ing the inspired gases. This approach has almost two thousand years of medical endorsement. Aretaeus of Capadocia recommended as early as 100 A.D. b lowing "evi l -smel l ing fumes" into the faces of those a f f l i c ted . " A 17th century formulary gives the prescript ion for a " p a r f u m " consisting of castorea, partr idge feathers, paper and asa foetida to be smelled by patients suffering f rom "les suffocation de la ma t r i ce " . " Castorea is a substance extracted f rom the perineal glands of beavers and its effect may have been comparable to the sensat ion of being sprayed by a skunk — a powerfu l deterrent to hyperventi lat ion, if not respiration of any k ind. A textbook of medicine publ ished in 1766 suggests "s t ink ing and volatile spir i ts" or just singed feathers, burn ing leather or burnt horncombs be held under the nose of those s u f f e r i n g f r o m " s u f f o c a t i o hysterica".'" Wi th theadvento f the ageof reason, the method was merely altered, but not abol ished. That the ammonia in the smelling-salt bottles of the Victorian lady actually stimulated the medullary centers other than momentari ly is hard to believe, but it is a permissible assumpt ion that the act of smell ing ammonia wou ld slow down an accelerated respiratory rate. One British physician invented a spring belt to be worn around the chest in order to reduce the patient's breathing rate. Since the inventor of this gadget applied it indiscriminately to hyperventi lators as well as to patients suffering f rom heart disease, it fell understandably soon into ob l iv ion. " ' One may speculate that the enormous popularity of the cigarette, especially in t imes r iddled by the anxiety of strife and war, may not so much be due to "ora l fixat i o n " as to the fact that one cannot smoke and hyperventilate easily at the same t ime. (It is proverbial to " l ight u p " after a bad scare). Since t ime immemorial, people have used singing and whist
l ing ("whist l ing in the dark") to regulate their respiratory rates dur ing times of anxiety.
Modern medicine has cont inued the tradit ion by recommending the use of the "paper bag m e t h o d " (increasing arterial carbon dioxide tension by breathing f rom a bag and thus helping to correct the respiratory alkalosis which explains some of the acute symptoms). The method can be dramatically effective at t imes. In my own experience, however, the paper bag method is more a liability than an asset. It may work once or even twice; but since it does nothing to attenuate the anxiety underlying the hyperventi lat ion attack, the patient soon loses faith or feels that he is being r id iculed. Its use may drive the patient to seek help in the emergency room of another hospital at the t ime of his next attack, leaving the physician wi th the erroneous belief that he had " c u r e d " his patient.
One simple method to regulate the patient's breathing rate is by encouraging him or her to talk. Provided that the acute hyperventi lat ion attack has not progressed too far (in which case the patient's sensorium may be clouded to the point where rational conversation is no longer possible), it is usually helpful to ask the patient to give a thorough and clear descript ion of symptoms. Relatives ought to be excluded because they tend to insist on tel l ing their side of the story. The patient is encouraged to talk loudly and clearly (it may be permissible to develop a transient partial deafness dur ing the interview). The combinat ion of reassurance and enforced respiratory slowdown is often sufficient to br ing relief wi th in five to ten minutes.
B. Drugs
Evaluation of the efficacy of drugs in the hyperventi lat ion syndrome is diff icul t . First, hyperventi lat ion attacks are
205
von Brauchitsch
too unpredictable and the reassuring effect of medical attention is too pronounced to d is t inguish between a genuine drug and a placebo-effect. Second , since many hyperventi lators have been exposed to a mul t i tude of drugs, p rescr ibed unsuccessfu l ly by the i r physicians, they tend to be skeptical about any kind of drug. Subsequently, their drug-taking habits are unpredictable and there is a pronounced tendency to modify or discont inue prescriptions at wi l l . Finally, because of the marked anxiety pervading the cond i t ion , and the need for medical support , the patient may reject the very medication which wou ld ult imately be effective, because he subconsciously fears that improvement wi l l cut him off f rom his justificat ion to contact his doctor. These are the patients who develop the strangest and most outlandish "side ef fects" to drugs which are known to be totally harmless.
Prior to the advent of effective and safe tranquil izers, the medical l i terature recommended the use of drugs which wou ld affect the b lood pH directly. Ammonium chlor ide, 1 gm three to four times daily, was said to be the medicat ion of cho i ce , " although to my knowledge there are no control led or fo l low-up studies reported in the l i terature. Equally unsupported appears the claim that acid-ash diets, carbonated water, phenoxyethy lamine, ergotamine, yoh imbine, hydrastine, qu in ine, pilocarpine, histamine or acetylcholine wi l l br ing relief.
Wi th the development of modern tranqui l izers, it is possible to affect the anxiety component of the hyperventi lat ion syndrome. Surprisingly enough, although much effort has been dedicated to the evaluation of the various drugs' usefulness in anxiety states, very little has been said about their use in the h y p e r v e n t i l a t i o n s y n d r o m e . Many
hyperventi lators have been exposed over the years to the ent ire pharmacological armamentar ium of off ice practice. In my practice, I cannot remember a single patient w h o had not had previous drug treatment. This drug exposure implies l imited usefulness but ineffectiveness may not be so much a funct ion of their chemistry, as of the prescribed dosage. Many physicians tend to use the min imum recommended dosage of any psychotropic drug only, notwithstanding the fact that the massive anxiety, encountered especially in the acute hyperventi lat ion syndrome, cannot be expected to yield to such homeopathic administrations as five or ten mill igrams of chlordiazepoxide. In view of the paroxysmal nature of the actue hyperventi lat ion syndrome, I have found tranquil izers useful on a demand schedule in moderate to high dosage. If the fu l lb lown syndrome is already present (for instance, at the t ime of admission to the emergency room), 100 mgm of chlordiazepoxide may be administered intramuscularly. Patient and family should be to ld that drowsiness or sleep wi l l ensue. After establishing a good work ing relationship w i th a patient, I prescrit je 25 mgm chlordiazepoxide capsules (or an equivalent dosage of any minor tranqui l izer) , two capsules to be taken as soon as an impending attack is felt. Again, the patient is instructed to rest and to abstain temporar i ly f rom driving a car or any potential ly hazardous occupat ion. Sometimes the dosage has to be repeated unti l the attack is under ful l cont ro l . Admit tedly this regimen is less effective once the disease has entered a chronic stage.
Contro l led clinical trials have been conducted of antidepressant drugs'* wi th favorable results, al though clinically manifest depression is qui te rare in hyperventi lat ion syndrome. No pharmacological rationale has been of fered, nor are there long-term or fo l low-up
206
Treatment of the Hyperventilation Syndrome
studies in the l i terature. I tend to agree cautiously that, in chronic hyperventi lation syndrome, antidepressant drugs appear more beneficial than tranquil izers. A trial w i th antidepressants or ant idepressant / t ranqu i l i zer comb inations appears justif ied especially if a strong pain component (chest wall pain) is present. In patients wi th the chief complaint of l ightheadedness, depersonal izat ion sensat ions, xeros tomia, and excessive thirst, such drugs may produce adverse rather than beneficial results. From the antidepressants it is a short step to the use of stimulants. Again, my own experience is not unfavorable, especially if the patient complains about chronic fatigue and exhaust i on . Due precautions against the abuse of these drugs have to be taken.
Relevant in this context is the question which drugs not to use in the hyperventilation syndrome. The chronic hyperventi lation syndrome, especially if chest wall pains are present, may be mistaken for angina pectoris and treated wi th ni troglycerine or amylnitr i te. Both drugs have been proven to aggravate abnormal EEC findings related to hyperventi lat ion. ' ' If the psychological roots of the disease are recognized, some physician may erroneously conclude that the patient is "hyster ica l " and revert to the use of placebos. This does the patient injustice because it is recognized by many psychiatrists that placebos should be used under no circumstances.
Finally, since chronic hyperventi lators suffer f rom such a large number of ills and ai lments, the role of over-the-counter drugs should also be assessed. I have seen hyperventi lat ing patients who consumed staggering doses of acetyl-salicylic acid day in and day out . Salicylates, if used in suff iciently high dosages, can produce hyperventi lat ion alkalosis by themselves, thereby predisposing the hyperventi lator to some of the most t roublesome symptoms of the disease.
C. Psychological approaches
Some authors recommend a very simple procedure to alleviate the patient's apprehension. They instruct the patient to forcibly hyperventi late in the presence of the physician. The re-emergence of the symptoms of the hyperventi lat ion syndrome then not only secures the correct diagnosis, but serves as a major therapeutic too l . It clarifies the under ly ing mechanism of the condi t ion for the pat ient, thus alleviating his anticipatory anxiety and strengthening his conf i dence in the phys ic ian. ' . " . • " , ' "
This technique can be highly effective but should be used cautiously. First, not all hyperventi lators are able to reproduce an attack in the physician's off ice. There is no real mot ivat ion for prolonged hyperventi lat ion because the very presence of the physician is reassuring to the point where no true anxiety bui ld-up can occur. The more chronic the cond i t ion , the less likely is the test to succeed. The net result may be a mere embarrassment to the patient and the physician alike, or an angry reaction on the side of the latter because the patient "d i d not cooperate" .
Even if some or all of the acute symptoms can be reproduced, the relief felt by the patient may turn out to be short lived. The inf luence of intellectual understanding on the under ly ing emot ions is minute, and the first recurrence of an uncontrol lable hyperventi lat ion attack outside of the doctor 's off ice may shatter all hopes, as well as the faith in the physician's skills. Hyperventi lat ion is a chronic habit disturbance, and bad habits cannot be overcome by simply point ing out to the patient that they exist.^
Psychotherapy is almost universally recommended, but since not all investigators were psychiatrists, the meaning of the word is frequent ly vague. It ranges
207
von Brauchitsch
f rom simple reassurance, preferably by a non -psych ia t r i c p h y s i c i a n ' " over "psychocatharsis and re-educat ion"," "at t i tude therapy" ' ' ' to intensive, uncove r i n g , psychoana ly t i ca l l y o r i e n t e d psychotherapy.' '" The outcome is usually considered favorable, an opt imism which is as surprising as it is unsupported by clinical data.
To clarify the issue, it wi l l be necessary to digress briefly into the history of the development of psychotherapeutic concepts. In classic psychoanalytic nosology, the hyperventi lat ion syndrome is viewed as an organ neurosis.^'' The cont e m p o r a r y psych ia t r i c t e r m is psychosomatic disease. Even if viewed as a modification of an anxiety state (or anxiety neurosis), in the older nomenclature the condi t ion wou ld be categorized as an ac tua l neuros is . (The " a c t u a l neuroses" are anxiety states, neurasthenia, and hypochondriasis). Unfor tunately, and obviously caused by a historical misunderstanding of the Freudian use of the word neurosis, contemporary nomenclature lists the actual neurosis together w i th the transference neuroses, (hysteria, phobia, obsessive-compulsive and depressive neurosis) wi th which they have litt le in common . Psychoanalytic psychotherapy is the treatment of choice in the transference neurosis, but almost all psychoanalysts, including Freud and Fenichel,' ' ' state that it is ineffectual in the actual neuroses and the organ neuroses.
The explanation for the lack of success of insight (interpretative) psychotherapy in the hyperventi lat ion syndrome is obvious. As in many psychosomatic diseases, the ult imate root of the condi t ion is a physiological emergency reaction. In the face of danger the organism is biologically prepared for f ight or f l ight . ' This is an entirely di f ferent mechanism than the one seen in the transference neuroses, which are symbolic expressions of repressed instinctual confl icts.
In the majority of cases, hyperventi lat ion is a physiological reflex and therefore not accessible to psychoanalytic interpretation or insight. The actual cause of the anxiety is, according to my observations, not so much repressed by the hyperventi lator, but rather suppressed or plain ignored. A great many of these patients are either too isolated to be able to relate their fears to a sympathetic listener, or have a peculiar sense of shame preventing them f rom "comp la in ing " , which they regard as a sign of weakness. If encouraged, they are able to recall traumatic experiences leading directly to their acknowledged fear of sudden death. In a large number of cases this event was either the sudden death of a member of the family or the patient's own involvement in an accident. It is qui te surprising to observe the rapid decrease of hyperventi lat ion attacks once the patient is given the opportuni ty to talk about his worr ies. The drawback of this therapeutic approach is the fact that it is interminable: As soon as the patient ceases to ventilate his fears, he is bound to hyperventilate again.
Theoretically, the need for venti lation and catharsis and the disturbances of interpersonal communicat ion skills could make the hyperventi lator an excellent candidate for group psychotherapy. In my experience, that approach works only in a few selected cases. Llnless very wel l prepared, the patient wi l l quickly revert into customary silence, feeling that he cannot afford to " b o t h e r " other group members wi th his apprehensions. One important exception to this rule are inspirational groups like "Recovery Inc." who are often highly effective in keeping the patient funct ion ing.
Thus, the psychotherapeutic approach to the hyperventi lat ion syndrome resembles closely the psychotherapy of most psychosomatic diseases. The main accent is on the establishment of a
208
Treatment of the Hyperventilation Syndrome
"med ica l f r i endsh ip " , involv ing the therapist as a person who is capable of showing sympathy and understanding, who wi l l not hesitate to help the patient wi th everyday decisions and the resolut ion of environmental problems, if warranted. Since fear of death is one of the mainsprings of the cond i t ion , the physician wi l l do well to emphasize the medical role. Dependency on the physician is bound to develop but must be regarded as a reasonable price to prevent invalidity. As in many other psychosomatic condi t ions, therapy can offer cure only in very few cases, some degrees of improvement in many, and prevention of further deteriorat ion in patients w h o already have entered into the chronic stage of the disease.
Discussion
If the approach used in this paper is impressionistic and possibly even poly-pragmatic in an era of strict scientific demands, one has to realize that this less-than-scientif ic t reatment of the issue was not by choice, but by necessity.
Dealing wi th a problem wi th scientific objectivity requires operat ing in a def ined conceptual f ramework. Criteria for diagnosis must be standardized and the natural history of the disease — its course wi thout treatment — must have been established. To assess the effectiveness of therapy there must be some yardstick to measure the degree and
severity of the illness. None of these are possible in the hyperventi lat ion syndrome. Here, condit ions for research are still pre-scientif ic. Any attempt at investigating the efficacy of treatment is at such an early and unsophisticated stage that results may sound like a treatise on the remedy of swamp fever wr i t ten in the early nineteenth century.
This is a surprising state of affairs. The physiological f indings in the hyperventilation syndrome have been well exp lored. At least the physical aspects of the condi t ion should be easily accessible to exact, scientific measurement. There seems to be no valid excuse for diagnosing a condi t ion characterized by simple and clear metabolic and physiological abnormalit ies by the same intuit ive and impressionistic criteria as "neurasthen ia" and "hypochondr ias is . "
If this observation is true for diagnostic methods, it should be equally valid for therapy. If the metabolic aberrations responsible for the condi t ion can be measured, then, one may assume, they can also be reversed. A medical science that feels competent to modify the genetic code ought to be capable of dealing wi th the biochemical sequelae of transient hypocapnia. One may anticipate that correct ion of the underly ing somatic factors may do very litt le to inf luence the emotional maladjustment reaction. But, that is an indispensible first step to rendering the patient accessible to other means of treatment.
References
Wahl CW: Commonly neglected chosomatic syndromes. In Arieti, S. American Handbook of Psychiatry.
psy-ed.: Vol.
I l l , pp 158-65, Inc, 1966
New York Basic Books
McKell TE and Sullivan T: The hyperventilation syndrome in gastroenterology. Gastroenterology 9:6-16, 1947
3. Rice RL: Symptom patterns of hyperventilation. Amer J Med 8:691-700, 1950
4. Kerr WJ, Dalton JW and Gliebe PA: Some physical phenomena associated with the anxiety states and their relation to hyperventilation. Ann Intern Med 37:962-92, 1937
209
von Brauch i tsch
5. Enzer NB and Walker PA: Hyperventi lat ion syndrome in ch i ldhood . J Pediat 70:521-32, 1967
6. Motoyama EK, Rivard G, Acheson F and Cook, C: Adverse effects of maternal hypervent i lat ion on the foetus. Lancet 1:286-8, Feb 1966
7. Ames, F: The hypervent i lat ion syndrome. / Ment 5c/ 101:466-525, 1955
10. W o o d P: DaCosta's syndrome (or ef for t syndrome). Brit M e d J 1:767-72, 1941
11. Edwards WL and Lummus WL: Functional hypoglycemia and the hypervent i lat ion syndrome: A clinical study. Ann Intern M e d 42:1031-40, 1955
12. A c k e r k n e c h t E: A shor t h is to ry o f psychiatry. Translated by S. Wol f f , New York, London : Hafner, 1959
8. W i t t k o w e r ED and W h i t e KL: Psychophysiologic aspects of respiratory d isorders . A r i e t i , S., Ed.: Amer ican Handbook o f Psychiatry, 1:690-707. New York, Basic Books Inc. 1959
9. Engel CL, Ferris EB and Logan M : Hypervent i la t ion; analysis of clinical symptomatology. Ann Intern Med. 27:683-704, 1947
13. Tencke H: Formules de medecine tirees de la pharmacie galenique et chymique. Part I,Sec IV, Chapitre V I : Des parfums, pp 270-2. Lyon: Jean Certe 1640
14. Heisters DL: Practisches Medizinisches Handbuch. Capitel 10: Von den Mutter-beschwerden. Malum hyster icum, pp 192-5, Nuernberg : Gabriel Raspe, 1766
210
top related