Is breathing into a paper bag a recommended treatment for anxiety attacks?

Breathing into a Paper Bag is NOT Recommended for Anxiety Attacks

Rebreathing from a paper bag is dangerous and is NOT advised as a treatment for hyperventilation or anxiety attacks. 1

Why Paper Bag Breathing is Dangerous

The British Thoracic Society (BTS) explicitly warns against this practice in their guidelines for oxygen use in healthcare settings. This recommendation is based on several important safety concerns:

1. Risk of hypoxemia: Paper bag rebreathing can cause dangerous drops in oxygen levels. Research has shown that rebreathing into a paper bag for just 30 seconds can decrease oxygen levels by approximately 16 mmHg, and by 3 minutes, oxygen levels can drop by an average of 26 mmHg 2. Some individuals experienced drops as severe as 42 mmHg.

2. Misdiagnosis risk: What appears to be anxiety-induced hyperventilation may actually be a symptom of a serious underlying condition requiring oxygen, such as:

   • Asthma attack
   • Pulmonary embolism
   • Myocardial infarction
   • Diabetic ketoacidosis

3. Documented fatalities: There have been reported cases where paper bag rebreathing, erroneously applied to patients who were actually hypoxemic or had myocardial ischemia, resulted in death 2.

Safe Alternatives for Managing Anxiety Attacks

Instead of paper bag breathing, the following evidence-based approaches are recommended:

1. Controlled Breathing Techniques

• Pursed-lip breathing: Inhale through the nose for several seconds, then exhale slowly through pursed lips for 4-6 seconds 1
• Diaphragmatic breathing exercises
• Coordinated breathing training

2. Body Positioning

• Sitting upright increases peak ventilation and reduces airway obstruction 1
• Leaning forward with arms bracing a chair or knees has been shown to improve ventilatory capacity 1
• Relaxing and dropping the shoulders reduces the hunched posture associated with anxiety 1

3. Sensory Grounding Techniques

These techniques help keep people present in the moment and prevent dissociation 1:

• Noticing environmental details (colors, textures, sounds)
• Cognitive distractions (word games, counting backward)
• Sensory-based distractors (feeling textured items)

4. Psychological Approaches

• Cognitive restructuring to address catastrophic thoughts about physical sensations 1
• Education about the physiological process of anxiety and its physical impact 1
• Mindfulness and relaxation techniques

Special Considerations

For patients experiencing severe, persistent anxiety attacks:

• Ensure organic illness is excluded before making a diagnosis of hyperventilation 1
• Monitor oxygen saturation in patients with diagnosed hyperventilation 1
• Those with normal or high SpO₂ do not require oxygen therapy 1
• Consider referral for cognitive behavioral therapy, which has shown effectiveness for panic disorder 1, 3

Conclusion

While paper bag rebreathing was once a common recommendation for anxiety-related hyperventilation, current clinical guidelines explicitly advise against this practice due to serious safety concerns. The BTS guidelines clearly state that "rebreathing from a paper bag can be dangerous and is NOT advised as a treatment for hyperventilation" 1. Instead, healthcare providers should recommend evidence-based breathing techniques, proper positioning, and psychological approaches to manage anxiety attacks safely and effectively.