Is breathing into a paper bag an effective treatment for hyperventilation?

Breathing into a Paper Bag for Hyperventilation: Not Recommended and Potentially Dangerous

Rebreathing from a paper bag is dangerous and is NOT recommended as a treatment for hyperventilation syndrome. 1 This traditional practice can lead to significant drops in oxygen levels, potentially causing hypoxemia and increasing risk of death, particularly in patients with underlying cardiac or pulmonary disease.

Why Paper Bag Breathing Is Dangerous

• Studies have shown that paper bag rebreathing can cause dangerous drops in oxygen levels:

  • After just 30 seconds of rebreathing, mean oxygen levels drop by approximately 16 mmHg
  • After 3 minutes, oxygen levels can drop by an average of 26 mmHg, with some individuals experiencing drops as severe as 42 mmHg 2
  • These drops can be life-threatening in patients who are already hypoxemic or have myocardial ischemia

• Fatal cases have been documented when paper bag breathing was erroneously applied to patients who had:

  • Underlying hypoxemia
  • Myocardial ischemia
  • Other organic conditions misdiagnosed as hyperventilation 2

Proper Management of Hyperventilation

1. Rule out organic illness first

   • Organic illness must be excluded before making a diagnosis of hyperventilation 1
   • Monitor oxygen saturation to confirm normal or high SpO2 levels
   • Patients with normal or high SpO2 do not require oxygen therapy 1

2. Effective treatment approaches

   • Reassurance and education about symptoms
   • Breathing retraining techniques focusing on slow, controlled breathing
   • Relaxation techniques
   • Cognitive behavioral therapy for associated anxiety

3. For healthcare providers

   • Monitor oxygen saturation in all suspected cases
   • Position patients appropriately (upright if possible)
   • Avoid any interventions that could worsen hypoxemia
   • Consider underlying conditions that may mimic hyperventilation

Common Pitfalls in Managing Hyperventilation

• Misdiagnosis: Symptoms of hyperventilation (dizziness, chest pain, numbness) can mimic serious conditions like myocardial infarction, pulmonary embolism, or stroke
• Inappropriate interventions: Using paper bag rebreathing without ruling out organic causes first
• Overlooking psychological factors: Approximately 50% of patients with hyperventilation syndrome also meet criteria for panic disorder
• Excessive focus on CO2 levels: While hyperventilation does cause hypocapnia, the relationship between CO2 levels and symptoms is complex

Evidence Quality

The recommendation against paper bag rebreathing comes from high-quality guidelines, including the British Thoracic Society guideline for oxygen use 1, which explicitly states that "rebreathing from a paper bag may cause hypoxaemia and is not recommended." This recommendation is supported by research demonstrating the potential dangers of this practice 2.

Despite the common portrayal in media and some outdated medical practices, there is no credible evidence supporting the effectiveness or safety of paper bag rebreathing for hyperventilation syndrome 3.