What is the treatment for hyperventilation?

Treatment of Hyperventilation

The treatment of hyperventilation requires first excluding organic illness before making the diagnosis, then monitoring oxygen saturation without administering oxygen therapy if SpO2 is normal or high, while rebreathing from a paper bag is dangerous and NOT recommended. 1

Diagnostic Approach

• Organic causes of hyperventilation must be ruled out before diagnosing hyperventilation syndrome 1
• Hyperventilation is defined as breathing in excess of metabolic needs, eliminating more CO2 than produced, resulting in respiratory alkalosis and elevated blood pH 2
• The spectrum of symptoms is extremely broad and can stem from virtually any body system, caused by low PaCO2 or increased sympathetic adrenergic tone 2

Initial Management

• Monitor oxygen saturation in patients with confirmed hyperventilation 1
• Do NOT administer oxygen therapy to patients with normal or high SpO2 1
• AVOID rebreathing from a paper bag as this can be dangerous and potentially fatal 1
  • Paper bag rebreathing can cause significant oxygen desaturation (average drop of 26 mmHg within 3 minutes) 3
  • Deaths have been reported when this technique was erroneously applied to patients who were hypoxemic or had myocardial ischemia 3

Therapeutic Approach

• Treatment should follow a staged approach based on severity 2:
  • Psychological counseling to address anxiety triggers 2, 4
  • Physiotherapy and relaxation techniques to normalize breathing patterns 2, 5
  • Drug therapy in more severe cases 2

Special Considerations

• Hyperventilation syndrome and panic disorder frequently co-occur (approximately 50% overlap) 4
• Consider screening for underlying asthma, as studies have found asthma in up to 80% of patients with hyperventilation syndrome 6
• Breathing retraining has shown success in treating panic disorder with hyperventilation symptoms 5

Contraindications for Induced Hyperventilation

• Avoid induced hyperventilation in patients with:
  • Recent stroke or significant carotid stenosis 7
  • Recent intracranial hemorrhage 7
  • Moyamoya disease 7
  • Sickle cell disease or trait 7
  • Increased intracranial pressure (relative contraindication) 7
  • Severe cardiac or pulmonary disease 7

Common Pitfalls to Avoid

• Do NOT use paper bag rebreathing technique despite its historical popularity 1, 3
• Do NOT assume hyperventilation is always psychogenic without ruling out organic causes 1
• Do NOT overlook comorbid conditions like asthma that may contribute to or mimic hyperventilation 6
• Do NOT use hyperventilation therapeutically in patients with increased intracranial pressure as it may cause rebound increases in ICP after CO2 normalization 1