What is the treatment for hyperventilation?

Treatment of Hyperventilation

The treatment of hyperventilation depends critically on the underlying cause: avoid hyperventilation in critically ill patients (cardiac arrest, acute liver failure, post-cardiac arrest care) where it worsens outcomes, but for anxiety-related hyperventilation syndrome, use reassurance, breathing retraining, and anxiolytic therapy as needed.

Critical Care Settings: Hyperventilation Should Be Avoided

Post-Cardiac Arrest Management

• Hyperventilation after cardiac arrest should be avoided as it increases intrathoracic pressure, decreases cardiac output, and reduces cerebral blood flow through vasoconstriction. 1
• Target normocapnia with ventilation at 10-12 breaths per minute, titrating to achieve PETCO2 of 35-40 mm Hg or PaCO2 of 40-45 mm Hg 1
• Oxygen should be titrated to the lowest level required to achieve arterial oxygen saturation of 94% to avoid oxygen toxicity 1

Pediatric Cardiac Arrest

• In pediatric cardiac arrest with an advanced airway, use age-appropriate respiratory rates and avoid both hypoventilation and hyperventilation. 1
• Ventilatory rates >10 breaths per minute may be reasonable for pediatric cardiac arrest with an advanced airway in place 1
• The traditional adult recommendation of 10 breaths per minute can cause hypoventilation in infants and children 1

Acute Liver Failure with Intracranial Hypertension

• Prophylactic hyperventilation has no role in acute liver failure and does not reduce cerebral edema or improve survival. 1
• Hyperventilation may be used temporarily only for life-threatening intracranial hypertension not controlled by mannitol, to prevent imminent herniation 1
• When used acutely, reduce PaCO2 to 25-30 mm Hg, but recognize this effect is short-lived and cerebral vasoconstriction may worsen cerebral edema through hypoxia 1

Pediatric Pulmonary Hypertension

• Brief hyperventilation or sodium bicarbonate infusions are useful for immediate management of pulmonary hypertensive crises 1
• However, prolonged alkalosis has adverse effects: hyperventilation can induce lung injury, and sodium bicarbonate may decrease cardiac output and cerebral blood flow 1
• Maintain adequate lung volumes and avoid acidosis, as acute hypercarbia with acidosis abruptly increases pulmonary vascular resistance 1

Acute Heart Failure

• In acute heart failure with respiratory distress, non-invasive positive pressure ventilation (CPAP or BiPAP) should be considered for patients with respiratory rate >25 breaths/min and SpO2 <90% 1
• Avoid hyperoxia and monitor acid-base balance during oxygen therapy 1

Hyperventilation Syndrome (Anxiety-Related)

Pathophysiology

• Hyperventilation syndrome involves breathing in excess of metabolic needs, eliminating more carbon dioxide than produced, resulting in respiratory alkalosis and elevated blood pH 2
• Symptoms stem from low PaCO2 and increased sympathetic adrenergic tone, with psychological mechanisms contributing to or generating symptoms 2
• About 50% of patients with hyperventilation syndrome show evidence of panic disorder, suggesting shared pathophysiology 3

Diagnostic Approach

• Confirm the patient hyperventilates with low PaCO2 2
• Exclude somatic diseases causing hyperventilation 2
• Document complaints related to hypocapnia, though recent studies question the tight relationship between hypocapnia and symptoms 2
• Arterial blood gas analysis confirms hypocapnia and may identify underlying clinical causes 4

Treatment Strategy

Stage 1: Reassurance and Education

• Educate patients about the physiologic basis of their symptoms 4
• Explain the relationship between breathing patterns and symptoms 2

Stage 2: Breathing Retraining

• Direct attention to breathing, which significantly reduces respiratory rate and decreases tidal volume instability 5
• Simple instructions to breathe more slowly or shallowly often fail because changes in respiratory rate are compensated by changes in tidal volume 5
• Avoid instructions for shallow breathing, which increases anxiety 5

Stage 3: Psychological Interventions

• Provide psychological counseling and psychotherapy for underlying anxiety 2, 4
• Use voluntary hyperventilation diagnostically to educate patients about symptoms and activate catastrophic cognitions that need restructuring 6
• Employ interoceptive exposure to sensations associated with panic 6

Stage 4: Pharmacotherapy

• Use anxiolytic drug therapy in the acute phase for anxiety-related hyperventilation 4
• Reserve pharmacotherapy for more severe cases or when other interventions are insufficient 2

Key Clinical Pitfalls

• Never use paper bag rebreathing in critically ill patients, as it may mask serious underlying conditions like hypoxemia, pulmonary embolism, or metabolic acidosis 4
• Simple breathing instructions without physiologic monitoring may not achieve the intended respiratory changes 5
• Hyperventilation during EEG recordings is contraindicated in patients with recent stroke, significant carotid stenosis, recent intracranial hemorrhage, Moyamoya disease, and sickle cell disease 7