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Treatment of the Hyperventilation Syndrome Hans Von Brauchitsch

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Treatment of the Hyperventilation Syndrome Hans Von Brauchitsch Henry Ford Hospital Medical Journal Volume 22 | Number 4 Article 4 12-1974 Treatment of the Hyperventilation Syndrome Hans von Brauchitsch Follow this and additional works at: https://scholarlycommons.henryford.com/hfhmedjournal Part of the Life Sciences Commons, Medical Specialties Commons, and the Public Health Commons Recommended Citation von 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 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 Henry Ford Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons. Henry Ford Hosp. Med. Journal Vol. 22, No. 4, 1974 Treatment of the Hyperventilation Syndrome Hans von Brauchitsch, MD* I HE American Handbook of Psychiatry discusses the hyperventilation syndrome under the heading of "Commonly Neglected Psychosomatic Syndromes".' Considering the fact that this disorder may be more prevalent than schizo­ A review oi the literature on the hyperventila­ phrenia, that subjectively it is pro­ tion syndrome reveals a variety of treatment foundly unpleasant, and that millions of approaches and a virtual absence of con­ dollars are spent yearly for emergency trolled studies of this common problem. At­ care and treatment, one wonders why tempts to treat the condition by changing the respiratory pattern through mechanical most textbooks lend it a few fleeting sen­ means can be traced back to the first century tences, at best. A.D. The "paper bag method" of treatment has many psychological drawbacks and is It has been established that approxi­ often unsuccessful. Several avenues of drug treatment have been explored: acidifiers, mately 5% of all patients ^een in gas­ minor tranquilizers, antidepressants, and troenterology,' over 10% of those stimulants. Reports of success with insight- seen in internal medicine' and up to oriented intensive psychotherapy are scarce. one third of all patients in general prac­ Some forms of group psychotherapy have been tried with success. The model of the tice" suffer from hyperventilation. The "medical friendship" may be most appro­ syndrome is frequently encountered by priate, and abreaction as well as verbal ventila­ the pediatrician^ and is of great con­ tion may prevent respiratory hyperventilation cern to the obstetrician." Of all at least temporarily. Research is badly needed, medical specialities, the psychiatrist's of­ utilizing the physiological changes occurring in the hyperventilation syndrome. fice appears to be the only one in which hyperventilators are seen rarely, if at all. Since patients with hyperventilation syndromes are almost always first seen by non-psychiatric physicians, one ques­ tions why are they so rarely referred to psychiatrists? It may well be that the seemingly gross organic pathology of 'Formerly, Department of Psychiatry, Henry the syndrome leads the primary physi­ Ford Hospital cian to rule out all possible concomitant organic factors. Or the opposite may be Address requests for reprints to Dr. von true: the sharp discrepancy between the Brauchitsch at the University of Oklahoma, Health Sciences Center, P.O. Box 26901, alleged harmlessness of the condition Oklahoma City, OK 73190. and its dramatic symptomatology may 203 von Brauchitsch produce a shrug-of-the-shoulder, "just- hyperventilation syndrome is frequently another-hyperventilator" attitude from associated with acute, overwhelming the emergency room physician. The at­ anxiety and therefore also called anxiety titude of belittling the seriousness of the state, anxiety neurosis, hysterical attack, syndrome is the least justified. Hyper­ or hyperventilation tetany. The anxiety ventilation attacks may not threaten label is popular among psychiatrists, but physical survival, but the hyperventila­ not entirely correct, since not all hyper­ tion syndrome in its chronic form can ventilation attacks are accompanied by become an exceedingly disabling and in­ overt anxiety, and because not all anxiety tractable condition. In my experience, states produce noticeable hyperventila­ very few hyperventilators are ever cured, tion. It is certainly not related to hysteria and a large percentage become literally in the form of neurosis, although it may crippled to the point of social useless- occur more frequently in patients diag­ ness. For this reason, a review of the un­ nosed as hysterical characters."-'' The fortunately meager therapeutic ar­ chronic hyperventilation syndrome mamentarium available to the physician tends to produce a multitude of physical may help to stimulate efforts to find symptoms often without pronounced more reliable remedies. emotional concomitants. Many physical complaints refer to the heart rather than Nosology and Classification to respiration and account for hyperven­ tilation syndrome being labelled as Da It is reasonable to question whether Costa's syndrome, neurocirculatory as­ the hyperventilation syndrome is a dis­ thenia, effort syndrome, soldier's heart, ease entity or one of the ubiquitous irritable heart, vasomotor instability, physiological concomitants of anxiety. I vasomotor neurosis, cardiac neurosis, have chosen to treat the condition for etc.'" practical reasons as if it were a nosologi­ cal entity. But I am willing to concede that, even in the context of this paper, In many cases, the chronic fatigue the term could delineate a target symp­ (chronic hyperventilation from vigor­ tom rather than a disease. The fact that ous physical exercise') forms a pic­ the hyperventilation syndrome produces ture identical with that of neurasthenia, measurable organic changes of blood effort syndrome, or chronic exhaustion gases, pH of blood and urine, elec­ state. The condition may simulate the trocardiogram, electroencephalogram, symptoms of functional hypoglycemia"; etc would place it theoretically into the the typical dry tongue caused by mouth- category of psychosomatic diseases. breathing has been described under the One source of confusion regarding def­ name of xerostomia. Finally, it may be inition of the syndrome, however, is associated with chronic aerophagia, that it tends to be grouped with purely producing a multitude of "functional" psychological disturbances, especially gastrointestinal symptoms.Common with the so-called "actual neuroses". to all forms is the pathognomic "sigh­ The list of conditions identical with or ing", open-mouthed respiratory pattern closely related to the hyperventilation which uses intercostal respiratory mus­ syndrome appears endless. cles. Treatment It is possible to distinguish between acute and chronic hyperventilation syn­ A. Increase of Blood Dioxide Content drome. Transitions occur and the pres­ Since the hyperventilation syndrome ence of one form does not preclude the is characterized by carbon dioxide de­ emergence of the other. The acute pletion and paradoxical stimulation of 204 Treatment of the Hyperventilation Syndrome the medullary respiratory centers, it ap­ ling ("whistling in the dark") to regulate pears logical to treat the condition by their respiratory rates during times of manipulating the inspired gases. This anxiety. approach has almost two thousand years of medical endorsement. Aretaeus of Modern medicine has continued the Capadocia recommended as early as 100 tradition by recommending the use of A.D. blowing "evil-smelling fumes" into the "paper bag method" (increasing ar­ the faces of those afflicted." A 17th cen­ terial carbon dioxide tension by breath­ tury formulary gives the prescription for ing from a bag and thus helping to cor­ a "parfum" consisting of castorea, par­ rect the respiratory alkalosis which ex­ tridge feathers, paper and asa foetida to plains some of the acute symptoms). The be smelled by patients suffering from method can be dramatically effective at "les suffocation de la matrice"." Cas­ times. In my own experience, however, torea is a substance extracted from the the paper bag method is more a liability perineal glands of beavers and its effect than an asset. It may work once or even may have been comparable to the sensa­ twice; but since it does nothing to at­ tion of being sprayed by a skunk — a tenuate the anxiety underlying the hyper­ powerful deterrent to hyperventilation, ventilation attack, the patient soon loses if not respiration of any kind. A textbook faith or feels that he is being ridiculed. of medicine published in 1766 suggests Its use may drive the patient to seek help "stinking and volatile spirits" or just in the emergency room of another hos­ singed feathers, burning leather or burnt pital at the time of his next attack, leav­ horncombs be held under the nose of ing the physician with the erroneous be­ those suffering from "suffocatio lief that he had "cured" his patient. hysterica".'" With theadventof the ageof reason, the method was merely altered, but not abolished. That the ammonia in One simple method to regulate the the smelling-salt bottles of the Victorian patient's breathing rate is by encourag­ lady actually stimulated the medullary ing him or her to talk. Provided that the centers other than momentarily is hard acute hyperventilation attack has not to believe, but it is a permissible as­ progressed too far (in which case the sumption that the act of smelling am­ patient's sensorium may be clouded to monia would slow down an accelerated the point
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