Munemoto et al. BioPsychoSocial Medicine 2013, 7:9 http://www.bpsmedicine.com/content/7/1/9 CASE REPORT Open Access Prolonged post-hyperventilation apnea in two young adults with hyperventilation syndrome Takao Munemoto1,4*, Akinori Masuda2, Nobuatsu Nagai3, Muneki Tanaka4 and Soejima Yuji5 Abstract Background: The prognosis of hyperventilation syndrome (HVS) is generally good. However, it is important to proceed with care when treating HVS because cases of death following hyperventilation have been reported. This paper was done to demonstrate the clinical risk of post-hyperventilation apnea (PHA) in patients with HVS. Case presentation: We treated two patients with HVS who suffered from PHA. The first, a 21-year-old woman, had a maximum duration of PHA of about 3.5 minutes and an oxygen saturation (SpO2) level of 60%. The second patient, a 22-year-old woman, had a maximum duration of PHA of about 3 minutes and an SpO2 level of 66%. Both patients had loss of consciousness and cyanosis. Because there is no widely accepted regimen for treating patients with prolonged PHA related to HVS, we administered artificial ventilation to both patients using a bag mask and both recovered without any after effects. Conclusion: These cases show that some patients with HVS develop prolonged PHA or severe hypoxia, which has been shown to lead to death in some cases. Proper treatment must be given to patients with HVS who develop PHA to protect against this possibility. If prolonged PHA or severe hypoxemia arises, respiratory assistance using a bag mask must be done immediately. Keywords: Post-hyperventilation apnea, PHA, Hyperventilation syndrome, HVS, Hypocapnia, Hypoxemia Background incidence of death, severe hypoxia, or myocardial infarc- Hyperventilation syndrome (HVS) is characterized by tion in association with the paper-bag method [2]. functional hyperventilation attacks with no underlying Recently, the paper-bag method was not recommended organic abnormality. In Japan, 508 patients with acute for the treatment of patients with HVS [2]. HVS were reported to range in age from 5–85 years, We have experienced several patients with HVS who and acute HVS was particularly prevalent among women had post-hyperventilation apnea(PHA). PHA is apnea that in their late teens and among men in their twenties [1]. follows hyperventilation due to HVS or another cause. The male-to-female ratio is 3 to 7 [1]. HVS is also related In most cases, the patient spontaneously recovered from to psychosomatic stressors. HVS patients show various PHA within one minute without any clinical problems. clinical symptoms such as anxiety, dyspnea, hypocapnia, Moreover, we recently encountered two patients with tetany, and unconsciousness. HVS in whom PHA persisted with cyanosis, hypoxemia, Traditionally, it has been considered that hyperventila- and loss of consciousness for more than three minutes. tion attacks spontaneously disappear and that the paper- We were confronted with difficult decisions as to whether bag method or the administration of anxiolytic agents or not to perform cardiopulmonary resuscitation (CPR) leads to the disappearance of such attacks regardless of on these patients. their severity. However, there is little evidence regarding Previously, Haldane and Douglas reported PHA in the use of the paper-bag method for HVS and the humans [3,4]. Some studies have indicated experimental PHA in healthy adults [5,6]. According to several studies, * Correspondence: [email protected] PHA is frequent in patients with central nervous ab- 1Department of Domestic Science, Kagoshima Women’s College, 6-9 normalities [7,8], can be complicated by lung disease kourai-chou, Kagoshima 890-8520, Japan (pulmonary emphysema, bronchial asthma) [9,10], and led 4Yoshimura Hospital, Dairyu-chou, Kagoshima 892-0805, Japan Full list of author information is available at the end of the article to the death of one patient [9]. Few studies have reported © 2013 Munemoto et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Munemoto et al. BioPsychoSocial Medicine 2013, 7:9 Page 2 of 7 http://www.bpsmedicine.com/content/7/1/9 PHA related to HVS. To our knowledge, only Inagaki mass index (BMI) values of patients 1 and 2 were 20.1 and [11], MacDonald [12], and Chin [13] reported PHA with 17.8, respectively. We performed several medical examina- hypoxemia related to HVS. However, aside from tions, such as blood tests, chest X-ray, echocardiogram, MacDonald’s case, there are few previous case reports of electrocardiogram, and cephalic CT, to rule out organic HVS patients who were rescued from PHA after having diseases that could cause hyperventilation. There were no long term PHA accompanied by cyanosis, hypoxemia, and abnormalities in the blood test results of either patient loss of consciousness. Here we present two patients with (WBC: 4800/μL and 5200/μL, Hb: 13.1 g/dL and 11.3 g/dL, HVS who developed prolonged PHA. In analyzing these platelet: 20.1 × 104/μLand28.9×104/μL, AST: 23 IU/L cases, the risk of prolonged PHA and the possible treat- and 18, ALT: 13 IU/L and 17 IU/L,s-AMY: 66 IU/L and ment for hyperventilation attack were examined. The aim 97 IU/L,CRP: none and o.1 mg/dL, creatinine: 0.7 mg/dL of this report is to demonstrate the development and and o.9 mg/dL, Na: 143 mEq/L and 141 mEq/L, K: clinical risk of PHA with severe hypoxemia in patients 3.9 mEq/L and 4.3 mEq/L, fT4: 1.2 ng/dL and i.0 ng/dL, with HVS. fT3: 1.2 pg/dL and 3.3 pg/dL,TSH: 0.41 μIU/mL and 1.08 μIU/mL). There were no abnormal findings in the Case presentation chest X-ray, electrocardiogram, echocardiogram, or ceph- Patient 1 alic CT, so lung, heart and brain disease were ruled out. A The patient was a 21-year-old woman. At the age of hyperventilation attack was identified based on respiration 18 years, she suffered a hyperventilation attack following that obviously exceeded the usual breathing rate (about 12 stressors at her nursing school. Her strongest stressor to 20 breaths per minute) and clinical symptoms such as was practicing as a nurse at the hospital. She was sub- tetany. A physician used a stethoscope to confirm that sequently hospitalized several times for frequent hyper- therewerenoairwaystenosissoundsorabnormalalveolar ventilation attacks. There were no organic abnormalities sounds. We could not analyze arterial blood-gas to according to several medical examinations including a prove hypocapnia because the hospital did not possess blood test, chest X-ray, electrocardiogram, electro- the device needed to perform this analysis. Neither pa- encephalogram and head CT. She was diagnosed with tient presented with hypoxemia during the hyperventi- HVS. Her hyperventilation attacks gradually decreased lation attacks or normal respiration. Therefore, the in response to the paper-bag method or anxiolytic agents possibility of a hyperventilation attack being caused by administered during hospitalization. For approximately other disorders was ruled out. Although the arterial PCO2 one year after being discharged from the hospital, no level was not measured for either patient, the clinical attacks occurred. However, the hyperventilation attacks presentation left little doubt that over-breathing resulted recurred when triggered by acute tonsillitis. Because of in HVS. To examine the psychological aspects, the the frequent attacks she was referred to our hospital to Minnesota multiphasic personality inventory(MMPI)was undergo a regimen of psychotherapy and fasting therapy performed. The MMPI showed high scores of Hs: 30, [14,15], which is effective for various stress-related D: 48 and Hy: 33 for Patient 1 and Sc: 54, Pt: 49 and D:35 diseases. Immediately on hospitalization, she developed for Patient 2. These data suggest a depressive state for frequent hyperventilation attacks. both patients, namely anxiety about her physical symp- toms by Patient 1 and unreasonable fears or anxiety and Patient 2 obsessions by Patient 2. In both patients, some stressors The patient was a 22-year-old woman. At the age of were present prior to the hyperventilation attacks. In case 21 years, she suffered from affective disorder following 1, acute tonsillitis induced the hyperventilation attacks, sexual harassment in her office. Her symptoms were which occurred frequently and increased her anxiety level. relieved by antidepressants and counseling. However, Immediately on hospitalization, she developed frequent she was admitted to our hospital for relapse, which hyperventilation attacks before fasting therapy [14,15] was might have been caused by her stopping taking the begun. She agreed to undergo fasting therapy but had medication without consulting the attending physician. considerable anxiety over receiving the therapy. Hos- After her admission, she began to improve. About one pitalization and anxiety about the fasting therapy became month after admission, a visit from one of her coworkers the stressors and triggers of her hyperventilation attacks reminded her of several episodes of sexual harassment, after admission to the hospital. In case 2, a co-worker’s and her emotional state became unstable. She then visit to her in the hospital evoked memories of the developed hyperventilation attacks for the first time. sexual harassment in the office and induced hy- perventilation attacks. Both cases were diagnosed with Clinical profiles of the patients HVS because they had preceding stressors and no There was no medical/family history of bronchial asthma organic abnormalities that could cause hyperventila- or epilepsy for either patient. On admission, the body tion attacks. Munemoto et al. BioPsychoSocial Medicine 2013, 7:9 Page 3 of 7 http://www.bpsmedicine.com/content/7/1/9 Hospital course of PHA ventilation, SpO2 and recorded minimum SpO2 were Figure 1 shows a series of hyperventilation attacks by frequently measured during PHA.