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At the heart of general practice since 1960

Are our fears over patient confidentiality justified?

Research indicates that overbreathing

may contribute to 40 per cent of symptoms presenting to GPs ­ Anne Pitman advises on diagnosis and management

Almost every GP in the country has several patients who regularly attend with a list of symptoms that trouble them deeply but for which endless investigations fail to find a cause. Many such cases result from disturbed breathing.

Duncan stated in 1987 that chronic hyperventilation contributed to 40 per cent of symptoms in general practice1.

The box on the right details common symptoms of chronic hyperventilation. With such a long diverse list of symptoms it is easy to understand how this condition can also be called 'fat folder syndrome' as patients visit one specialist after another, failing to find a diagnosis and accruing larger and larger sets of notes. Eventually such patients are labelled neurotic and hypochondriacal.

A lot of time and resources are being used up by investigations, so how can the GP recognise these patients and help them?

Assessment and diagnosis

There can be great variation in how people overbreathe ­ some may have a fairly normal speed of breathing but are taking large volumes in, while others may be taking normal tidal volumes but have increased the speed. Others have normal patterns and speed but punctuate their breathing with frequent vital capacity breaths.

The most common tendency is to breathe predominantly with the upper chest, giving rise to complaints of tension and tightness in the neck and shoulder girdle.

Once the overbreathing becomes established and the patient has lowered carbon dioxide levels the respiratory centre reprogrammes to the new low level and strives to keep the level low ­ this situation of chronic hypocarbia brings about a respiratory alkalosis

and a reduction in bicarbonate in the arterial blood.

This causes increased activity of the nerve cells and therefore motor excitability.

The sympathetic nervous system is activated, giving rise to heightened autonomic responses. As carbon dioxide controls the diameter of blood vessels the ensuing vasoconstriction results not only in reduced cerebral blood flow but also less oxygenation of the tissues of the body.

Patients can be assessed using the following approach:

·Eliminate organic causes of symptoms such as anaemia, thyroid dysfunction, cardiovascular disease or respiratory conditions. Investigations could include blood tests, lung function tests, CXRs, ECGs, and possibly arterial blood gases.

·Careful history taking: ask about events/happenings/environments that bring on the symptoms. This can be helpful in making the diagnosis. Often the patient will describe episodes of breathlessness unrelated to physical exertion.

·Patient to fill out symptom checklist.

·Nijmegen Questionnaire (a score of more than 23 out of possible 64 is positive for hyperventilation)2.

·Measure breath-holding time

­ probable hyperventilation = 0-30 secs

­ possible hyperventilation = 30-40 secs

­ normal = 54 secs

Other tell-tale signs include:

·Observation ­ unrelaxed, over-talkative, highly strung.

·Body language ­ tenseness, raised shoulders, very active.

·Rate of breathing ­ fast breathing, small breaks or normal pace and big breaths.

·Erratic breathing.

·Which part of the chest moves first? ­ Sufferers tend to be upper-chest breathers.

·Is the breathing noisy?

·Breath control on talking ­ ie, big breath to say three words.

·Speed of speech ­ ie, fast.

·Excessive sighing, yawning, coughing, clearing of throat or sniffing.

It is always extremely helpful for the patient to understand that a scientific reason exists to explain their myriad symptoms.

In my experience a rational explanation of the problem peels away the first layer of anxiety and allows the patient to begin the process of breathing retraining.

A circle of symptoms and anxiety has invariably been set up and the

anxiety and the overbreathing continue to fuel one another, leading to a continuation and possible escalation of the situation. This can be easily explained to the patient by the easy diagram on the left.

As well as occasionally being the primary problem, chronic hyperventilation is frequently associated with other conditions ­ it is very common in the asthmatic patient, a

link brought into the public domain by the work of Professor Konstantin Buteyko (subsequent breathing techniques can be found at www.buteykobreathing.com)

Articles in 1999 by Ringsberg and Thomas in 2001 support the prevalence of hyperventilation syndrome (HVS) in patients with asthma3,4.

Chronic fatigue, fibromyalgia, panic disorder, chronic pain and interstitial lung disease are some of the organic causes that can lead on to HVS but emotional factors such as bereavement, work pressures, exam worries, money and relationship problems can also be triggers for overbreathing to set in.

Typically a certain sort of personality tends to develop HVS.

This is a type A perfectionist, slightly obsessional character, someone who sets themselves high standards and enjoys feeling in control ­ often highly-motivated people who have

previously prided themselves on being able to cope with whatever life throws

at them.

The manner and symptoms of HVS are especially distressing for this type of person and they have a loss of self-esteem and confidence.

Occasionally an understandable explanation of the problem is enough for the patient to correct the hyperventilation and recover, but other more established overbreathers need more help and guidance.

Box 2 below details the advice

and objectives that can be given to patients.

1 Common symptoms of

chronic hyperventilation

Cardiovascular

·Chest pains and pseudo-angina

·Palpitations and tachycardia

·Cold hands and feet

Respiratory

·Feelings of breathlessness

·Air hunger

·Feelings of inability to take a satisfying breath

·Excessive sighing and yawning

·Breathing with the upper chest with overuse of the accessory muscles

·Feelings of chest tightness

Neurological

·Dizziness and faintness

·Numbness and tingling, especially in face and hands

·Depersonalisation and feelings of being detached from reality

·Blurred vision

·Headaches

Gastrointestinal

·Dry mouth and throat

·Difficulty in swallowing/

globus hystericus

·Excessive burping and reflux with heartburn

·Abdominal bloating and irritable bowel symptoms

General

·Weakness and exhaustion ­

tired all the time

·Lethargy

·Difficulty in concentrating and poor memory

·Sleep disturbance

Further information

The Physiotherapy for Hyperventilation Group

has a website www.physiohypervent.org which contains information of interest to patients and health workers. Listed on the site is a directory of physiotherapists who have an interest in treating chronic hyperventilation.

The group also produces an information pack (£7.50) and video (£15)

The author has made an audio cassette as a breathing retraining programme (£12.50 ) and is shortly to produce a CD.

It is also possible to download an assessment sheet and the Nijmegen Questionnaire from the site.

2 Advice and objectives

for patient

1 Explanation of condition ­ provide with information

booklet (shortly to be available from British Lung Foundation)

2 Reassure patient that improvement is possible but will take some time and effort

3 Give information on breathing retraining

·Breathing awareness

·Practise breathing retraining

- diaghragm

- volume reduced

- rate reduced

- pattern corrected

·Positions

- lying

- sitting

- standing

4 Advise about relaxation and awareness of tension

5 Stress management strategies especially if trigger factors can be identified

6 Advice on sleep

7 Awareness of need to control breathing and slow speed of talking

8 Advise patient how to feel they are controlling their breathing rather than their breathing controlling them

References

1 Duncan SR (1987). Hyperventilation Syndrome.

Hosp Med., 23, 86-98

2 Van Dixhoorn (1985). Efficacy of the Nijmegen Questionnaire in recognition of the Hyperventilation Syndrome. Journal of Psychosomatic Research. 29, 393-399

3 Ringsberg MC (1999). Presence of hyperventilation in patients with asthma-like symptoms but negative asthma test responses. J Allergy Clin Immunol, 103, 601-8

4 Thomas M (2001). Prevalence of dysfunctional

breathing in patients treated for asthma in primary care. BMJ, 322, 1098-1100

Anne Pitman

is a chartered physiotherapist at The London Clinic and a founder of the Physiotherapy for Hyperventilation Group

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