Hyperventilation syndrome - Symptoms

Among the numerous symptoms of hyperventilation syndrome, five leading ones can be identified:

1. vegetative disorders;
2. changes and disturbances of consciousness;
3. muscular-tonic and motor disorders;
4. pain and other sensory disturbances;
5. mental disorders.

The complexity of the symptoms of hyperventilation syndrome is related to the fact that the complaints presented by patients are non-specific. The classic ("specific") triad of symptoms - increased breathing, paresthesia and tetany - only minimally reflect the richness of the clinical picture of hyperventilation syndrome. Although a bright hyperventilation crisis (hyperventilation attack) sometimes causes serious diagnostic difficulties, it is nevertheless accepted that acute hyperventilation paroxysm is easy to recognize. Clinical manifestations of hyperventilation crisis or paroxysm are presented below.

Paroxysmal symptoms of hyperventilation syndrome

Simultaneously (or a little later) with the feeling of anxiety, worry, fear, most often the fear of death, the patient experiences a feeling of lack of air, difficulty breathing, a feeling of chest compression, a lump in the throat. In this case, rapid or deep breathing, disturbance of the rhythm and regularity of the respiratory cycles are usually noted. At the same time, patients experience unpleasant sensations from the cardiovascular system - in the form of palpitations, a feeling of cardiac arrest, its irregular work, pain in the left half of the chest. Objectively, the lability of the pulse (most often tachycardia) and arterial pressure, extrasystoles are stated.

In the structure of a crisis, three groups of symptoms are most often, almost obligatorily, represented, forming a certain core: emotional (most often anxiety), respiratory and cardiovascular disorders.

Hyperventilation crisis implies the presence of a leading phenomenon in its structure - excessive, increased breathing. However, many patients do not realize the fact of hyperventilation, since their attention is focused on other manifestations from various organs and systems: the heart, the gastrointestinal system, muscles, i.e., on the consequences that occur as a result of hyperventilation. If the patient notices painful breathing sensations in the form of shortness of breath, lack of air, etc., he most often attributes them to heart pathology. It should be noted that the hyperventilation phenomenon is an integral part of the vegetative syndrome.

Most of the well-known researchers of the hyperventilation syndrome problem believe that acute hyperventilation paroxysms or attacks, as they are usually called, are only a small part of the clinical manifestations of hyperventilation syndrome. Spontaneous tetanic crises (as the most obvious expression of hyperventilation paroxysm) are the "tip of the iceberg" visible on the surface. The "body of the iceberg" (99%) are chronic forms of hyperventilation syndrome. This point of view is shared by most researchers studying the problem of hyperventilation syndrome.

Most often, the signs of hyperventilation syndrome are permanent in nature, which manifests itself differently in different systems.

Vegetative-visceral manifestations of hyperventilation syndrome

Respiratory disorders. It is necessary to distinguish four variants of respiratory clinical manifestations of hyperventilation syndrome.

Option I - "empty breath" syndrome. The main sensation is dissatisfaction with inhalation, a feeling of lack of air, oxygen. In literature, this phenomenon is referred to as "lack of breath", a feeling of lack of air, "air hunger". It should be emphasized that the breathing process itself is performed (and most importantly - felt) by patients completely freely. Usually, patients claim that they periodically (every 5-15 minutes) need deep breaths to feel like they are breathing fully; however, this does not always work the first time, repeated deep breaths are required.

During the examination of patients, we observed their attempts to take a “successful” breath, which was no different in depth from the previous ones, which were “unsuccessful” for them. Other patients claim that they “breathe, breathe, and cannot get enough.” This variant of “air bulimia” changes the behavior of patients. The feeling of dissatisfaction with the breath gradually fixes the attention of patients on the “air atmosphere” around them, they do not tolerate stuffiness well, the patients’ sense of smell becomes more acute, they are constantly disturbed and worsened by numerous odors that did not bother them before. Such patients constantly open the window, the ventilator even in the most severe frosts, i.e. they are mainly occupied with the implementation of their “breathing behavior,” become “fighters for fresh air” or, in the figurative expression of the patients themselves, “air maniacs.” In addition to the above situations, breathing sensations sharply increase in conditions that cause anxiety (exams, public speaking, transport, especially the metro, heights, etc.).

Objectively, the breathing of such patients is frequent and (or) deep, most often quite even. However, emotional factors easily disrupt its regularity.

Option II- a feeling of inadequate functioning of the automatic breathing, a sensation of stopping breathing. Patients claim that if they do not inhale themselves, then independent automatic realization of it will not occur. Concerned by this fact, i.e. "loss of their breathing" (more precisely - loss of the feeling of automatic breathing), patients anxiously monitor the completion of the breathing cycle, actively, voluntarily "joining" its function.

Most likely, the "stopping" of breathing is most likely a sensation of patients, but further research will be required to identify the brain mechanisms of such a phenomenon, which is phenomenologically reminiscent of the "curse of Ondina" and sleep apnea syndrome.

Option III- more generally it can be called "shortness of breath syndrome". The feeling of lack of air, as in variant I, is also present, however, unlike variant I, the act of breathing is felt by patients as difficult, performed with great effort. Patients feel a lump in the throat, air not passing into the lungs, a feeling of an obstacle in the path of air penetration (in this case they most often indicate the level of the upper third of the chest), "constriction" of breathing inside or compression from the outside, the inability to sometimes perform a deep act of breathing or at times "stiffness", "constriction" of the chest. These painful sensations are poorly tolerated by the patient, whose attention (unlike variant I breathing) is fixed mainly not on the external environment, but on the performance of the act of breathing himself. This is one of those variants that were called "atypical asthma". During objective observation, increased breathing, an irregular rhythm, the use of the chest in the act of breathing are also noted. Breathing is performed with the inclusion of additional respiratory muscles, the patient's appearance is restless, tense, focused on the difficulty of performing the act of breathing. Usually, an objective examination of the lungs does not reveal any pathological signs.

The described variants of I and III breathing retain their pattern both in the situation of hyperventilation crisis and in the state of permanent dysfunction. In contrast, variant IV of respiratory disorders can disappear in the paroxysmal state of hyperventilation attack.

Hyperventilation equivalents are periodically observed sighs, cough, yawning and sniffling in patients. The aforementioned erased, reduced respiratory manifestations are considered sufficient to maintain a long-term or even permanent blood alkalosis, which has been proven by special studies. At the same time, some patients often do not realize that they cough, yawn, and sigh deeply from time to time. Usually, their colleagues at work and close people point this out to them. Such paradoxical forms of hyperventilation syndrome, in which there is no increased breathing in the usual sense ("hyperventilation without hyperventilation"), are the most common forms of hyperventilation syndrome, when the greatest diagnostic difficulties arise. In these cases, we are apparently talking about a disorder of the very organization of the act of breathing, a disorder that requires minimal respiratory excess to maintain long-term hypocapnia and alkalosis with a change in the reaction of the respiratory center to the concentration of CO2 in the blood.

Thus, respiratory dysfunction occupies a leading place in the structure of hyperventilation syndrome. Manifestations of this dysfunction may be the leading complaint in patients with hyperventilation syndrome, or they may be less pronounced and even absent as active complaints.

Cardiovascular disorders

Heart pain in soldiers is known to have been the complaint that historically aroused interest in the study of hyperventilation syndrome, first studied in detail and described by the American physician J. Da Costa in 1871. In addition to heart pain, patients usually report palpitations, discomfort in the heart, compression and pain in the chest. Objectively, the most common findings are lability of pulse and blood pressure, extrasystole. Fluctuations in the S-T segment (usually an increase) may be observed on the ECG.

Most authors attribute vascular headaches, dizziness, tinnitus and other disorders to neurovascular manifestations of hyperventilation syndrome. The group of peripheral vascular disorders of hyperventilation syndrome includes acroparesthesia, acrocyanosis, distal hyperhidrosis, Raynaud's phenomenon, etc. It should be emphasized that distal vascular disorders (angiospasm) apparently underlie sensory disorders (paresthesia, pain, tingling, numbness), which are considered classic manifestations of hyperventilation syndrome.

Gastrointestinal disorders

In a special work "Hyperventilation syndrome in gastroenterology" T. McKell, A. Sullivan (1947) examined 500 patients with complaints of gastrointestinal disorders. Hyperventilation syndrome with the above-mentioned disorders was detected in 5.8% of them. There are numerous gastroenterological manifestations of hyperventilation syndrome. The most frequent complaints are about disturbance (usually increase) of peristalsis, belching, aerophagia, bloating, nausea, vomiting. It should be noted that the picture of hyperventilation syndrome includes abdominalgia syndrome, which is often encountered in the clinical practice of gastroenterologists, as a rule, against the background of an intact digestive system. Such cases cause great diagnostic difficulties for internists. Quite often, patients complain of a feeling of "constriction" of the intestine, which is often encountered in patients with neuroses, in whom hyperventilation syndrome is combined with neurogenic tetany syndrome.

Other vegetative-visceral systems are involved in the pathological process of hyperventilation syndrome. Thus, dysuric phenomena indicate damage to the urinary system. However, the most common sign of hyperventilation disorders is polyuria, expressed during and especially after the end of the hyperventilation paroxysm. The literature also discusses the issue of hyperthermic permanent states and hyperthermia accompanying paroxysms being closely related to hyperventilation syndrome.

Changes and disturbances of consciousness

Hyperventilation lipothymia and fainting are the most striking manifestations of cerebral dysfunction in patients with hyperventilation syndrome.

Less pronounced changes in consciousness are blurred vision, "fog", "grid" before the eyes, darkening before the eyes, narrowing of the visual fields and the appearance of "tunnel vision", transient amaurosis, hearing loss, noise in the head and ears, dizziness, unsteadiness when walking. A feeling of unreality is a fairly common phenomenon in patients with hyperventilation syndrome. It can be assessed in the context of the phenomena of reduced consciousness, but with long-term persistence, it is legitimate to include it in the rubric of phenomena of altered consciousness. In its phenomenology, it is close to what is usually referred to as derealization; this phenomenon is quite often found together with other manifestations of a similar plan - depersonalization. Phobic anxiety-depersonalization syndrome is also distinguished in hyperventilation syndrome.

Some patients with hyperventilation syndrome may experience persistent, recurring phenomena of the “already seen” type, which necessitates differentiation from temporal lobe epileptic paroxysms.

Motor and muscular-tonic manifestations of hyperventilation syndrome

The most common phenomenon of hyperventilation paroxysm is chill-like hyperkinesis. The tremor is localized in the arms and legs, and the patient complains of a feeling of internal tremor. Chills are combined with thermal manifestations in different ways. Some patients complain of a feeling of cold or heat, while an objective change in temperature is noted only in some of them.

Muscular-tonic manifestations occupy a special place in the structure of hyperventilation syndrome, including in paroxysmal situations. In our studies devoted to this issue, it was shown that muscular-tonic tetanic (carpopedal) spasms in the structure of vegetative paroxysm are closely related to the hyperventilation component of the crisis. It should be emphasized that a number of sensory disturbances, such as paresthesia, a feeling of stiffness in the limbs, a feeling of compression, tension, contraction in them, can precede convulsive muscle spasms or may not be associated with paroxysm. Tetanic syndrome (in particular, its normocalcemic, neurogenic variant) in patients with vegetative disorders can serve as a subtle indicator of the presence of hyperventilation manifestations in them. Therefore, a positive Chvostek symptom most often indicates a connection between neuromuscular excitability and hyperventilation manifestations within a certain psychovegetative syndrome.

Sensory and algic manifestations of hyperventilation syndrome

As noted above, sensory disturbances (paresthesia, tingling, numbness, crawling sensation, etc.) are classic, specific and most common signs of hyperventilation syndrome. As a rule, they are localized in the distal parts of the extremities, in the face area (perioral region), although cases of numbness of the whole or half of the body have been described. From this group of sensory disturbances, pain sensations should be singled out, which, as a rule, arise in connection with a sharp increase in paresthesia and the formation of muscle spasm and can be very painful. However, pain sensations often arise without direct connection with sensorimotor tetanic disturbances. Pain syndrome as such can be one of the manifestations of hyperventilation syndrome. This is evidenced by literature data and our own observations, which allowed us to identify a fairly common combination: hyperventilation - tetany - pain. However, we did not find any identification of pain syndrome as a separate phenomenon of chronic hyperventilation in the literature, although such an identification, in our opinion, is legitimate. This is evidenced by the following.

Firstly, modern studies of the pain phenomenon have revealed, in addition to the connection with a certain organ, its independent "supra-organ" character. Secondly, pain has a complex psychophysiological structure. Within the framework of hyperventilation syndrome, manifestations are closely related to psychological (emotional-cognitive), humoral (alkalosis, hypocapnia) and pathophysiological (increased nervous and muscular excitability), including vegetative, factors. Our examination of patients with abdominal syndrome allowed us to establish the presence of hyperventilation-tetanic mechanisms in the pathogenesis of pain manifestations.

Clinically, the algic syndrome within the hyperventilation syndrome is most often represented by cardialgia, cephalgia and, as already noted, abdominalgia.

Mental manifestations of hyperventilation syndrome

Disturbances in the form of anxiety, worry, fear, melancholy, sadness, etc. occupy a special place in the structure of hyperventilation disorders. On the one hand, mental disorders are part of the clinical symptoms along with other somatic changes; on the other hand, they represent an emotionally unfavorable background against which hyperventilation syndrome occurs. Most authors note a close connection between two interacting phenomena: anxiety - hyperventilation. In some patients, this connection is so close that activation of one component of this dyad (for example, increased anxiety in stressful situations, voluntary hyperventilation, hyperventilation, or simply increased breathing as a result of light intellectual or physical exertion) can provoke a hyperventilation crisis.

Thus, it is necessary to note the important pathogenetic connection between mental disorders and increased pulmonary ventilation in patients with hyperventilation syndrome.

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