[Symptoms and management of tetany]

Tetany is a series of symptoms characterized by painful muscle cramp that derives from enhanced neuromuscular excitability due to hypocalcemia, hypomagnesemia or alkalosis. In a broad sense, tetany includes associated sensory disturbance. Typical symptoms of tetany include carpopedal spasm, laryngospasm and generalized seizure. Chvostek and Trousseau signs are provocative tests for diagnosis of latent tetany. Many diseases including endocrine disorders like hypoparathyroidism and alkalosis by hyperventilation can cause tetany. Infusion of calcium or magnesium is effective as an acute therapy for tetany. However, subsequent diagnosis and treatment of underlining diseases are mandatory.

Hyperventilation in patients with chronic fatigue syndrome: the role of coping strategies

Hyperventilation has been suggested as a concomitant and possible maintaining factor that may contribute to the symptom pattern of chronic fatigue syndrome (CFS). Because patients accepting the illness and trying to live with it seem to have a better prognosis than patients chronically fighting it, we investigated breathing behavior during different coping response sets towards the illness in patients with CFS (N=30, CDC criteria). Patients imagined a relaxation script (baseline), a script describing a coping response of hostile resistance, and a script depicting acceptance of the illness and its (future) consequences. During each imagery trial, end-tidal PCO2 (Handheld Capnograph, Oridion) was measured. After each trial, patients filled out a symptom checklist. Results showed low resting values of PetCO2 overall, while only imagery of hostile resistance triggered a decrease and deficient recovery of PetCO2. Also, more hyperventilation complaints and complaints of other origin were reported during hostile resistance imagery compared with acceptance and relaxation. In conclusion, hostile resistance seems to trigger both physiological and symptom perception processes contributing to the clinical picture of CFS.

The role of hyperventilation: hypocapnia in the pathomechanism of panic disorder

OBJECTIVE: The authors present a profile of panic disorder based on and generalized from the effects of acute and chronic hyperventilation that are characteristic of the respiratory panic disorder subtype. The review presented attempts to integrate three premises: hyperventilation is a physiological response to hypercapnia; hyperventilation can induce panic attacks; chronic hyperventilation is a protective mechanism against panic attacks. METHOD: A selective review of the literature was made using the Medline database. Reports of the interrelationships among panic disorder, hyperventilation, acidosis, and alkalosis, as well as catecholamine release and sensitivity, were selected. The findings were structured into an integrated model. DISCUSSION: The panic attacks experienced by individuals with panic disorder develop on the basis of metabolic acidosis, which is a compensatory response to chronic hyperventilation. The attacks are triggered by a sudden increase in (pCO2) when the latent (metabolic) acidosis manifests as hypercapnic acidosis. The acidotic condition induces catecholamine release. Sympathicotonia cannot arise during the hypercapnic phase, since low pH decreases catecholamine sensitivity. Catecholamines can provoke panic when hyperventilation causes the hypercapnia to switch to hypocapnic alkalosis (overcompensation) and catecholamine sensitivity begins to increase. CONCLUSION: Therapeutic approaches should address long-term regulation of the respiratory pattern and elimination of metabolic acidosis.

Hyperventilation-induced hypocapnic alkalosis slows the adaptation of pulmonary O2 uptake during the transition to moderate-intensity exercise

The effect of voluntary hyperventilation-induced hypocapnic alkalosis (RALK) on pulmonary O2 uptake (VO2) kinetics and muscle deoxygenation was examined in young male adults (n=8) during moderate-intensity exercise. Subjects performed five repetitions of a step-transition in work rate from 20 W cycling to a work rate corresponding to 90% of the estimated lactate threshold during control (CON; PET,CO2, approximately 40 mmHg) and during hyperventilation (RALK; PET,CO2, approximately 20 mmHg). was measured breath-by-breath and relative concentration changes in muscle deoxy- (DeltaHHb), oxy- (DeltaO2Hb) and total (DeltaHbtot) haemoglobin were measured continuously using near-infrared (NIR) spectroscopy (Hamamatsu, NIRO 300). The time constant for the fundamental, phase 2, VO2 response (tau VO2) was greater (P<0.05) in RALK (48+/-11 s) than CON (31+/-9 s), while tauHHb was similar between conditions (RALK, 12+/-4 s; CON, 11+/-4 s). The DeltaHb(tot) was lower (P<0.05) in RALK than CON, prior to (RALK, -3+/-5 micromol l(-1); CON, -1+/-4 micromol l(-1)) and at the end (RALK, 1+/-6 micromol l(-1); CON, 5+/-5 micromol l(-1)) of moderate-intensity exercise. Although slower adaptation of during RALK may be related to an attenuated activation of PDH (and other enzymes) and provision of oxidizable substrate to the mitochondria (i.e. metabolic inertia), the present findings also suggest a role for a reduction in local muscle perfusion and O2 delivery.

Quantitative Correlation of Hyperventilation with Flicker Sensitivity

PURPOSE

The relationship between hyperventilation and the associated increase in flicker sensitivity is poorly defined but may be relevant to display viewing. This exploratory study investigates the potential for quantifying the relationship between the severity of hypocapnia and critical flicker frequency (CFF).

METHOD

Repeated ascending (fusion) and descending (flicker) measurements were made while breathing normally (normocapnia), and at four levels of progressive, mild to moderate hypocapnia that were induced by voluntary hyperventilation and controlled using continuous respiratory mass spectrometry. The mesopic stimulus was a 2.6 degree-Gaussian blob viewed through a 5.2-mm-diameter artificial pupil.

RESULTS

Five discrete respiratory conditions were generated. The influences of intersubject variability and severity of hypocapnia upon mean CFF were examined using two-way analysis of variance, demonstrating a statistically significant effect of target end-tidal partial pressure of carbon dioxide [F(4,40) = 4.63, p = 0.005]. The relationship between decreasing mean end-tidal partial pressure of carbon dioxide and increasing mean CFF was consistent with a linear correlation (Pearson R = -0.949, p = 0.013).

CONCLUSIONS

The results support a close relationship between the respiratory partial pressure of carbon dioxide and flicker sensitivity. However, the absolute magnitude of the underlying increase in flicker sensitivity with hypocapnia is small and the effect is unlikely to be relevant in aviation.

Haploinsufficiency of TCF4 causes syndromal mental retardation with intermittent hyperventilation (Pitt-Hopkins syndrome)

Pitt-Hopkins syndrome is a rarely reported syndrome of so-far-unknown etiology characterized by mental retardation, wide mouth, and intermittent hyperventilation. By molecular karyotyping with GeneChip Human Mapping 100K SNP arrays, we detected a 1.2-Mb deletion on 18q21.2 in one patient. Sequencing of the TCF4 transcription factor gene, which is contained in the deletion region, in 30 patients with significant phenotypic overlap revealed heterozygous stop, splice, and missense mutations in five further patients with severe mental retardation and remarkable facial resemblance. Thus, we establish the Pitt-Hopkins syndrome as a distinct but probably heterogeneous entity caused by autosomal dominant de novo mutations in TCF4. Because of its phenotypic overlap, Pitt-Hopkins syndrome evolves as an important differential diagnosis to Angelman and Rett syndromes. Both null and missense mutations impaired the interaction of TCF4 with ASCL1 from the PHOX-RET pathway in transactivating an E box-containing reporter construct; therefore, hyperventilation and Hirschsprung disease in patients with Pitt-Hopkins syndrome might be explained by altered development of noradrenergic derivatives.

Hyperventilation in a motion sickness desensitization program

INTRODUCTION

In motion sickness desensitization programs, the motion sickness provocative stimulus is often a forward bending of the trunk on a rotating chair, inducing Coriolis effects. Since respiratory relaxation techniques are applied successfully in these courses, we investigated whether these repetitive trunk movements by themselves may induce hyperventilation and consequently add to the motion sickness.

METHODS

There were 12 healthy subjects who participated in our study. In the Baseline condition, subjects sat relaxed on the stationary chair. In the Hypervent condition, subjects performed voluntary hyperventilation (the level was prescribed). In two other conditions subjects rhythmically bent their trunk on a stationary chair (Tilt-Stat condition) and on a rotating chair (Tilt-Rot condition). In all conditions we measured respiratory and cardiovascular activity (heart frequency, tidal volume, end-tidal CO2, and respiration frequency).

RESULTS

Of the 12 subjects, 9 had to stop prematurely in the Tilt-Rot condition because of moderate nausea. Except for heart rate in the Tilt-Rot condition, the measured physiological parameters in these subjects in the Tilt-Stat and Tilt-Rot conditions were not statistically different from the Baseline condition. Only in the Hypervent condition were significant differences observed, but no nausea.

DISCUSSION

The findings show that hyperventilation is not the main cause of nausea during the Coriolis effects. We conclude that during the pilot desensitization program with Coriolis stimuli, measurement of cardiovascular and respiratory parameters is not necessary; however, in those cases that do not respond to the intervention, we recommend paying attention to respiratory parameters because hyperventilation does occur on an individual basis.

Hyperventilation following head injury: effect on ischemic burden and cerebral oxidative metabolism

OBJECTIVE

To determine whether hyperventilation exacerbates cerebral ischemia and compromises oxygen metabolism (CMRO2) following closed head injury.

DESIGN

A prospective interventional study.

SETTING

A specialist neurocritical care unit.

PATIENTS

Ten healthy volunteers and 30 patients within 10 days of closed head injury.

INTERVENTIONS

Subjects underwent oxygen-15 positron emission tomography imaging of cerebral blood flow, cerebral blood volume, CMRO2, and oxygen extraction fraction. In patients, positron emission tomography studies, somatosensory evoked potentials, and jugular venous saturation (SjO2) measurements were obtained at Paco2 levels of 36+/-3 and 29+/-2 torr.

MEASUREMENTS AND MAIN RESULTS

We estimated the volume of ischemic brain and examined the efficiency of coupling between oxygen delivery and utilization using the sd of the oxygen extraction fraction distribution. We correlated CMRO2 to cerebral electrophysiology and examined the effects of hyperventilation on the amplitude of the cortical somatosensory evoked potential response. Patients showed higher ischemic brain volume than controls (17+/-22 vs. 2+/-3 mL; p<or=.05), with worse matching of oxygen delivery to demand (p<.001). Hyperventilation consistently reduced cerebral blood flow (p<.001) and resulted in increases in oxygen extraction fraction and ischemic brain volume (17+/-22 vs. 88+/-66 mL; p<.0001), which were undetected by SjO2 monitoring. Mean CMRO2 was slightly increased following hyperventilation, but responses were extremely variable, with 28% of patients demonstrating a decrease in CMRO2 that exceeded 95% prediction intervals for zero change in one or more regions. CMRO2 correlated with cerebral electrophysiology, and cortical somatosensory evoked potential amplitudes were significantly increased by hyperventilation.

CONCLUSIONS

The acute cerebral blood flow reduction and increase in CMRO2 secondary to hyperventilation represent physiologic challenges to the traumatized brain. These challenges exhaust physiologic reserves in a proportion of brain regions in many subjects and compromise oxidative metabolism. Such ischemia is underestimated by common bedside monitoring tools and may represent a significant mechanism of avoidable neuronal injury following head trauma.

Effects of bronchodilators on dynamic hyperinflation following hyperventilation in patients with COPD

BACKGROUND AND OBJECTIVE

The present study was performed to examine the occurrence of dynamic hyperinflation following hyperventilation in COPD patients and former smokers without COPD, and the efficacy of short-acting anticholinergic agents (SAAC) and beta2-agonists (SABA) for lung hyperinflation following metronome-paced hyperventilation in COPD.

METHODS

Fifty-nine patients with COPD, 20 ex-smokers without COPD and 20 healthy subjects who had never smoked were examined for dynamic hyperinflation by metronome-paced hyperventilation with respiratory rate increasing from 20 to 30 and 40 tidal breaths/min. Dynamic hyperinflation was evaluated as the decrease in inspiratory capacity (IC) following hyperventilation, and the effects of SAAC and SABA on dynamic hyperinflation were assessed.

RESULTS

COPD patients showed a significant increase in end-expiratory lung volume and a decrease in IC following hyperventilation, and ex-smokers without COPD also showed mild but significant dynamic hyperinflation. Multiple stepwise linear regression analysis revealed that the carbon monoxide transfer coefficient (DLco/VA) and RV/TLC were significant and independent determinants of dynamic hyperinflation in COPD. Treatment with SAAC and SABA significantly increased IC at each respiratory rate, independently of the increases in FEV1. Furthermore, SABA significantly inhibited the decrease in IC due to hyperventilation.

CONCLUSIONS

These findings suggest that lung hyperinflation following hyperventilation may be a useful method for detecting dynamic hyperinflation observed not only in patients with COPD but also in ex-smokers without COPD, and both SAAC and SABA are effective in reducing dynamic hyperinflation in COPD.

Brain changes to hypocapnia using rapidly interleaved phosphorus-proton magnetic resonance spectroscopy at 4 T

Substantial controversy persists in the literature concerning the physiologic consequences hypocapnia, or low partial pressure of carbon dioxide (PaCO(2)). Invasive animal studies have demonstrated large pH increases (>0.25 U), phosphocreatine (PCr) decreases (>30%), and adenosine triphosphate (ATP) decreases (>10%) after hyperventilation (HV) (20 mm Hg PaCO(2)). However, using magnetic resonance spectroscopy, HV studies in awake humans have demonstrated only small pH changes ( approximately 0.05 U) and no changes in PCr or ATP. It remains important to ascertain whether this failure to detect PCr changes in human studies reflects a true absence of changes, or a limitation in data fidelity. The present study used a rapidly interleaved phosphorus-proton spectroscopy acquisition from large samples at high magnetic field (4 T), to measure pH, PCr, inorganic phosphate, beta-ATP, and lactate changes with high temporal and signal sensitivity. Five of six subjects had usable data. During 20 mins HV, PaCO(2) reached a minimum at 16 mins (17 mm Hg); however, the maximum pH change (+0.047) peaked earlier (14 mins). Maximal lactate increases were measured at 15 mins. By 10 mins, maximum changes were observed for PCr (-3.4%) and inorganic phosphate (+6.4%). No changes in beta-ATP were observed. The peak in pH, despite continued decreases in PaCO(2), suggests active buffering during HV. These data, and the small magnitude of early PCr and inorganic phosphate changes, do not support substantial energy compromise during HV. Other mitigating factors, such as anesthesia-induced deregulation of the cerebrovasculature, might have contributed to the exaggerated metabolic changes observed in previous animal investigations.

Hypoxia and circadian patterns

In mammals, biological time keeping is organised with a hierarchical and pyramidal structure, under the control of the master clock in the suprachiasmatic hypothalamic nuclei (SCN). Body temperature (Tb) and metabolic rate have robust circadian patterns, and probably represent primary variables controlled closely by the SCN. From the data of studies in animals (mostly rats) and humans, it appears that the most common effect of prolonged hypoxia is to decrease, and in some cases to abolish, the amplitudes of the daily oscillations, irrespective of the state of arousal or activity level. On the other hand, the evidence is that hypoxia causes only minimal and transient perturbation of the period of the rhythm. The fact that hypoxia modifies the circadian oscillations of variables as important as body temperature and metabolism leads to the expectation that the daily rhythms of many other functions are perturbed by hypoxia, according to their link to the primary variables. The data currently available, although sparse and fragmentary, support this view. It is speculated that the alterations of the normal circadian oscillations can contribute to many common symptoms during sustained hypoxia, from sleep fragmentation, to malaise and loss of appetite.

Symptoms of premenstrual syndrome may be caused by hyperventilation

OBJECTIVE

To determine whether women with premenstrual syndrome (PMS) differ from healthy women in the extent of hyperventilation during the luteal phase of the cycle.

DESIGN

Case report.

SETTING

Medical university.

PATIENT(S)

Three reproductive-age women with severe symptoms of PMS in whom dramatic decline in end-tidal PCO2 (PETCO2) occurred during the luteal phase of the cycle.

INTERVENTION(S)

Measurements of PETCO2, administration of GnRH agonist triptorelin.

MAIN OUTCOME MEASURE(S)

PETCO2 was determined daily by sidestream capnometry.

RESULT(S)

The decline in PETCO2 in women with PMS was 12-18 mm Hg, on the average. This was significantly more pronounced than the decline of PETCO2 that was observed in healthy women. With the decline of PETCO2 the symptoms of PMS appeared. Symptoms disappeared at the end of the luteal phase when PETCO2 was increasing again. During treatment with the GnRH agonist, PETCO2 did not decline, and all women were free of symptoms.

CONCLUSION(S)

The symptoms of PMS observed in our patients were associated with a pronounced decline of PETCO2 that occurred during the luteal phase of the cycle. Because the symptoms were similar to symptoms observed in the chronic hyperventilation syndrome it is suggested that some symptoms of PMS may be caused by chronic hyperventilation. It appears that in women with PMS the sensitivity of the respiratory center to CO2 is increased more than normal by P or some other secretory product of the corpus luteum, resulting in pronounced hyperventilation with the associated clinical signs and symptoms of a chronic hyperventilation syndrome.

Increasing the yield of EEG

The EEG is the most common neurodiagnostic test performed to evaluate patients with suspected seizures. The majority of EEGs are requested in patients because of suspected seizures or for seizure management. It is unlikely that the patient's usual spell will be recorded during a routine EEG. Therefore, several activation techniques have been used in clinical EEG to help increase the occurrence of interictal epileptiform abnormalities, which are highly correlated with the diagnosis of a seizure disorder. EEG laboratories have long employed these techniques, which include hyperventilation, intermittent photic stimulation, sleep, and sleep deprivation. However, despite being utilized in routine clinical EEGs for decades, a number of differing views on the usefulness and indications for these procedures exist. This review will evaluate these procedures and review their history, technique, effectiveness, controversies, and unanswered questions.

Cyanotic episodes in a male child with fragile X syndrome

A 9-year-old male with a diagnosis of fragile X syndrome (FXS) was evaluated for cyanotic episodes of unknown etiology. Clinical observation revealed frequent episodes of hyperventilation lasting several minutes, only while the patient was awake. This was followed by apnea associated with cyanosis and oxygen desaturation. Polysomnogram confirmed episodic central apnea temporally associated with hypocapnia, only during the awake state. Extensive evaluation failed to reveal other neurological, cardiac, gastrointestinal, or pulmonary etiologies for the events. The clinical observations and investigations allowed us to conclude that the patient's cyanotic episodes were caused by primary behavioral hyperventilation in the awake state. Similar behaviors have been reported in children with a variety of diagnoses but to our knowledge have not been previously reported in children with FXS. Treatment for this unusual behavior in FXS consists of reassurance and behavior modification to decrease the frequency and severity of the cyanotic episodes.

Electroencephalography hyperventilation and stroke in children with sickle cell disease

A recent study and report in which hyperventilation was used during electroencephalography (EEG) in 6 children with sickle cell disease (SCD) and seizures, without serious complication, prompted a cautionary response regarding the potential risks attending the practice of EEG hyperventilation in SCD patients. Earlier reports of neurological impairment and stroke precipitated by the routine use of hyperventilation in children with SCD are reviewed, the mechanism and management of vascular infarction following hyperventilation are discussed, and readers are reminded of the AEEGS guidelines and contraindications to routine hyperventilation, which include SCD and trait and cerebrovascular disorders. The frequent nonobservance of these guideline recommendations among neurologists, and the need to more widely inform practitioners of the risks of hyperventilation in SCD are discussed.

Positional hyperventilation-induced hypoxaemia in pectus excavatum

The presented case is of a young male (aged 19 yrs) with a pectus excavatum who showed significant exercise intolerance, despite normal pulmonary function at rest, including carbon monoxide diffusing capacity. Clinical exercise testing led to a strong suspicion of a right-to-left shunt due to an abnormally wide alveolo-arterial oxygen gradient (26.4 kPa) at peak oxygen uptake, with severe arterial hypoxaemia (arterial oxygen tension 12.54 kPa). A right-to-left shunt was confirmed by transoesophageal echocardiography demonstrating a permeable foramen ovale, despite normal right heart pressures. The right-to-left venous flow was mainly dependent on the upright body position and the deep inspiration. Indeed, i.v. dobutamine infusion to selectively affect cardiac output and hyperventilation induced by tidal volume expansion at constant breathing rate in the supine position did not result in arterial oxygen desaturation or shunting. Closure of the foramen ovale through atrial umbrella placement dramatically improved clinical and physiological abnormalities. This observation demonstrates that a hyperventilatory manoeuvre in the upright position is able to detect a permeable foramen ovale favouring flow in the inferior vena cava in the direction of the abnormal pre-existing atrial channel in a patient with a pectus excavatum.

Bronchial epilepsy or broncho-pulmonary hyper-excitability as a model of asthma pathogenesis

Over the last 20 years, the prevalence of asthma has nearly doubled in industrialized countries. A similar increase has been predicted for the next two decades. Asthma is major illness in terms of morbidity and suffering, asthma is the leading cause of hospitalizations in children under 15 years of age. According to many top experts, asthma is correctly characterized as a syndrome rather than disease. This lack of definition for asthma makes the search for a cause, prevention and potential cure elusive. Episodic airway obstruction and reversible bronchial hyperresponsiveness to non-specific irritants are the major symptoms of asthma. Airway inflammation is now widely accepted as the key factor underlying the pathogenesis of asthma. However, many patients show no signs of inflammation, yet they still have severe airflow limitation and asthma symptoms. The primary clinical symptoms of asthma are attacks of shortness of breath, wheezing, and coughing resulting from excessive and inappropriate constriction of the airway smooth muscle. Our research suggests a possible epileptic or hyper-excitatory condition of bronchial system in asthma pathogenesis. The paroxysmal, spasmodic character of asthma attacks may be similar to seizures. We propose a unified pathogenetic mechanism of asthma as a syndrome of inducible or genetically predisposed membrane hyper-excitability (bronchial epilepsy).

Patterns of Hypocapnia on Tilt in Patients with Fibromyalgia, Chronic Fatigue Syndrome, Nonspecific Dizziness, and Neurally Mediated Syncope

OBJECTIVES

To assess whether head-up tilt-induced hyperventilation is seen more often in patients with chronic fatigue syndrome (CFS), fibromyalgia, dizziness, or neurally mediated syncope (NMS) as compared to healthy subjects or those with familial Mediterranean fever (FMF).

PATIENTS AND METHODS

A total of 585 patients were assessed with a 10-minute supine, 30-minute head-up tilt test combined with capnography. Experimental groups included CFS (n = 90), non-CFS fatigue (n = 50), fibromyalgia (n = 70), nonspecific dizziness (n = 75), and NMS (n =160); control groups were FMF (n = 90) and healthy (n = 50). Hypocapnia, the objective measure of hyperventilation, was diagnosed when end-tidal pressure of CO2 (PETCO2) less than 30 mm Hg was recorded consecutively for 10 minutes or longer. When tilting was discontinued because of syncope, one PETCO2 measurement of 25 or less was accepted as hyperventilation.

RESULTS

Hypocapnia was diagnosed on tilt test in 9% to 27% of patients with fibromyalgia, CFS, dizziness, and NMS versus 0% to 2% of control subjects. Three patterns of hypocapnia were recognized: supine hypocapnia (n = 14), sustained hypocapnia on tilt (n = 76), and mixed hypotensive-hypocapnic events (n = 80). Hypocapnia associated with postural tachycardia syndrome (POTS) occurred in 8 of 41 patients.

CONCLUSIONS

Hyperventilation appears to be the major abnormal response to postural challenge in sustained hypocapnia but possibly merely an epiphenomenon in hypotensive-hypocapnic events. Our study does not support an essential role for hypocapnia in NMS or in postural symptoms associated with POTS. Because unrecognized hypocapnia is common in CFS, fibromyalgia, and nonspecific dizziness, capnography should be a part of the evaluation of patients with such conditions.

Early Left Ventricular Lead Dislodgement Related to Hyperpnea Respiration

Left ventricular lead dislodgement remained a problem for cardiac resynchronization therapy and is one of the major causes of repeated procedures. We report a 30-year-old lady with possible left ventricular lead dislodgement related to hyperpnea respiration.

Acquired lightheadedness in response to odors after hyperventilation

OBJECTIVE

This study aimed to investigate whether lightheadedness in response to odors could be acquired through previous associations with hyperventilation-induced hypocapnia.

METHODS

Diluted ammonia and acetic acid served as conditional odor cues (CSs) in a differential associative learning paradigm. Hyperventilation-induced hypocapnia (unconditional stimulus [US]) was used to induce lightheadedness. In a training phase, participants (n = 28) performed three hypocapnic and three normocapnic overbreathing trials of 60 seconds each. One odor was consistently paired with the hypocapnic overbreathing (CS+); the other (control) odor was paired with normocapnic overbreathing (CS-). In the test phase, each odor was presented once during spontaneous breathing and once during normocapnic overventilation. Lightheadedness was assessed online during each breathing trial, which was followed by an extensive hyperventilation symptom checklist. Fractional end-tidal CO2, breathing frequency, and inspiratory volume were measured throughout the experiment.

RESULTS

In the test phase, participants experienced lightheadedness more quickly in response to the odor that had been paired with hypocapnic overbreathing compared with the control odor. They also scored higher on the symptom "feeling unreal."

CONCLUSION

Lightheadedness in response to odors can be acquired easily. The present results may help to elucidate the paradox that both avoidance and exposure to chemicals seem to be effective in reducing symptoms in idiopathic environmental illness.

Nasal congestion and hyperventilation syndrome

BACKGROUND

This article evaluates the prevalence of hyperventilation syndrome (HVS) in patients who continue to complain of ongoing nasal congestion, despite an apparently adequate surgical result and appropriate medical management.

METHODS

Prospective case series of 14 patients from June 2002 to October 2003 was performed. Patients, who presented complaining of nasal congestion after previous nasal surgery and who appeared to have an adequate nasal airway with no evidence of nasal valve collapse, were evaluated for HVS. When appropriate, nasal steroids and oral antihistamines also had been tested without success. Three patients had end-tidal P(CO2) levels measured and five patients underwent breathing reeducation.

RESULTS

All patients had an elevated respiratory rate (>18 breaths/minute) with an upper thoracic breathing pattern. Twelve of the 14 patients complaining of nasal obstruction had an elevated Nijmegen score indicative of HVS. An average number of 2.5 procedures had been performed on each patient. End-tidal P(CO2) levels were < or = 35 mmHg in the three patients who had expired P(CO2) levels measured. Breathing retraining was successful in correcting the nasal congestion in two of five patients.

CONCLUSION

HVS should be included in the differential diagnosis of patients presenting with nasal congestion, particularly after failed nasal surgery. One possible explanation is increased nasal resistance secondary to low arterial P(CO2) levels. Another possible explanation is reduced alae nasae muscle activity secondary to the reduced activity of serotonin-containing raphe neurons. Additional surgery may not necessarily be the answer in HVS patients complaining of nasal congestion.