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Dyspnea Microchapters




Differentiating Hyperventilation from other Diseases

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Vindhya BellamKonda, M.B.B.S [2], Iqra Qamar M.D.[3]


Hyperventilation is the state of rapid breathing which results in the reduction in carbon dioxide levels (below normal) thereby leading to hypocapnia.[1] During rapid breathing, the body loses more carbon dioxide (CO2) than it can produce resulting in net reduction of CO2 levels. This state of rapid/faster breathing is most commonly seen in stress and anxiety and termed as hyperventilation syndrome. Kussmaul breathing is also a type of hyperventilation and done to reduce the acidity of body as seen in metabolic acidosis. Hyperventilation may also be voluntarily manifested following episodes of rapid deep breathing. The symptoms of hyperventilation are variable. Some patients are completely asymptomatic while others may present with minimal symptoms such as headache and numbness or tingling in the hands, feet, and lips. More severe symptoms include dizziness, lightheadedness, and fainting. Some patient also report having chest pain and slurred speech particularly when accompanied by the Valsalva maneuver. Voluntary deep breathing and induction of hyperventilation is a common practice among young individuals to attain focus and adrenaline rush. Other similar terms that are completely different from hyperventilation include hyperpnea and tachypnea.

Hyperpnea is commonly seen with exercise or any major physical activity as well as in response to hypoxic states. In these conditions the energy demand of the body either goes up or is not adequately met. To meet this energy deficit, the body increases the depth and rate of breathing which is known as hyperpnea. Other common examples of hyperpneic state include sepsis, anemia, and individuals living at high altitudes. Tachypnea is derived from a Greek word which means "rapid breathing". Tachypnea means rapid and shallow breathing and is also seen with exercise as a compensatory mechanism to increase the oxygen content of the body.


Physiology of breathing

The basic physiology of normal breathing is as follows:

  • The CNS regulates the depth and frequency of each breath to maintain normal levels of carbon dioxide (CO2) and oxygen (O2) in the blood and tissues.
  • The CNS measures the amount of CO2 in the body to regulate the breathing process.
  • As the CO2 and O2 gas exchange mechanism is simultaneous and continuous, any condition resulting in increased high carbon dioxide concentration primarily signals a low oxygen concentration.
  • In addition, metabolism in the body uses O2 and results in the production of CO2 as a byproduct.


Under physiologic conditions, the volume of alveolar gas is in equilibrium with the arterial gas. [2]

  • With each breath approximately 10% of the alveolar gas is replaced with atmospheric air.
  • The rate and depth of breathing determines the level of CO2 in the body.
  • A rapid and deep breath will lead to a better alveolar - atmospheric gas exchange leading to low CO2 levels.
  • It is to be noted that atmospheric air has 21% O2 content as compared to just 0.03% of CO2 content.
  • This results in low CO2 content (hypocapnia) with each rapid and deep breath.

Mechanism of Alkalosis

The mechanism of the development of alkalosis following hyperventilation is as follows:[3]

  • Majority of the CO2 in human body is stored as carbonic acid and is a major factor in determining the pH of the body.
  • Loss of CO2 results in blood becoming more alkaline and increase in blood pH.
  • In the normal individual, the resultant alkalosis would automatically be countered by reduced breathing except when the neural control is altered or disturbed.

Response of brain vasculature to hyperventilation and hypoventilation

The response of vessels in the brain to hyperventilation and hypoventilation is as follows:[4][5][6]

  • Conditions causing high CO2 levels (hypercapnia) results in the body assuming that the O2 levels are low.
  • As a result, to increase the O2 supply the blood vessels in the brain dilate.


Following are the various causes of hyperventilation.

Life-Threatening Causes

Common Causes

Causes by Organ System

Cardiovascular Cheyne-stokes respirations, congestive cardiac failure, pulmonary embolism, stroke
Chemical/Poisoning Ammonium chloride, camphor , glycol ether , inhalation of irritants, methanol, salicylate poisoning
Dental No underlying causes
Dermatologic No underlying causes
Drug Side Effect Aminophylline, aspirin, coffee abuse, pralidoxime, tiagabine
Ear Nose Throat No underlying causes
Endocrine Diabetic ketoacidosis, renal disease
Environmental Acute stress disorder
Gastroenterologic Abdominal surgery, acute liver failure, acute porphyria, end stage liver failure, hepatic cirrhosis, intestinal fistula, pyloric stenosis
Genetic Acute porphyria, arginosuccinic aciduria, carbamoylphosphate synthetase 1 deficiency disease, carbonic anhydrase va deficiency, hereditary fructose-1,6-bisphosphatase deficiency, Pitt-hopkins syndrome
Hematologic Acute porphyria
Iatrogenic No underlying causes
Infectious Disease CNS infection, fever
Musculoskeletal/Orthopedic Hip cancer
Neurologic Altitude sickness, acute brain trauma, central neurogenic hyperventilation, cerebrovascular accident, CNS infection, Cree leukoencephalopathy, damaged respiratory pathways, epilepsy, epileptic encephalopathy, early infantile, 2; head injury, intracranial space-occupying lesion, meningoencephalitis, pain, Pitt-Hopkins syndrome, raised intracranial pressure, stroke, vasovagal attacks
Nutritional/Metabolic Diabetic ketoacidosis, hereditary fructose-1,6-bisphosphatase deficiency, heat stroke, lactic acidosis
Obstetric/Gynecologic No underlying causes
Oncologic Bronchial neoplasm, rib tumor
Ophthalmologic No underlying causes
Overdose/Toxicity Biguanide intolerance
Psychiatric Acute stress disorder, adult panic-anxiety syndrome, agoraphobia, anxiety, Briquet's syndrome, combat stress reaction, Cree leukoencephalopathy,crying or severe distress, Da Costa syndrome, depression, distress, excitement, fear, functional disorders, grief, hypochondriasis, hysteria, malingering, pain, panic attack, phobia, primary habit disorder, Rett's syndrome, schizophrenia, stress, strong emotions
Pulmonary Acute altitude sickness, apneustic respirations, asthma, ataxic respiration, biot's respiration, central neurogenic hyperventilation, Cheyne-stokes respirations, damaged respiratory pathways, diffuse pulmonary fibrosis, emphysema , hyperventilation syndrome, inhalation of irritants, lung damage, metabolic acidosis, persistent hypoxemia, pleural effusion, pneumonia, pneumothorax, pulmonary embolism, pulmonary oedema
Renal/Electrolyte Acid-base imbalance, metabolic acidosis, phaeochromocytoma, renal disease
Rheumatology/Immunology/Allergy Asthma, pseudoallergic reactions
Sexual No underlying causes
Trauma Brain trauma, head injury, lung damage, raised intracranial pressure, sponatneous pneumothorax, stroke, surgical relocation of ureters in ileum or colon
Urologic Surgical relocation of ureters in ileum or colon
Miscellaneous Abdominal surgery, adulation, childbirth, fever

Causes in Alphabetical Order

Differentiating Hyperventilation from other Diseases

Various diseases that can cause hyperventilation may include diseases of respiratory, cardiovascular, endocrine, central nervous system, and musculoskeletal system. Pregnancy, sepsis, and hepatic failure are other conditions that may also result in hyperventilation. Given below is a differential diagnosis of diseases presenting with hyperventilation.

Abbreviations: ABG (arterial blood gas); ACE (angiotensin converting enzyme); βhCG (beta human chorionic gonadotropin); BMP (basic metabolic panel); BNP (brain natriuretic peptide); CBC (complete blood count); COPD (chronic obstructive pulmonary disease); CSF (cerebrospinal fluid); CXR (chest X-ray); CT (computed tomography); DLCO (diffusing capacity of the lung for carbon monoxide); DOE (dyspnea on exercise); ECG (electrocardiogram); FEF (forced expiratory flow rate); FEV1 (forced expiratory volume); FT4 (free T4); FVC (forced vital capacity); HRCT (high resolution computed tomography); JVD (jugular vein distention); LFTs (liver function tests); MCV (mean corpuscular volume); MEN (multiple endocrine neoplasia); MRI (magnetic resonance imaging); P2 (pulmonic heart sound); Plt (platelet); PT (prothrombin time); RBC (red blood cell); RV (residual volume); SIADH (syndrome of inappropriate antidiuretic hormone); S3 ( third heart sound); S4 (fourth heart sound); T3 ((Triiodothyronine); TLC (total lung capacity); TSH (thyroid stimulating hormone); VC (vital capacity); VMA(vanillylmandelic acid); Vt (tidal volume); WBC (white blood cell);

Organ system Diseases Clinical manifestations Diagnosis Other features
Symptoms Physical exam
Chest pain Dyspnea Fever Palpitations Cyanosis Tachypnea JVD Peripheral edema Auscultation ABGs Lab findings Imaging PFT Gold standard
Pulmonary system Pneumothorax[7] + + +/- + +/- + - - +/- Hypoxemia - X- ray -

CT-scan -

  • bullae
Pulmonary embolism[8] +/- + +/- + +/- + +/- - Respiratory alkalosis
  • Normal
Pneumonia[9] +/- + + + +/- + - - +/- Hypoxemia
  • Normal
Exacerbation of asthma/COPD[10] +/- + +/- + + + - - +/- Hypoxemia
Interstitial lung disease[11][12] +/- + +/- + + + +/- - +/- Hypoxemia _
  • CXR- Reticular infiltrates
  • Honey combing
Intrapulmonary shunt[13] +/- + - - + +/- - - +/- Hypoxemia
Upper airway obstruction[14] - + - -/+ -/+ + -/+ - +/- Hypoxemia -
High altitude sickness[15][16][17] - + +/- + +/- + - + Respiratory alkalosis
  • EKG- Right sided heart strain
  • Test in a hypobaric chamber with and without supplemental O2-breathing
Cardiovascular system Acute coronary syndrome[18] + + - +/- +/- +/- +/- +/- - -
Heart failure[19] +/- + - +/- + +/- + + Respiratory alkalosis CXR shows
Dysrhythmias[18] +/- + - + - +/- - - Normal
  • Normal
  • Normal
Shock[20][21] +/- +/- +/- +/- +/- +/- +/- +/- Combined acid-base disorders are frequently encountered in different stages
Metabolic/Systemic disorders Diabetic ketoacidosis[22] - + +/- - - - - - Metabolic acidosis
  • Normal
  • Normal
Hypocalcemia[23][24] - + - + - +/- - - Respiratory alkalosis
  • Normal
  • Serum Ionized calcium
Hypoglycemia[25][26] - +/- - +/- - - - - Normal
  • Normal
  • 72-hour supervised fasting test
Endocrine system Hyperthyroidism[27][28] +/- + - +/- - +/- - - Variable
  • Normal
Pheochromocytoma[29][30] - + +/- + - +/- - -
  • Asymmetric chest expansion
  • Normal
CNS Central nervous system tumor[31][32] - +/- - - - +/- - -
  • Normal
Variable based on tumor location
  • Normal
Anxiety/panic attacks[33] +/- + - +/- - - - -
  • Normal
  • Normal
  • Normal
  • Normal
Others Pregnancy[34] +/- + - - - - - +/-
  • Normal
Respiratory alkalosis
  • Normal
Hepatic failure[35][36] - +/- +/- +/- +/- + + + +/- Respiratory alkalosis
  • Normal
Sepsis[37] - + +/- +/- - - - -
  • Normal
Variable based on the sepsis phase
  • Normal
  • Normal


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See also

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