1.) Hyperventilation (HV)
In the domain of musculoskeletal complaints, chronic hyperventilation (HV) is usually not commonly looked at and is therefore rarely recognized (Warburton and Jack 2008).

According to Gardner (2004), HV: "Hyperventilation is breathing in excess of metabolic requirements and is associated with reduction in arterial PCO2 (PaCO2), respiratory alkalosis, and a wide range of symptoms."

Most clinicians recognize an acute HV attack relatively quickly.
Various triggers, such as anxiety, pain, low blood oxygen levels, fever are common triggers but reactions to drugs, for example an aspirin overdose (Jafari et al 2017), can also cause a disturbance in respiratory regulation, resulting in an increase in breathing activity (tachypnoea), which can lead to dyspnea (breathlessness). Too much carbon dioxide (CO2) is exhaled, which in turn leads to a reduction in the partial pressure of CO2 (paCO2) in the arterial blood (hypocapnia).
In the brain, cerebral vasoconstriction occurs reactively, resulting in cerebral hypoxia (Chin et al 2007), which presents as drowsiness, cyanotic skin color and shortness of breath.
At the same time, there is an increase in the pH value in the blood, which is referred to as alkalosis from a value > 7.45. Respiratory alkalosis in turn leads to hypocalcemia (reduced calcium level in the blood serum), which is responsible for a general hyperexcitability of the nervous system (Deetjen et al 2005). The resulting symptoms (Tab. 1) are typical of acute HV (Wilson 2018).

Tab. 1: Symptoms of various organ systems during (acute) hyperventilation. (Wilson 2018).

After ruling out other causes, treatment of acute symptoms consists of reassurance (or sedation) and stabilization of the oxygen supply (only at <94% O2 saturation) (Wilson 2018). Rebreathing (into hands or bag) is no longer recommended because of the risk of hypoxia (Kishikawa 2015). Stress and anxiety management, various forms of relaxation therapies (such as yoga, autogenic training), psychological therapy and respiratory therapy are recommended as long-term therapy (Schäffler et al 2014).

But what do we know about chronic HV?

It can also be idiopathic, but it can also be caused by psychological factors, respiratory diseases such as asthma and COPD (Agache et al 2012), or stressful situations and pain (Warburton and Jack 2006). Tachypnoea, dyspnea, dizziness and a feeling of chest constriction also occur during ADLs, but paranesthesia or other acute symptoms are less common (Warburton and Jack 2006).

The recommended assessment then also consists of (Chenivesse et al 2014):

1. Observation
2. Pulmonary function testing (e.g. spirometry, plethysmography)
3. Cardiopulmonary exercise test
4. Nijmegen Questionnaire (NQ)
5. Hyperventilation Provocation Test (HVPT)
6. Breath- Hold-Time
7. Anxiety and/or depression questionnaires
8. Rotation chair test

Not all the above-mentioned measurement methods are specific for the detection of HV. In addition to anamnesis and observation, the Cardiopulmonary Exercise Test (Jack et al 2004, physician) and the Nijmegen Questionnaire (van Dixhoorn et al 2015), HVPT ((partly in simplified form) Tiotiu et al 2021) and Breath-Hold-Time (Warburton et al 2006) seem to be most appropriate and can be performed by a physical therapist.

Execution HVPT:

1. 3 min resting breathing, then 1 (Tiotiu et al 2021) or 3 (Hornsveld et al 1996) min conscious HV breathing (high-frequency and deep breathing), followed by 5 min recovery (back to resting breathing).
2. Measurement of PET CO2 (carbon dioxide pressure), respiratory rate, heart rate, oxygen saturation (SpO2), ventilation /min.
3. HVPT positive if >3 symptoms of NQ present during test, and PET CO2 <35mmHg after recovery.
4. Recovery time significantly longer in chronic HV (Warburton et al 2006)

Execution Breath Hold Time:

1. Breath hold after complete inspiration
2. HV group will be significantly lower than control group (21 sec. vs. 58 sec.)
3. HV group remains even after administration of 80-100% oxygen (24 sec. vs. 123 sec.)
4. Exclusion of organic disorders necessary

2.) HV in musculoskeletal complaints

But how often does HV occur in musculoskeletal complaints?

There are no clear figures on this. In the literature there are clear instructions for a significant correlation between LBP (low back pain) and (chronic) respiratory diseases such as asthma, allergies, respiratory infections, and dyspnea (Beekmans et al 2016), but no study on LBP and HV.

HV is categorized as a chronic respiratory disorder and, according to Chaitow (2004), this can be a contributing factor to persistent complaints such as disturbed postural control, muscle function, neural sensitization, pain threshold and balance.

Work-related musculoskeletal complaints of the upper limb are also related to HV, whereby altered respiratory movements (from diaphragmatic to thoracic) can be triggered by biomechanical stress of the shoulder-neck musculature on the one hand, and thus lead to HV. Conversely HV alters respiratory activity, which can lead to changes in tone of the upper limb and thoracic muscles (Schleifer et al 2002).

HV may also be a response to persistent, uncontrollable musculoskeletal pain, anxiety and stress (Olivia 2021), and respiratory control has been shown to influence musculoskeletal pain (Jafari et al 2017).

It also appears that respiratory alkalosis makes skeletal muscle more susceptible to fatigue, trigger points, dysfunction and increased resting tone (Bradley et al 2014). It can also lead to other changes as reduction in excitability of peripheral nerves, muscle spasms/muscle tone increase, increased pain perception and emotional lability up to anxiety (Perri et al 2004).

3.) Therapy of HP for musculoskeletal complaints

Generally, a combination of respiratory therapy, psychological interventions and education is recommended for (chronic) HV (Tavel 2017).

However, as respiratory muscles such as diaphragm, mm. scalenii, m. transversus abdominus, mm. intercostales, deep intrinsic muscles of the spine and pelvic floor muscles also have a function of core stability of the trunk (Olivial 2021), manual therapy and active (re-) activation of these muscles is recommended along with special breathing techniques. Slow breathing, deep breathing and breath holding techniques can even significantly reduce pain (Jafari et al 2017).

Other recommended breathing therapies include breath control, Buteyko breathing therapy and yoga breathing techniques (Jones et al 2013).

In summery we can conclude that trained physical therapists can recognize chronic HV are able to treat and manage this complaints.

Daniela von Piekartz

Unless otherwise stated, the images are from Pixabay

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