Archive for December, 2011

Hyperventilation – makes you feel as if you can’t get your breath


At last I am beginning to understand hyperventilation. It has never made sense to me until now after I have read Buteyko’s book.

I have never understood why humans evolved such an inefficient system of breathing. We inhale most of our recently exhaled air, which to me seemed a nonsense: it is much more efficient to have a one way flow of air over a surface, like fish do with water over gills. However, there is a good reason. Life evolved over millions of years in an atmosphere rich in carbon dioxide, the waste gas of respiration. Carbon dioxide became essential for normal cell metabolism because cells used carbon dioxide to maintain their optimal pH (acidity). When levels of carbon dioxide in the atmosphere fell, cells had to develop a mechanism for artificially bathing themselves in the right level of carbon dioxide for their efficient metabolism. And so lungs evolved.

Lungs are necessary to keep carbon dioxide levels high in inhaled air and therefore in the blood. The blood is very efficient at gathering oxygen and all arterial blood is 100% saturated with oxygen. But here comes the crunch! Oxygen is only readily released from red blood cells to supply oxygen to the tissues in the presence of high levels of carbon dioxide. So what does this mean in practice?
Short of breath? Breathe less!

Many patients, particularly asthma patients, but also CFS patients, have a sensation that they are not getting enough oxygen to their tissues. Their response to this is to breathe more deeply. However blood cannot become more than 100% saturated with oxygen. All that happens is that more carbon dioxide is washed out of the blood. This makes oxygen cling more fiercely to haemoglobin in red blood cells and therefore oxygen delivery to the tissues is made worse! Paradoxically, to improve oxygen supply to the tissues you have to breathe less! Breathing less increases carbon dioxide levels and improves oxygen delivery.

Lowering carbon dioxide levels in the blood has other dire effects. It upsets the acidity of the blood and causes what is known in medical jargon as a respiratory alkalosis. This causes all sorts of awful symptoms such as panic attacks, pain, fatigue, feeling spaced out and dizzy, brain fag, brain fog and so on.

Again, taking the evolutionary approach, humans used to live a far more active existence. Because we are now so sedentary, we do not need the oxygen supply our lungs have evolved to deliver. We do not produce enough of the waste gas carbon dioxide either. The system is under used and so there is an in-built tendency to breathe too much. This is worsened by stimulants such as excitement (sitting in front of an exciting film, but not using any oxygen up), caffeine, computer games and so on.

Hyperventilation is probably extremely common and we could all benefit from breathing less. We have simply got into bad habits and have to re-learn how to breathe.

Asthma is how the body tries to prevent you from hyperventilating. The airways constrict to try to reduce gaseous exchange to allow carbon dioxide to be retained. Breathing harder, or deep breathing makes asthma worse. Inhalers to open up the airway, whilst relieving the airway constriction in the short term, in the long term worsen hyperventilation and therefore the cause of asthma.
Typical symptoms of hyperventilation

Vivid dreams or nightmares; tingling and numbness of hands, feet, and area around mouth; yawning or sighing; sensation of needing to take a deep breath; panic attacks; feeling of being spaced out, faint or dizzy, episodes of weakness and exhaustion; muscle spasms, twitching, cramp, aching.
Diagnosis of Hyperventilation

If you are asthmatic then the answer is a definite yes. All asthmatics hyperventilate (it is only in the very extreme forms of asthma that oxygen levels in the blood fall).

Many CFS symptoms are the same as those from hyperventilation. Buteyko suggests you test yourself with his controlled pause: Sit comfortably in an upright chair, breathe in normally and out holding your nose after the out breath. Count the seconds using a watch until you feel you have to breathe in again. The number of seconds counted gives your control pause. The ideal pause is 60 seconds, but a pause of 40-60 denotes good health. (Editor’s note: 60 seconds seems too long! I can’t do this, but perhaps I need retraining!) A control pause of 30 (according to Buteyko) means you are breathing enough for 2 people and suggests mild asthma. A control pause of 15 seconds indicates you are breathing for 4 people: this is serious hyperventilation. A control pause of 10 seconds denotes severe asthma. Like I said before, his controlled pauses seem like a long time to me and I can’t do 60 seconds!

The other method to check for hyperventilation is to do a forced test of over breathing. Sit and breathe deeply through your mouth, as if you are running. Within 30-40 seconds you will develop unpleasant symptoms which may include dizziness, palpitations, cough or wheeze. If your troublesome symptoms are flared, this suggests hyperventilation may be the cause.

If one is hyperventilating the blood and therefore urine becomes alkali. This can be tested for with litmus paper – I can send you some if you order. Indeed many people with CFS tend to have acidic urine because they are constantly switching into anaerobic metabolism with the production of lactic acid. Hyperventiliation may be the body’s response to ry to restore normal blood pH.
Treatment of Hyperventilation

For those patients who do not have a chronic fatigue syndrome, physical exercise is extremely helpful. Take up some sort of physical activity, such as running, swimming or cycling on a daily basis to reduce your hyperventilation. Singing is also very helpful and the breathing exercises for singing are very much like those for hyperventilation, particularly breath control. The third possibility is to take up a wind instrument such as a trumpet, which again teaches breathing control and which can be helpful for hyperventilation.

The following principles apply both to non-CFS and CFS patients.

Firstly you must always breathe through your nose. This increases the amount of air which is exhaled and immediately re-inhaled and is therefore relatively rich in carbon dioxide. Mouth breathers must make a conscious effort to close their mouths always, if necessary tape your lips closed at night.

Secondly, breathe less deeply and more slowly. Initially this brings a feeling of wanting to breathe more, but this must be ignored. It is a bit like having an irritating itch and not being allowed to scratch it. Some anti-hyperventilation techniques ask you to practice breathing using your diaphragm instead of your chest. I don’t see the logic of this because whether you use your diaphragm or your chest muscles, air will still be drawn into the lungs. Buteyko is similarly unconcerned about diaphragmatic breathing, so in this we agree! The results of reducing your rate of breathing are felt very quickly (within a few minutes) good positive feedback to encourage you to continue! But improvement may continue over weeks, so keep at it!

Thirdly, if you catch yourself sighing, yawning or taking a deep breath, hold your breath for a few seconds, breathe out very slowly, then start breathing slowly and shallowly again.

There is another mystery which may also be explained by hyperventilation. Virtually all of my CFS patients are magnesium deficient. Why? The body’s response to a respiratory alkalosis is to pee out bicarbonate. Bicarbonate is a negatively charged ion and cannot leave without a positively charged ion. Guess which positively charged ion goes out with it? Spot on, magnesium! Magnesium deficiency may well be another indicator of hyperventilation. Taking magnesium carbonate may be very helpful (suggest 2-4 grams daily).

Further information can be obtained from the Buteyko Breathing Association via their website or contact your local teacher for more information. A list of Buteyko teachers is displayed on their website. Recommeded reading “Freedom from Asthma, Buteyko’s Revolutionary Treatment” cost £7.99 from the Nutri Centre Bookshop tel 0207 323 2382. Also “The Carbon Dioxide Syndrome” by Jennifer and Russell Stark from the Buteyko Asthma Management website.

It is interesting to speculate about the relationship between asthma and hyperventilation and fatigue. In my experience it is unusual to see fatigue and asthma in the same patient at the same time, although with CFS patients there is sometimes a past history of asthma. Perhaps the local reaction to hyperventilation is asthma (by constricting the airways to reduce gaseous exchange) and the systemic reaction is fatigue (through reducing blood supply, to try to increase carbon dioxide retention in the blood in an attempt to improve local oxygen delivery). Perhaps treatment of asthma by using bronchodilaters (blue inhalers), whilst relieving the local airways obstruction and wheeze actually then allow the systemic symptoms to become a problem? This is speculation! But it squares with clinical observation.

Further information from Physiotherapy for Hyperventilation
Test for Hyperventilation

John McLaren Howard has now developed a test for hyperventilation at Acumen. This measures levels of red cell carbonic anhydrase. In chronic hyperventilation this becomes depleted and the ratio between the activity and the protein gives a good indication of whether or not hyperventilation is a problem. This test tells us how much effort we have to put in to correcting this and essentially there is a two-pronged approach – firstly biochemical and secondly physical. More information about this can be found under test details, see link below to carbonic anhydrase test details.
Related Tests

Litmus paper test
Carbonic anhydrase studies in red blood cells

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Why am I having difficulty breathing?

A swimmer’s nightmare…not being able to breathe. Sometimes it is an uncontrollable cough, midway through training; other times it is an inability to control a breath rate. Is it asthma? exercise induced? Is it Vocal Cord Dysfunction? Is it Hyperventilating? Bronchitis? Sinusitis? Is it contagious?

We are looking for answers. We do know that we are not alone. Talking with coaches, swimmers and parents, persistent coughing during or after practice is more common, than not. As dedicated athletes, we often just put up with it, whether it be from sickness, or environmental.

It would be simple to point out one single cause, but this isn’t the case. From experience, air quality issues can be identified, but not, as yet, quantified. If you can smell something in the air…be prepared.

So many swimmers have been diagnosed with asthma, without most doctors looking into environmental conditions. Athletes will typically have greater lung capacities further challenging the medical profession.

Full blood analysis exposes the dermal, (through the skin,) absorption of what it is we smell in the air. History shows that the athletes with a higher metabolism are the first to react to questionable air quality. We can chronicle the duration until an attack occurs, as well. It happens to correspond to the point in time when athletes are ‘warmed-up, and at a point with peak body temperature and subsequent sweat production…

What are the causes when the air doesn’t smell? More times than not, it is stress, or panic induced. Think how well you breathe when you are nervous, upset, or crying…

In any event, consulting with the medical profession is the most prudent response.

Hyperventilation Syndrome Recognizing Symptoms of Hyperventilation Syndrome

Hyperventilation syndrome is a nonmedical cause of shortness of breath. Hyperventilation syndrome is very scary, but not life-threatening. It can be hard to tell hyperventilation syndrome apart from other causes of shortness of breath. If there is any doubt about the cause of difficulty breathing, call 911 immediately.

Read How to Treat Hyperventilation Syndrome to learn the steps for helping a victim overcome the feelings that cause hyperventilation syndrome.
Causes of Hyperventilation Syndrome
The term hyperventilation syndrome evolved from the more descriptive psychogenic hyperventilation syndrome, which indicates a psychosomatic cause for the hyperventilation. Basically, that means there is usually some sort of behavioral or emotional reason for the hyperventilation. In most cases, hyperventilation goes hand-in-hand with anxiety or panic disorders. Many of the symptoms of hyperventilation syndrome appear during what are commonly called panic attacks.

There are other, more serious, medical conditions that may lead to hyperventilation. The most serious is related to an increase of pressure inside the skull (intracranial pressure). The increased pressure pushes the brain through the foramen magnum, the opening in the base of the skull where the spinal cord exits. This is called herniation of the brain and leads to neurogenic hyperventilation syndrome, an involuntary reaction of the respiratory centers in the brain to increases in pressure.

For the purposes of this article, the term hyperventilation syndrome refers to conditions stemming from behavioral causes.
Recognizing Hyperventilation Syndrome
If a victim with rapid, shallow breathing has the ability to become more calm and slow his or her breathing, it may be hyperventilation syndrome. A behavioral cause of hyperventilation can be overcome, a medical cause of rapid breathing probably cannot. Treating hyperventilation syndrome often distinguishes the condition from other causes of shortness of breath as well as treats it.

Never assume a victim is suffering from hyperventilation syndrome. Always assess victims for other causes of shortness of breath first. It’s important to note that hyperventilation syndrome patients must be conscious and able to communicate. Unconscious or unresponsive victims are likely not suffering from hyperventilation syndrome.
Hyperventilation Symptoms: The Nijmegen Questionnaire
Developed to screen patients complaining of shortness of breath for possible hyperventilation syndrome, the Nijmegen questionnaire identifies several signs and symptoms of hyperventilation syndrome. Correctly using this screening tool requires a clinical background, especially since many of the screening questions could be symptoms of much more serious medical conditions.

Of the hyperventilation syndrome symptoms and signs listed in the Nijmegen questionnaire, there are several that are distinctly related to hyperventilation syndrome. These signs and symptoms are strong indicators of hyperventilation syndrome, especially if the victim has several of them:

Tense feeling
Fast or deep breathing
Tingling in fingers and hands
Stiffness or cramps in fingers and hands
Tightness around the mouth
Cold hands or feet
Palpitations in the chest

Despite their relationship to hyperventilation syndrome, each of these signs and symptoms could also be related to other medical conditions. Always assume the worst possible scenario first, then proceed to less serious conditions, in order to identify the cause of shortness of breath.

Vitamin D Deficiency Linked to Vocal Cord Dysfunction

from MedScape

December 8, 2011 (Cancun, Mexico) — Vitamin D deficiency is associated with exercise-induced paradoxical vocal cord dysfunction (VCD) in young athletes, according to research presented here at the World Allergy Organization XXII World Allergy Conference (WAC). The study was conducted during the winter in a town above 45 degrees latitude.

Exercise can be associated with exercise-induced bronchospasm (EIB) or laryngospasm, which can be mistaken for asthma. The researchers had previously demonstrated that vitamin D deficiency is associated with VCD during a hyperventilation test, especially in hypocapnic conditions.

In a population of 37 nonsmoking young athletes (24 males, 13 females; age, 13 to 25 years), the researchers investigated the prevalence of EIB and exercise-induced VCD during a hyperventilation test. They then related the findings to vitamin D levels.

The hyperventilation test included five 1-minute runs in isocapnic (breathing carbon dioxide–enriched air) or hypocapnic (breathing normal air) conditions. Each test was performed 1 week apart. Capnography was used to monitor exhaled carbon dioxide pressure. The researchers used a 10% decrease in forced expiratory volume in 1 second as a marker of EIB and a 25% reduction in mid-inspiratory flow (MIF50) as a marker for exercise-induced VCD.

Of the participants, 16 (43%) were atopic and 6 (16%) reported that they had previously been diagnosed with asthma. None used drugs or had had respiratory infections in the previous month, and all had normal results on lung function tests. In isocapnic conditions on hyperventilation testing, 10 participants experienced EIB and 12 experienced exercise-induced VCD. Under hypocapnic conditions, 8 participants experienced EIB and 15 had exercise-induced VCD.

Vitamin D deficiency (serum 25-hydroxycholecalciferol < 25 ng/mL) was recorded in 18 participants (49%). Athletes with exercise-induced VCD had significantly lower serum levels of vitamin D than those without it, in both isocapnic (19.1 ± 1.8 vs 25.7 ± 1.5 ng/mL; P = .013) and hypocapnic (20.2 ± 1.9 vs. 26.2 ± 1.8 ng/mL; P = .029) conditions.

The researchers also found an association between vitamin D levels and a decrease in MIF50 (as percentage of baseline) during the test (under isocapnic conditions: r = .41; P < .015; under hypocapnic conditions: r = .42; P = .017).

The researchers found no correlation between vitamin D and EIB.

“I think the role of vitamin D and other micronutrients [in respiratory problems] is still poorly understood, and for sure they have a role both in this particular syndrome, but also in airway inflammation and so also asthma. I think it’s an interesting field to be expanded,” Enrico Heffler, MD, PhD, from the University of Torino, Italy, who presented the research at a poster session here, told Medscape Medical News.

Dr. Heffler also related a previous case study of a patient with severe vitamin D deficiency who experienced VCD and bronchospasm; symptoms and lung function were significantly improved after vitamin D supplementation.

“This study is fascinating because it links vitamin D deficiency to something new. [The researchers] need to do a double-blind placebo-controlled trial in these individuals,” Glenis Scadding, MD, a consultant allergist and rhinologist at the Royal National Throat, Nose and Ear Hospital, London, United Kingdom, who attended the session, told Medscape Medical News.

Vocal Cord Dysfunction: Something to Talk About

By Laurie Ross
Nine-year-old Ellie Carson lives to play soccer. To her, happiness is flying down the field after the ball.

For a while, though, it looked like she might have to stop chasing her dream.

Ellie was having trouble keeping up. Just minutes into a game she would begin to wheeze and feel short of breath. As symptoms slowed her down, she became frustrated and upset. That would make it even harder to breathe and she would have to come off the field.

The wheezing and shortness of breath were classic exercise-induced asthma symptoms, so Ellie’s pediatrician prescribed an inhaled bronchodilator for her to use before practice and games to prevent breathing problems.

When that treatment didn’t work, Ellie and her medical care team tried different combinations of asthma and allergy medications to help her breathe, including corticosteroids to treat airway inflammation. Still, game after game and practice after practice, Ellie would have to come off the field.

Determined to find out what was wrong with her daughter, Yvonne Carson took Ellie to see a pediatric pulmonologist, Sunil Kapoor, MD, of the Pediatric Lung Center in Fairfax, Virginia. Dr. Kapoor says he listened to Ellie’s story and checked her lungs but was pretty sure from the outset that what was causing Ellie’s difficulties wasn’t asthma, but a very good imitation: vocal cord dysfunction (VCD).

Following the Clues
“Vocal cord dysfunction,” explains Dr. Kapoor, “looks and feels a lot like asthma. However, since asthma medications weren’t helping Ellie, I suspected she had VCD. It’s a process where your vocal cords move the wrong way when you inhale – closing instead of opening – and it’s closely related to stress, anxiety and exercise. Ellie fit the profile of many of my VCD patients: a very competitive, high achieving, young female athlete.”

You can’t see vocal cords when you look down your throat in the mirror – but you can feel where they live. Put your hand on the front of your throat and swallow. That hard ball that moves up and down when you swallow (on guys it’s called the Adam’s apple) is your voice box, also called the larynx. Vocal cords are folds of tissue that stretch across your voice box. As you breathe in, your vocal cords open to let air go through into your lungs, then narrow as you breathe out. Most of us can’t control this opening and closing, but we do learn to use our vocal cords to talk and sing – it’s the vibration of our vocal cords that makes these sounds.

If you have vocal cord dysfunction, your vocal cords suddenly close when they’re not supposed to, cutting off your air supply. Often this happens during exercise or when you’re emotionally upset or crying – just when you need air the most!

Symptoms of VCD include

wheezing or stridor (a high-pitched sound)
chronic cough or throat clearing
shortness of breath
upper chest or throat tightness
intermittent hoarseness

Diagnosing vocal cord dysfunction is tricky because it so closely resembles asthma – and will often occur alongside asthma – and because the symptoms may seem random. It may happen to an athlete during a game but not a practice, for instance. Or it may happen outside of exercise, when the person is laughing or crying.

In addition to stress and exercise, VCD can be set off by other factors often associated with asthma, including cigarette smoke, perfume and other strong scents, upper respiratory infections, air pollution and cold air.

The most definitive way to identify VCD is to use a laryngoscope (a flexible, fiber optic tube and tiny camera inserted into the back of the throat) to view the vocal cords. However, it must be done while the symptoms are actually occurring – an uncomfortable technique Dr. Kapoor hesitates to use with his young patients. Instead, he has the patient exercise on equipment in his office to induce symptoms, then he uses a spirometer to measure patient lung function. When VCD is occurring, the spirometer reading will show very different results from those seen with asthma.

Some patients may have both asthma and VCD. According to Susan Brugman, MD, one of the leading VCD experts at the National Jewish Medical and Research Center in Colorado, “In my experience with adolescents, 30 to 40 percent of those with VCD also have some degree of asthma.”

Michael Mellon, MD, a pediatric allergist with the Southern California Permanente Medical Group in San Diego, says, “It’s important to look at the overall pattern of symptoms. Patients with exercise-induced asthma will usually have symptoms of asthma at other times (with an upper respiratory infection, for instance, or during allergy seasons) whereas VCD patients may have extreme episodes of difficult breathing in only very isolated situations such as competitive sports or exercise.”

Pointing to a Cause
There’s no single cause for this vocal cord miscue. Dr. Brugman says one aspect is the stress factor. “I see pediatric patients, most of whom are adolescents for whom the vocal cords have become their stress organ,” she explains. “It’s similar to stress-related migraine headaches or irritable bowel syndrome.”

VCD may also be linked to chronic irritation of the throat that makes the vocal cords sensitive. The irritation could come from postnasal drip caused by chronic nasal and/or sinus congestion or from gastroesophageal reflux, where stomach acids leak up into the esophagus. In some people, Dr. Brugman says, the acids travel all the way up to the top of the esophagus, where it meets the windpipe and larynx. “Even a small amount of this fluid spilling over onto the larynx can cause severe irritation and prompt the vocal cords to close,” she explains.

Dr. Kapoor agrees. “Quite often, people with vocal cord dysfunction don’t realize they have reflux,” he says, “because they don’t experience the classic heartburn symptoms. This kind of ‘silent’ reflux that affects the upper airways is so common among my VCD patients that I give the majority of them a trial run with reflux medications.”

Treatment Talk
Beyond treating an underlying throat irritation such as reflux or sinusitis, there is no specific medication available to treat VCD. However, many patients are referred to a speech pathologist (therapist).

“When people think of speech therapy, they tend to think about learning to pronounce r’s and s’s correctly,” says Susan Miller, PhD, CCC-SLP, assistant professor of otolaryngology at the Georgetown University Hospital and a certified speech-language pathologist. “But your voice is an instrument you play by learning to control your breathing and the vibration of your vocal cords. A speech pathologist can help you learn to relax your breathing. And we can teach you techniques that help keep the vocal cords from tightening in the first place.”

Dr. Miller specializes in treating vocal cord dysfunction. She’s also a runner, which helps her understand athlete patients like Ellie. “Vocal cord dysfunction is very much a learned behavior which may have begun with a physical cause, such as silent reflux or sensitivity to an odor,” she explains. “It is very disturbing to patients, especially if they are athletes who have experienced very loud wheezing or even vomiting during exercise. They become embarrassed and afraid that it will happen again. That fear and stress tends to set it off again – whether through tensing the muscles or through reflux, since stress can influence reflux. Then it becomes a self-fulfilling prophecy.”

Dr. Miller says athletes with VCD have to learn new ways to breathe. “Many athletes have been taught to relax by breathing in through the nose and exhaling through the mouth. But when you run or exercise heavily, you can’t do this – you don’t get enough air. So you need a different technique. I teach them to breathe with their jaw relaxed and mouth open, using small, rapid inhalations, then exhaling through pursed lips.”

She also teaches them to reduce reflux by not eating acidic foods like orange juice, soda, chocolate or pizza before exercise. In fact, Dr. Miller thinks one reason so many teenagers have VCD is that they tend to eat a lot of junk food; even the power bars that athletes eat before exercising can cause problems if they contain chocolate.

Dr. Miller taught Ellie about dietary changes that could reduce her reflux and helped her learn to relax her breathing while exercising. According to Ellie’s mother, the techniques are working.

“It’s been a struggle,” says Yvonne. “It’s so easy to assume the breathing problems are asthma and to medicate without testing for anything else. We just kept pushing to find answers. Finally, we’re seeing improvements. Ellie still takes medicine for her allergies and watches what she eats before games. She’s also learned to use her breathing technique on the field while she’s running. She knows she can’t wait till there’s a problem, but has to control it early on. I remind her that she has to control it herself and I try to give her confidence that she can. I think the confidence is a big part of the control, since it allows less room for the anxiety.”

Separating the Symptoms
Vocal cord dysfunction (VCD) is often mistaken for asthma, especially exercise-induced asthma (EIA). This is no surprise, since symptoms of the two conditions are so similar. There are some differences, however, that you might notice. If you suspect you have VCD, consult this chart and talk with your physician.



Timing of symptoms
less than 5 minutes after beginning exercise 5-10 minutes or more after beginning exercise

in throat middle or lower chest

Wheezing or high-pitched sound
when breathing in; hoarse voice when breathing out

symptoms can recur immediately and more severely when exercise resumes symptoms tend to be less severe when exercise resumes (after bronchodilator use)

Recovery time
may take less than 10 minutes usually takes up to an hour without medication

bronchodilator won’t help bronchodilator will help

First published: Allergy & Asthma Today, Volume 6, Issue 1
Updated: February 2009